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Ando Y, Dbouk M, Yoshida T, Saba H, Abou Diwan E, Yoshida K, Dbouk A, Blackford AL, Lin MT, Lennon AM, Burkhart RA, He J, Sokoll L, Eshleman JR, Canto MI, Goggins M. Using Tumor Marker Gene Variants to Improve the Diagnostic Accuracy of DUPAN-2 and Carbohydrate Antigen 19-9 for Pancreatic Cancer. J Clin Oncol 2024:JCO2301573. [PMID: 38457748 DOI: 10.1200/jco.23.01573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/25/2023] [Accepted: 12/22/2023] [Indexed: 03/10/2024] Open
Abstract
PURPOSE Circulating carbohydrate antigen 19-9 (CA19-9) levels reflect FUT3 and FUT2 fucosyltransferase activity. Measuring the related glycan, DUPAN-2, can be useful in individuals unable to synthesize CA19-9. We hypothesized that similar to CA19-9, FUT functional groups determined by variants in FUT3 and FUT2 influence DUPAN-2 levels, and having tumor marker reference ranges for each functional group would improve diagnostic performance. MATERIALS AND METHODS Using a training/validation study design, FUT2/FUT3 genotypes were determined in 938 individuals from Johns Hopkins Hospital: 607 Cancer of the Pancreas Screening (CAPS) study subjects with unremarkable pancreata and 331 with pancreatic ductal adenocarcinoma (PDAC). Serum DUPAN-2 and CA19-9 levels were measured by immunoassay. RESULTS In controls, three functional FUT groups were identified with significant differences in DUPAN-2 levels: FUT3-intact, FUT3-null/FUT2-intact, and FUT3-null/FUT2-null. DUPAN-2 training set diagnostic cutoffs for each FUT group yielded higher diagnostic sensitivity in the validation set for patients with stage I/II PDAC than uniform cutoffs (60.4% [95% CI, 50.2 to 70.0] v 39.8% [30.0 to 49.8]), at approximately 99% (96.7 to 99.6) specificity. Combining FUT/CA19-9 and FUT/DUPAN-2 tests yielded 78.4% (72.3 to 83.7) sensitivity for stage I/II PDAC, at 97.7% (95.3 to 99.1) specificity in the combined sets, with higher AUC (stage I/II: 0.960 v 0.935 for CA19-9 + DUPAN-2 without the FUT test; P < .001); for stage I PDAC, sensitivity was 62.0% (49.1 to 73.2; AUC, 0.919 v 0.883; P = .03). CA19-9 levels in FUT3-null/FUT2-null PDAC subjects were higher than in FUT3-null/FUT2-intact subjects (median/IQR; 24.9/57.4 v <1/2.3 U/mL; P = .0044). In a simulated CAPS cohort, AUC precision recall (AUCPR) scores were 0.51 for CA19-9 alone, 0.64 for FUT/CA19-9, 0.73 for CA19-9/DUPAN-2, and 0.84 for FUT/CA19-9/DUPAN-2. CONCLUSION Using a tumor marker gene test to individualize CA19-9 and DUPAN-2 reference ranges achieves high diagnostic performance for stage I/II pancreatic cancer.
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Affiliation(s)
- Yohei Ando
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Mohamad Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Takeichi Yoshida
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Helena Saba
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Elizabeth Abou Diwan
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Kanako Yoshida
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Ali Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Amanda L Blackford
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Ming-Tseh Lin
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Anne Marie Lennon
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Richard A Burkhart
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Lori Sokoll
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - James R Eshleman
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Marcia Irene Canto
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Michael Goggins
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
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Kiemen AL, Dbouk M, Diwan EA, Forjaz A, Dequiedt L, Baghdadi A, Madani SP, Grahn MP, Jones C, Vedula S, Wu P, Wirtz D, Kern S, Goggins M, Hruban RH, Kamel IR, Canto MI. Magnetic Resonance Imaging-Based Assessment of Pancreatic Fat Strongly Correlates With Histology-Based Assessment of Pancreas Composition. Pancreas 2024; 53:e180-e186. [PMID: 38194643 PMCID: PMC10872776 DOI: 10.1097/mpa.0000000000002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVE The aim of the study is to assess the relationship between magnetic resonance imaging (MRI)-based estimation of pancreatic fat and histology-based measurement of pancreatic composition. MATERIALS AND METHODS In this retrospective study, MRI was used to noninvasively estimate pancreatic fat content in preoperative images from high-risk individuals and disease controls having normal pancreata. A deep learning algorithm was used to label 11 tissue components at micron resolution in subsequent pancreatectomy histology. A linear model was used to determine correlation between histologic tissue composition and MRI fat estimation. RESULTS Twenty-seven patients (mean age 64.0 ± 12.0 years [standard deviation], 15 women) were evaluated. The fat content measured by MRI ranged from 0% to 36.9%. Intrapancreatic histologic tissue fat content ranged from 0.8% to 38.3%. MRI pancreatic fat estimation positively correlated with microanatomical composition of fat (r = 0.90, 0.83 to 0.95], P < 0.001); as well as with pancreatic cancer precursor ( r = 0.65, P < 0.001); and collagen ( r = 0.46, P < 0.001) content, and negatively correlated with pancreatic acinar ( r = -0.85, P < 0.001) content. CONCLUSIONS Pancreatic fat content, measurable by MRI, correlates to acinar content, stromal content (fibrosis), and presence of neoplastic precursors of cancer.
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Affiliation(s)
- Ashley L. Kiemen
- Departments of Pathology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Departments of Chemical and Biomolecular Engineering, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
- Oncology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
| | - Mohamad Dbouk
- Departments of Pathology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Department of Medicine, Washington University St. Louis, St. Louis, USA; 1 Brookings Dr, St. Louis, MO 63130
| | - Elizabeth Abou Diwan
- Department of Medicine, Washington University St. Louis, St. Louis, USA; 1 Brookings Dr, St. Louis, MO 63130
| | - André Forjaz
- Departments of Chemical and Biomolecular Engineering, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
| | - Lucie Dequiedt
- Departments of Chemical and Biomolecular Engineering, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
| | - Azarakhsh Baghdadi
- Radiology and Radiological Science, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
| | - Seyedeh Panid Madani
- Radiology and Radiological Science, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
| | - Mia P. Grahn
- Departments of Chemical and Biomolecular Engineering, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
| | - Craig Jones
- Computer Science, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
- Malone Center for Engineering in Healthcare, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
| | - Swaroop Vedula
- Malone Center for Engineering in Healthcare, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
| | - PeiHsun Wu
- Departments of Chemical and Biomolecular Engineering, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
| | - Denis Wirtz
- Departments of Pathology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Departments of Chemical and Biomolecular Engineering, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
- Oncology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Materials Science and Engineering, The Johns Hopkins University; 3400 N Charles St, Baltimore, Maryland 21218, USA
| | - Scott Kern
- Departments of Pathology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Oncology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
| | - Michael Goggins
- Departments of Pathology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Oncology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
| | - Ralph H. Hruban
- Departments of Pathology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Oncology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
| | - Ihab R. Kamel
- Radiology and Radiological Science, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
| | - Marcia Irene Canto
- Oncology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine; 600 North Wolfe Street, Baltimore, Maryland 21287, USA
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Chandar AK, Keerthy K, Gupta R, Grady WM, Canto MI, Shaheen NJ, Thota PN, Iyer PG, Wang JS, Falk GW, Abrams JA, Dumot J, Faulx A, Markowitz SD, Willis J, Moinova H, Guda K, Brock W, Chak A. Patients With Esophageal Adenocarcinoma With Prior Gastroesophageal Reflux Disease Symptoms Are Similar to Those Without Gastroesophageal Reflux Disease: A Cross-Sectional Study. Am J Gastroenterol 2023:00000434-990000000-00945. [PMID: 37975600 DOI: 10.14309/ajg.0000000000002593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION A substantial proportion of patients with esophageal adenocarcinoma (EAC) do not report gastroesophageal reflux disease (GERD) symptoms. This study aimed to compare the risk factor profiles and cancer stage at presentation of patients with EAC with and without prior GERD. METHODS In this retrospective cross-sectional study, patients with EAC were divided into 2 cohorts: (i) EAC with prior GERD: patients who reported typical GERD symptoms (heartburn or regurgitation) ≥1 year before cancer diagnosis and (ii) EAC without prior GERD: patients who did not report prior GERD symptoms or reported symptoms within 1 year of their cancer diagnosis. Baseline demographics, risk factors, and cancer stage at presentation were compared between the 2 cohorts. In addition, the distribution of patients based on numbers of BE/EAC-associated risk factors (1, 2, 3, 4, and 5 or more) was examined in the symptomatic and asymptomatic cohorts. RESULTS Over 13 years, 388 patients with EAC with prior GERD and 245 patients with EAC without prior GERD were recruited. Both groups had similar baseline demographics and risk factors, but patients with EAC with prior GERD were more likely to have a history of BE. Asymptomatic patients had more advanced disease. Patients with 3 or more BE/EAC-related risk factors formed the largest proportion of patients in both the symptomatic and asymptomatic cohorts. DISCUSSION Patients with EAC with and without prior GERD symptoms are phenotypically similar, suggesting that BE screening efforts to prevent or detect early EAC should not be restricted to just those with GERD.
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Affiliation(s)
- Apoorva Krishna Chandar
- Division of Hematology-Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Komal Keerthy
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Gastroenterology and Liver Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Rajesh Gupta
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Gastroenterology and Liver Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - William M Grady
- Fred Hutchinson Cancer Center, Seattle, Ohio, USA
- Digestive Health Center, University of Washington Medical Center, Seattle, Washington, USA
| | - Marcia Irene Canto
- Division of Gastroenterology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Prashanthi N Thota
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean S Wang
- Division of Gastroenterology, Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julian A Abrams
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - John Dumot
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ashley Faulx
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sanford D Markowitz
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Joseph Willis
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Helen Moinova
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kishore Guda
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Wendy Brock
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Amitabh Chak
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Gastroenterology and Liver Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Dbouk M, Abe T, Koi C, Ando Y, Saba H, Abou Diwan E, MacGregor-Das A, Blackford AL, Mocci E, Beierl K, Dbouk A, He J, Burkhart R, Lennon AM, Sokoll L, Canto MI, Eshleman JR, Goggins M. Diagnostic Performance of a Tumor Marker Gene Test to Personalize Serum CA19-9 Reference Ranges. Clin Cancer Res 2023; 29:4178-4185. [PMID: 37566230 PMCID: PMC10570677 DOI: 10.1158/1078-0432.ccr-23-0655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/25/2023] [Accepted: 08/08/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE CA19-9 synthesis is influenced by common variants in the fucosyltransferase (FUT) enzymes FUT3 and FUT2. We developed a clinical test to detect FUT variants, and evaluated its diagnostic performance for pancreatic ductal adenocarcinoma (PDAC). EXPERIMENTAL DESIGN A representative set of controls from the Cancer of the Pancreas Screening study was identified for each FUT functional group. Diagnostic sensitivity was determined first in a testing set of 234 PDAC cases, followed by a 134-case validation set, all of whom had undergone resection with curative intent without neoadjuvant therapy. Tumor marker gene testing was performed in the Johns Hopkins Molecular Diagnostics Laboratory. CA19-9 levels were measured in the Hopkins Clinical Chemistry lab. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative ability of CA19-9 alone versus with the gene test. RESULTS Applying the CA19-9 standard cutoff (<36 U/mL) to all 716 subjects yielded a 68.8% sensitivity in the test set of cases, 67.2% in the validation set, at 91.4% specificity. Applying 99th percentile cutoffs according to each individual's FUT group (3, 34.9, 41.8, and 89.2, for the FUT3-null, FUT-low, FUT-intermediate, and FUT-high groups, respectively) yielded a diagnostic sensitivity for CA19-9 in the first set of cases of 66.7%, 65.7% in the validation set, at 98.9% specificity. ROC analysis for CA19-9 alone yielded an AUC of 0.84; with the tumor marker gene test, AUC improved to 0.92 (P < 0.001). CONCLUSIONS Using a tumor marker gene test to personalize an individual's CA19-9 reference range significantly improves diagnostic accuracy.
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Affiliation(s)
- Mohamad Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Toshiya Abe
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Chiho Koi
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yohei Ando
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Helena Saba
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Elizabeth Abou Diwan
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne MacGregor-Das
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amanda L. Blackford
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Evelina Mocci
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Katie Beierl
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ali Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard Burkhart
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne Marie Lennon
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Lori Sokoll
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Marcia Irene Canto
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - James R. Eshleman
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Goggins
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Moinova HR, Verma S, Dumot J, Faulx A, Iyer PG, Canto MI, Wang JS, Shaheen NJ, Thota PN, Aklog L, Willis JE, Markowitz SD, Chak A. NON-ENDOSCOPIC ESOPHAGEAL SAMPLING DEVICE AND BIOMARKER PANEL FOR DETECTION OF BARRETT'S ESOPHAGUS (BE) AND ESOPHAGEAL ADENOCARCINOMA (EAC). medRxiv 2023:2023.06.06.23291048. [PMID: 37333176 PMCID: PMC10275011 DOI: 10.1101/2023.06.06.23291048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
BACKGROUND We previously reported an encapsulated balloon (EsoCheck TM , EC), which selectively samples the distal esophagus, that coupled with a two methylated DNA biomarker panel (EsoGuard TM , EG), detected Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC), with a sensitivity and specificity of 90.3% and 91.7%, respectively. This previous study utilized frozen EC samples. AIM To assess a next generation EC sampling device and EG assay that utilizes a room temperature sample preservative to enable office-based testing. METHODS Cases with nondysplastic (ND) and dysplastic (indefinite=IND, low grade dysplasia = LGD, high grade dysplasia = HGD) BE, EAC, junctional adenocarcinoma (JAC) and controls with no intestinal metaplasia (IM) were included. Nurses or physician assistants at six institutions, who were trained in EC administration, delivered the encapsulated balloon per orally and inflated it in the stomach. The inflated balloon was pulled back to sample 5 cm of the distal esophagus, then deflated and retracted into the EC capsule to prevent sample contamination from proximal esophagus. Nextgen EG sequencing assays performed on bisulfite-treated DNA extracted from EC samples determined levels of methylated Vimentin (mVIM) and methylated Cyclin A1 (mCCNA1) in a CLIA-certified laboratory, blinded to patients' phenotypes. RESULTS A total of 243 evaluable patients - 88 cases (median age 68 years, 78% men, 92% white) and 155 controls (median age 57 years, 41% men, 88% white) - underwent adequate EC sampling. Mean time for EC sampling was just over 3 minutes. The cases included 31 NDBE, 16 IND/LGD, 23 HGD, and 18 EAC/JAC. Thirty-seven (53%) of the non-dysplastic and dysplastic BE cases were short-segment BE (SSBE; < 3 cm). Overall sensitivity for detecting all cases was 85% (95% CI= 0.78-0.93) and specificity was 85% (95% CI=0.79-0.90). Sensitivity for NDBE was 84% (n=37). The EC/EG test detected 100% of cancers. CONCLUSION The next-generation EC/EG technology has been both successfully updated to incorporate a room temperature sample collection preservative and successfully implemented in a CLIA certified laboratory. When performed by trained personnel, EC/EG detects non-dysplastic BE, dysplastic BE, and cancer with high sensitivity and specificity, replicating the operating characteristics of the initial pilot study of this technology. Future applications utilizing EC/EG to screen broader populations at risk for developing cancer are proposed. SIGNIFICANCE This multi-center study demonstrates the successful performance of a commercially available clinically implementable non-endoscopic screening test for BE in the U.S., as recommended in the most recent ACG Guideline and AGA Clinical Update. It transitions and validates a prior academic laboratory-based study of frozen research samples over to a CLIA laboratory, one that also integrates a clinically practical room temperature method for sample acquisition and storage, enabling office-based screening.
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Archibugi L, Capurso G, Canto MI. Cost-effectiveness of pancreatic cancer screening: Time for a more tailored approach. United European Gastroenterol J 2023; 11:264-266. [PMID: 36938945 PMCID: PMC10083457 DOI: 10.1002/ueg2.12380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023] Open
Affiliation(s)
- Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Marcia Irene Canto
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Dbouk M, Katona BW, Brand RE, Chak A, Syngal S, Farrell JJ, Kastrinos F, Stoffel EM, Canto MI, Goggins M. Reply to S. Raoof. J Clin Oncol 2023; 41:1147-1149. [PMID: 36315911 PMCID: PMC9928686 DOI: 10.1200/jco.22.01915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 02/09/2023] Open
Affiliation(s)
- Mohamad Dbouk
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Bryson W. Katona
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Randall E. Brand
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Amitabh Chak
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Sapna Syngal
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - James J. Farrell
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Fay Kastrinos
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Elena M. Stoffel
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Marcia Irene Canto
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Michael Goggins
- Mohamad Dbouk, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; Bryson W. Katona, MD, Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Randall E. Brand, MD, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; Amitabh Chak, MD, Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; Sapna Syngal, MD, Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA; James J. Farrell, MD, Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT; Fay Kastrinos, MD, Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY; Elena M. Stoffel, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Marcia Irene Canto, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Michael Goggins, MB, MD, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
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Ghosh G, Choi AY, Dbouk M, Greenberg J, Zarnegar R, Murray M, Janu P, Thosani N, Dayyeh BKA, Diehl D, Nguyen NT, Chang KJ, Canto MI, Sharaiha R. Transoral incisionless fundoplication for recurrent symptoms after laparoscopic fundoplication. Surg Endosc 2023; 37:3701-3709. [PMID: 36650353 DOI: 10.1007/s00464-023-09880-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/08/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Revision of a failed laparoscopic fundoplication carries higher risk of complication and lower chance of success compared to the original surgery. Transoral incisionless fundoplication (TIF) may be an endoscopic alternative for select GERD patients without need of a moderate/large hiatal hernia repair. The aim of this study was to assess feasibility, efficacy, and safety of TIF 2.0 after failed laparoscopic Nissen or Toupet fundoplication (TIFFF). METHODS This is a multicenter retrospective cohort study of patients who underwent TIFFF between September 2017 and December 2020 using TIF 2.0 technique (EsophyX Z/Z+) performed by gastroenterologists and surgeons. Patients were included if they had (1) recurrent GERD symptoms, (2) pathologic reflux based upon pH testing or Grade C/D esophagitis or Barrett's esophagus, and (3) hiatal hernia ≤ 2 cm. The primary outcome was improvement in GERD Health-Related Quality of Life (GERD-HRQL) post-TIFFF. The TIFFF cohort was also compared to a similar surgical re-operative cohort using propensity score matching. RESULTS Twenty patients underwent TIFFF (median 4.1 years after prior fundoplication) and mean GERD-HRQL score improved from 24.3 ± 22.9 to 14.75 ± 21.6 (p = 0.014); mean Reflux Severity Index (RSI) score improved from 14.1 ± 14.6 to 9.1 ± 8.0 (p = 0.046) with 8/10 (80%) of patients with normal RSI (< 13) post-TIF. Esophagitis healed in 78% of patients. PPI use decreased from 85 to 55% with 8/20 (45%) patients off of PPI. Importantly, mean acid exposure time decreased from 12% ± 17.8 to 0.8% ± 1.1 (p = 0.028) with 9/9 (100%) of patients with normalized pH post-TIF. There were no statistically significant differences in clinical efficacy outcomes between TIFFF and surgical revision, but TIFFF had significantly fewer late adverse events. CONCLUSION Endoscopic rescue with TIF is a safe and efficacious alternative to redo laparoscopic surgery in symptomatic patients with appropriate anatomy and objective evidence of persistent or recurrent reflux.
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Affiliation(s)
- Gaurav Ghosh
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1283 York Ave, 9th Floor, New York, NY, 10065, USA.
| | - Alyssa Y Choi
- HH Chao Comprehensive Digestive Disease Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jacques Greenberg
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | | | - Peter Janu
- Fox Valley Surgical Associates, Affinity Health Systems, Appleton, WI, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA, USA
| | - Ninh T Nguyen
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Kenneth J Chang
- HH Chao Comprehensive Digestive Disease Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1283 York Ave, 9th Floor, New York, NY, 10065, USA
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Mazer BL, Lee JW, Roberts NJ, Chu LC, Lennon AM, Klein AP, Eshleman JR, Fishman EK, Canto MI, Goggins MG, Hruban RH. Screening for pancreatic cancer has the potential to save lives, but is it practical? Expert Rev Gastroenterol Hepatol 2023; 17:555-574. [PMID: 37212770 PMCID: PMC10424088 DOI: 10.1080/17474124.2023.2217354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/21/2023] [Accepted: 05/19/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Most patients with pancreatic cancer present with advanced stage, incurable disease. However, patients with high-grade precancerous lesions and many patients with low-stage disease can be cured with surgery, suggesting that early detection has the potential to improve survival. While serum CA19.9 has been a long-standing biomarker used for pancreatic cancer disease monitoring, its low sensitivity and poor specificity have driven investigators to hunt for better diagnostic markers. AREAS COVERED This review will cover recent advances in genetics, proteomics, imaging, and artificial intelligence, which offer opportunities for the early detection of curable pancreatic neoplasms. EXPERT OPINION From exosomes, to circulating tumor DNA, to subtle changes on imaging, we know much more now about the biology and clinical manifestations of early pancreatic neoplasia than we did just five years ago. The overriding challenge, however, remains the development of a practical approach to screen for a relatively rare, but deadly, disease that is often treated with complex surgery. It is our hope that future advances will bring us closer to an effective and financially sound approach for the early detection of pancreatic cancer and its precursors.
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Affiliation(s)
- Benjamin L. Mazer
- The Sol Goldman Pancreatic Cancer Research Center, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jae W. Lee
- The Sol Goldman Pancreatic Cancer Research Center, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nicholas J. Roberts
- The Sol Goldman Pancreatic Cancer Research Center, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Oncology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Linda C. Chu
- Department of Radiology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anne Marie Lennon
- Department of Medicine, Division of Gastroenterology and Hepatology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alison P. Klein
- The Sol Goldman Pancreatic Cancer Research Center, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Oncology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James R. Eshleman
- The Sol Goldman Pancreatic Cancer Research Center, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Oncology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K. Fishman
- Department of Radiology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marcia Irene Canto
- Department of Medicine, Division of Gastroenterology and Hepatology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G. Goggins
- The Sol Goldman Pancreatic Cancer Research Center, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Oncology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H. Hruban
- The Sol Goldman Pancreatic Cancer Research Center, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Oncology, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kawamoto M, Yoshida T, Tamura K, Dbouk M, Canto MI, Burkhart R, He J, Roberts NJ, Klein AP, Goggins M. Endoplasmic stress-inducing variants in carboxyl ester lipase and pancreatic cancer risk. Pancreatology 2022; 22:959-964. [PMID: 35995657 PMCID: PMC9669157 DOI: 10.1016/j.pan.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoplasmic reticulum (ER) stress-inducing variants in several pancreatic secretory enzymes have been associated with pancreatic disease. Multiple variants in CEL, encoding carboxyl ester lipase, are known to cause maturity-onset diabetes of the young (MODY8) but have not been implicated in pancreatic cancer risk. METHODS The prevalence of ER stress-inducing variants in the CEL gene was compared among pancreatic cancer cases vs. controls. Variants were identified by next-generation sequencing and confirmed by Sanger sequencing. Variants of uncertain significance (VUS) were assessed for their effect on the secretion of CEL protein and variants with reduced protein secretion were evaluated to determine if they induced endoplasmic reticulum stress. RESULTS ER stress-inducing CEL variants were found in 34 of 986 cases with sporadic pancreatic ductal adenocarcinoma, and 21 of 1045 controls (P = 0.055). Most of the variants were either the CEL-HYB1 variant, the I488T variant, or the combined CEL-HYB1/I488T variant; one case had a MODY8 variant. CONCLUSION This case/control analysis finds ER stress-inducing CEL variants are not associated with an increased likelihood of having pancreatic cancer.
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Affiliation(s)
- Makoto Kawamoto
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Takeichi Yoshida
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Koji Tamura
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mohamad Dbouk
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Marcia Irene Canto
- Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Jin He
- Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Nicholas J Roberts
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Alison P Klein
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Research Center, And the Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael Goggins
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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11
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Dbouk M, Katona BW, Brand RE, Chak A, Syngal S, Farrell JJ, Kastrinos F, Stoffel EM, Blackford AL, Rustgi AK, Dudley B, Lee LS, Chhoda A, Kwon R, Ginsberg GG, Klein AP, Kamel I, Hruban RH, He J, Shin EJ, Lennon AM, Canto MI, Goggins M. The Multicenter Cancer of Pancreas Screening Study: Impact on Stage and Survival. J Clin Oncol 2022; 40:3257-3266. [PMID: 35704792 PMCID: PMC9553376 DOI: 10.1200/jco.22.00298] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/29/2022] [Accepted: 05/11/2022] [Indexed: 01/21/2023] Open
Abstract
PURPOSE To report pancreas surveillance outcomes of high-risk individuals within the multicenter Cancer of Pancreas Screening-5 (CAPS5) study and to update outcomes of patients enrolled in prior CAPS studies. METHODS Individuals recommended for pancreas surveillance were prospectively enrolled into one of eight CAPS5 study centers between 2014 and 2021. The primary end point was the stage distribution of pancreatic ductal adenocarcinoma (PDAC) detected (stage I v higher-stage). Overall survival was determined using the Kaplan-Meier method. RESULTS Of 1,461 high-risk individuals enrolled into CAPS5, 48.5% had a pathogenic variant in a PDAC-susceptibility gene. Ten patients were diagnosed with PDAC, one of whom was diagnosed with metastatic PDAC 4 years after dropping out of surveillance. Of the remaining nine, seven (77.8%) had a stage I PDAC (by surgical pathology) detected during surveillance; one had stage II, and one had stage III disease. Seven of these nine patients with PDAC were alive after a median follow-up of 2.6 years. Eight additional patients underwent surgical resection for worrisome lesions; three had high-grade and five had low-grade dysplasia in their resected specimens. In the entire CAPS cohort (CAPS1-5 studies, 1,731 patients), 26 PDAC cases have been diagnosed, 19 within surveillance, 57.9% of whom had stage I and 5.2% had stage IV disease. By contrast, six of the seven PDACs (85.7%) detected outside surveillance were stage IV. Five-year survival to date of the patients with a screen-detected PDAC is 73.3%, and median overall survival is 9.8 years, compared with 1.5 years for patients diagnosed with PDAC outside surveillance (hazard ratio [95% CI]; 0.13 [0.03 to 0.50], P = .003). CONCLUSION Most pancreatic cancers diagnosed within the CAPS high-risk cohort in the recent years have had stage I disease with long-term survival.
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Affiliation(s)
- Mohamad Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Bryson W. Katona
- Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Randall E. Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Sapna Syngal
- Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - James J. Farrell
- Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Elena M. Stoffel
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Amanda L. Blackford
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Anil K. Rustgi
- Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT
| | - Beth Dudley
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Linda S. Lee
- Cancer Genetics and Prevention Division, Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Gastroenterology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Ankit Chhoda
- Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, CT
| | - Richard Kwon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Gregory G. Ginsberg
- Division of Gastroenterology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alison P. Klein
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Ihab Kamel
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Bloomberg School of Public Health, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Jin He
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Eun Ji Shin
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Anne Marie Lennon
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Bloomberg School of Public Health, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Marcia Irene Canto
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Michael Goggins
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
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12
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Tanaka H, Tamura K, Abe T, Yoshida T, Macgregor-Das A, Dbouk M, Blackford AL, Borges M, Lennon AM, He J, Burkhart R, Canto MI, Goggins M. Serum Carboxypeptidase Activity and Genotype-Stratified CA19-9 to Detect Early-Stage Pancreatic Cancer. Clin Gastroenterol Hepatol 2022; 20:2267-2275.e2. [PMID: 34648951 PMCID: PMC9001752 DOI: 10.1016/j.cgh.2021.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/27/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Serum diagnostic markers of early-stage pancreatic ductal adenocarcinoma (PDAC) are needed, especially for stage I disease. As tumors grow and cause pancreatic atrophy, markers derived from pancreatic parenchyma such as serum carboxypeptidase A (CPA) activity lose diagnostic performance. We evaluated, with CA19-9, serum CPA as a marker of early pancreatic cancer. METHODS Serum CPA activity levels were measured in 345 controls undergoing pancreatic surveillance, divided into 2 sets, set 1 being used to establish a reference range. Variants within the CPA1 locus were sought for their association with pancreatic CPA1 expression to determine if such variants associated with serum CPA levels. A total of 190 patients with resectable PDAC were evaluated. RESULTS Among controls, those having 1 or more minor alleles of CPA1 variants rs6955723 or rs2284682 had significantly higher serum CPA levels than did those without (P = .001). None of the PDAC cases with pancreatic atrophy had an elevated CPA. Among 122 PDAC cases without atrophy, defining serum CPA diagnostic cutoffs by a subject's CPA1 variants yielded a diagnostic sensitivity of 18% at 99% specificity (95% confidence interval [CI], 11.7-26) (vs 11.1% sensitivity using a uniform diagnostic cutoff); combining CPA with variant-stratified CA19-9 yielded a sensitivity of 68.0% (95% CI, 59.0-76.2) vs 63.1% (95% CI, 53.9- 71.7) for CA19-9 alone; and among stage I PDAC cases, diagnostic sensitivity was 51.9% (95% CI, 31.9-71.3) vs 37.0% (95% CI, 19.4-57.6) for CA19-9 alone. In the validation control set, the variant-stratified diagnostic cutoff yielded a specificity of 98.2%. CONCLUSION Serum CPA activity has diagnostic utility before the emergence of pancreatic atrophy as a marker of localized PDAC, including stage I disease.
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Affiliation(s)
- Haruyoshi Tanaka
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Koji Tamura
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Toshiya Abe
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Takeichi Yoshida
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne Macgregor-Das
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mohamad Dbouk
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amanda L Blackford
- Department of Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Borges
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne Marie Lennon
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Medicine, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jin He
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard Burkhart
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Marcia Irene Canto
- Department of Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Medicine, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Goggins
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Medicine, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Wood LD, Canto MI, Jaffee EM, Simeone DM. Pancreatic Cancer: Pathogenesis, Screening, Diagnosis, and Treatment. Gastroenterology 2022; 163:386-402.e1. [PMID: 35398344 PMCID: PMC9516440 DOI: 10.1053/j.gastro.2022.03.056] [Citation(s) in RCA: 176] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/13/2022] [Accepted: 03/25/2022] [Indexed: 12/13/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a clinically challenging cancer, due to both its late stage at diagnosis and its resistance to chemotherapy. However, recent advances in our understanding of the biology of PDAC have revealed new opportunities for early detection and targeted therapy of PDAC. In this review, we discuss the pathogenesis of PDAC, including molecular alterations in tumor cells, cellular alterations in the tumor microenvironment, and population-level risk factors. We review the current status of surveillance and early detection of PDAC, including populations at high risk and screening approaches. We outline the diagnostic approach to PDAC and highlight key treatment considerations, including how therapeutic approaches change with disease stage and targetable subtypes of PDAC. Recent years have seen significant improvements in our approaches to detect and treat PDAC, but large-scale, coordinated efforts will be needed to maximize the clinical impact for patients and improve overall survival.
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Affiliation(s)
- Laura D Wood
- Departments of Pathology and Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth M Jaffee
- Sidney Kimmel Cancer Center, Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Diane M Simeone
- Departments of Surgery and Pathology, Perlmutter Cancer Center, NYU Langone Health, New York, New York
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14
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Snow GE, Dbouk M, Akst LM, Ihde G, Zarnegar R, Janu P, Murray M, Eskarous H, Sohagia A, Dhar SI, Irene Canto M. Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux. Ann Otol Rhinol Laryngol 2022; 131:662-670. [PMID: 34378427 DOI: 10.1177/00034894211037414] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD. METHODS Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction. RESULTS Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF (P < .001). CONCLUSION In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Grace E Snow
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohamad Dbouk
- Division of Gastrointestinal and Liver Pathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lee M Akst
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Glenn Ihde
- Department of General Surgery, The Matagorda Regional Medical Group, Bay City, TX, USA
| | | | - Peter Janu
- Department of Surgery, Fox Valley Surgical Associates, Appleton, WI, USA
| | - Michael Murray
- Department of Surgery, Northern Nevada Medical Center, Sparks, NV, USA
| | - Hany Eskarous
- Department of Medicine, Easton Hospital, Easton, PA, USA
| | - Amit Sohagia
- Department of Medicine, Easton Hospital, Easton, PA, USA
| | - Shumon I Dhar
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marcia Irene Canto
- Division of Gastroenterology, Department of Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Overbeek KA, Goggins MG, Dbouk M, Levink IJM, Koopmann BDM, Chuidian M, Konings ICAW, Paiella S, Earl J, Fockens P, Gress TM, Ausems MGEM, Poley JW, Thosani NC, Half E, Lachter J, Stoffel EM, Kwon RS, Stoita A, Kastrinos F, Lucas AL, Syngal S, Brand RE, Chak A, Carrato A, Vleggaar FP, Bartsch DK, van Hooft JE, Cahen DL, Canto MI, Bruno MJ. Timeline of Development of Pancreatic Cancer and Implications for Successful Early Detection in High-Risk Individuals. Gastroenterology 2022; 162:772-785.e4. [PMID: 34678218 DOI: 10.1053/j.gastro.2021.10.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/27/2021] [Accepted: 10/15/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS To successfully implement imaging-based pancreatic cancer (PC) surveillance, understanding the timeline and morphologic features of neoplastic progression is key. We aimed to investigate the progression to neoplasia from serial prediagnostic pancreatic imaging tests in high-risk individuals and identify factors associated with successful early detection. METHODS We retrospectively examined the development of pancreatic abnormalities in high-risk individuals who were diagnosed with PC or underwent pancreatic surgery, or both, in 16 international surveillance programs. RESULTS Of 2552 high-risk individuals under surveillance, 28 (1%) developed neoplastic progression to PC or high-grade dysplasia during a median follow-up of 29 months after baseline (interquartile range [IQR], 40 months). Of these, 13 of 28 (46%) presented with a new lesion (median size, 15 mm; range 7-57 mm), a median of 11 months (IQR, 8; range 3-17 months) after a prior examination, by which time 10 of 13 (77%) had progressed beyond the pancreas. The remaining 15 of 28 (54%) had neoplastic progression in a previously detected lesion (12 originally cystic, 2 indeterminate, 1 solid), and 11 (73%) had PC progressed beyond the pancreas. The 12 patients with cysts had been monitored for 21 months (IQR, 15 months) and had a median growth of 5 mm/y (IQR, 8 mm/y). Successful early detection (as high-grade dysplasia or PC confined to the pancreas) was associated with resection of cystic lesions (vs solid or indeterminate lesions (odds ratio, 5.388; 95% confidence interval, 1.525-19.029) and small lesions (odds ratio, 0.890/mm; 95% confidence interval 0.812-0.976/mm). CONCLUSIONS In nearly half of high-risk individuals developing high-grade dysplasia or PC, no prior lesions are detected by imaging, yet they present at an advanced stage. Progression can occur before the next scheduled annual examination. More sensitive diagnostic tools or a different management strategy for rapidly growing cysts are needed.
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Affiliation(s)
- Kasper A Overbeek
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.
| | - Michael G Goggins
- Division of Gastroenterology, Johns Hopkins University School of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland; Division of Pathology, Johns Hopkins University School of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland; Division of Oncology, Johns Hopkins University School of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Mohamad Dbouk
- Division of Pathology, Johns Hopkins University School of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Iris J M Levink
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Brechtje D M Koopmann
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Miguel Chuidian
- Division of Gastroenterology, Johns Hopkins University School of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Ingrid C A W Konings
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Julie Earl
- Department of Medical Oncology, Ramón y Cajal University Hospital, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain; Biomedical Research Network in Cancer (CIBERONC), Madrid, Spain
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, Philipps University of Marburg, Marburg, Germany
| | - Margreet G E M Ausems
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Nirav C Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas
| | - Elizabeth Half
- Department of Gastroenterology, Rambam Healthcare Campus, Haifa, Israel
| | - Jesse Lachter
- Department of Gastroenterology, Rambam Healthcare Campus, Haifa, Israel
| | - Elena M Stoffel
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Richard S Kwon
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Alina Stoita
- Department of Gastroenterology, St Vincent's Hospital, Sydney, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Aimee L Lucas
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sapna Syngal
- Population Sciences Division, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Randall E Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alfredo Carrato
- Department of Medical Oncology, Ramón y Cajal University Hospital, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain; Biomedical Research Network in Cancer (CIBERONC), Madrid, Spain; Department of Medicine and Medical Specialties, Medicine Faculty, Alcala University, Alcalá de Henares, Spain
| | - Frank P Vleggaar
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Detlef K Bartsch
- Department of Visceral, Thoracic- and Vascular Surgery, Philipps University of Marburg, Marburg, Germany
| | - Jeanin E van Hooft
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Gastroenterology & Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Djuna L Cahen
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Marcia Irene Canto
- Division of Gastroenterology, Johns Hopkins University School of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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Kohi S, Macgregor-Das A, Dbouk M, Yoshida T, Chuidian M, Abe T, Borges M, Lennon AM, Shin EJ, Canto MI, Goggins M. Alterations in the Duodenal Fluid Microbiome of Patients With Pancreatic Cancer. Clin Gastroenterol Hepatol 2022; 20:e196-e227. [PMID: 33161160 PMCID: PMC8120597 DOI: 10.1016/j.cgh.2020.11.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The tumor microbiome of patients with pancreas ductal adenocarcinoma (PDAC) includes bacteria normally present in the upper gastrointestinal tract. If the predominant source of intratumoral bacteria in patients with PDAC is retrograde migration from the duodenum, duodenal fluid could be a representative biospecimen for determining microbiome profiles of patients with PDAC or at risk of developing PDAC. METHODS We performed a case-control study comparing bacterial and fungal (16S and 18S rRNA) profiles of secretin-stimulated duodenal fluid collections from 308 patients undergoing duodenal endoscopy including 134 normal pancreas control subjects, 98 patients with pancreatic cyst(s) and 74 patients with PDAC. RESULTS Alterations in duodenal fluid microbiomes with diminished alpha diversity were significantly associated with age >70 and proton pump inhibitor use. Patients with PDAC had significantly decreased duodenal microbial alpha diversity compared with age-matched control subjects with normal pancreata and those with pancreatic cyst(s). There was evidence of enrichment of Bifidobacterium genera in the duodenal fluid of patients with PDAC compared with control subjects and those with pancreatic cyst(s). There were also enrichment of duodenal fluid Fusobacteria and Rothia bacteria among patients with PDAC with short-term survival. Duodenal fluid microbiome profiles were not significantly different between control subjects and patients with pancreatic cyst(s). CONCLUSION Patients with PDAC have alterations in their duodenal fluid microbiome profiles compared with patients with pancreatic cysts and those with normal pancreata. ClinicalTrials.gov, Number: NCT02000089.
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Affiliation(s)
- Shiro Kohi
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Anne Macgregor-Das
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Mohamad Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Takeichi Yoshida
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Miguel Chuidian
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Toshiya Abe
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Michael Borges
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Anne Marie Lennon
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Eun Ji Shin
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD.,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Marcia Irene Canto
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD.,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Michael Goggins
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, the Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Bejjani M, Yousaf MN, Ghandour B, Canto MI, Khashab M. Endoscopic submucosal dissection using scissors-type knife for a giant solitary duodenal polyp. VideoGIE 2021; 6:372-374. [PMID: 34401635 PMCID: PMC8351124 DOI: 10.1016/j.vgie.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kumar S, Saumoy M, Oh A, Schneider Y, Brand RE, Chak A, Ginsberg GG, Kochman ML, Canto MI, Goggins MG, Hur C, Kastrinos F, Katona BW, Rustgi AK. Threshold Analysis of the Cost-effectiveness of Endoscopic Ultrasound in Patients at High Risk for Pancreatic Ductal Adenocarcinoma. Pancreas 2021; 50:807-814. [PMID: 34149034 PMCID: PMC8577312 DOI: 10.1097/mpa.0000000000001835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Data from the International Cancer of the Pancreas Screening Consortium studies have demonstrated that screening for pancreatic ductal adenocarcinoma can be effective and that surveillance improves survival in high-risk individuals. Endoscopic ultrasound (EUS) and cross-sectional imaging are both used, although there is some suggestion that EUS is superior. Demonstration of the cost-effectiveness of screening is important to implement screening in high-risk groups. METHODS Results from centers with EUS-predominant screening were pooled to evaluate efficacy of index EUS in screening. A decision analysis model simulated the outcome of high-risk patients who undergo screening and evaluated the parameters that would make screening cost-effective at a US $100,000 per quality-adjusted life-year willingness to pay. RESULTS One-time index EUS has a sensitivity of 71.25% and specificity of 99.82% to detection to detect high-risk lesions. Screening with index EUS was cost-effective, particularly at lifetime pancreatic cancer probabilities of greater than 10.8%, or at lower probabilities if life expectancy after resection of a lesion that was at least 16 years, and if missed, lesion rates on index EUS are 5% or less. CONCLUSIONS Pancreatic cancer screening can be cost-effective through index EUS, particularly for those individuals at high-lifetime risk of cancer.
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Affiliation(s)
- Shria Kumar
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Monica Saumoy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Aaron Oh
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | - Yecheskel Schneider
- Division of Gastroenterology, St. Luke’s University Health Network, Allentown, PA
| | - Randall E. Brand
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Gregory G. Ginsberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Michael L. Kochman
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Marcia Irene Canto
- Division of Gastroenterology, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Gilbert Goggins
- Division of Gastroenterology, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chin Hur
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | - Bryson W. Katona
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Anil K. Rustgi
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
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Blackford AL, Canto MI, Klein AP, Hruban RH, Goggins M. Recent Trends in the Incidence and Survival of Stage 1A Pancreatic Cancer: A Surveillance, Epidemiology, and End Results Analysis. J Natl Cancer Inst 2021; 112:1162-1169. [PMID: 31958122 DOI: 10.1093/jnci/djaa004] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/20/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rapid access to pancreatic imaging and regular pancreatic surveillance may help identify stage I pancreatic cancer. We investigated recent trends in the stage of newly diagnosed pancreatic ductal adenocarcinoma (PDACs), age at diagnosis, and survival. METHODS Trends in age-adjusted incidence of stage IA PDAC between 2004 and 2016 were determined from the National Cancer Institute's Surveillance, Epidemiology and End Results database. All tests were two-sided. RESULTS The incidence of stage IA PDAC cases diagnosed increased statistically significantly from 2004 to 2016 (annual percent change = 14.5, 95% confidence interval [CI] = 11.4 to 17.7; P < .001). During the study period, average age at diagnosis for stage IA and IB casesAQ3 declined by 3.5 years (95% CI = 1.2 to 5.9; P = .004) and 5.5 years (95% CI = 3.4 to 7.6; P < .001), whereas average age increased for higher-stage cases (by 0.6 to 1.4 years). Among stage IA cases, the proportion of blacks was smaller (10.2% vs 12.5%), and the proportion of other non-Caucasians was higher compared with higher-stage cases (11.9% vs 8.4%; P < .001). Stage IA cases were more likely to carry insurance (vs Medicaid or none) than higher-stage cases (cases aged younger than 65 years; odds ratio = 2.45, 95% CI = 1.96 to 3.06; P < .001). The 5-year overall survival for stage IA PDAC improved from 44.7% (95% CI = 31.4 to 63.7) in 2004 to 83.7% (95% CI = 78.6% to 89.2%) in 2012; 10-year survival improved from 36.7% (95% CI = 24.1 to 55.8) in 2004 to 49.0% (95% CI = 37.2% to 64.6%) in 2007. CONCLUSIONS In recent years, the proportion of patients diagnosed with stage IA PDAC has increased, their average age at diagnosis has decreased, and their overall survival has improved. These trends may be the result of improved early diagnosis and early detection.
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Affiliation(s)
- Amanda L Blackford
- Affiliations of authors: Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Marcia Irene Canto
- Affiliations of authors: Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Alison P Klein
- Affiliations of authors: Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Departments of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ralph H Hruban
- Affiliations of authors: Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Departments of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael Goggins
- Affiliations of authors: Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Departments of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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20
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Douville C, Moinova HR, Thota PN, Shaheen NJ, Iyer PG, Canto MI, Wang JS, Dumot JA, Faulx A, Kinzler KW, Papadopoulos N, Vogelstein B, Markowitz SD, Bettegowda C, Willis JE, Chak A. Massively Parallel Sequencing of Esophageal Brushings Enables an Aneuploidy-Based Classification of Patients With Barrett's Esophagus. Gastroenterology 2021; 160:2043-2054.e2. [PMID: 33493502 PMCID: PMC8141353 DOI: 10.1053/j.gastro.2021.01.209] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Aneuploidy has been proposed as a tool to assess progression in patients with Barrett's esophagus (BE), but has heretofore required multiple biopsies. We assessed whether a single esophageal brushing that widely sampled the esophagus could be combined with massively parallel sequencing to characterize aneuploidy and identify patients with disease progression to dysplasia or cancer. METHODS Esophageal brushings were obtained from patients without BE, with non-dysplastic BE (NDBE), low-grade dysplasia (LGD), high-grade dysplasia (HGD), or adenocarcinoma (EAC). To assess aneuploidy, we used RealSeqS, a technique that uses a single primer pair to interrogate ∼350,000 genome-spanning regions and identify specific chromosome arm alterations. A classifier to distinguish NDBE from EAC was trained on results from 79 patients. An independent validation cohort of 268 subjects was used to test the classifier at distinguishing patients at successive phases of BE progression. RESULTS Aneuploidy progression was associated with gains of 1q, 12p, and 20q and losses on 9p and 17p. The entire chromosome 8q was often gained in NDBE, whereas focal gain of 8q24 was identified only when there was dysplasia. Among validation subjects, a classifier incorporating these features with a global measure of aneuploidy scored positive in 96% of EAC, 68% of HGD, but only 7% of NDBE. CONCLUSIONS RealSeqS analysis of esophageal brushings provides a practical and sensitive method to determine aneuploidy in BE patients. It identifies specific chromosome changes that occur early in NDBE and others that occur late and mark progression to dysplasia. The clinical implications of this approach can now be tested in prospective trials.
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Affiliation(s)
- Christopher Douville
- Department of Oncology, the Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Helen R Moinova
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Marcia Irene Canto
- Department of Oncology, the Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jean S Wang
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - John A Dumot
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Ashley Faulx
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Kenneth W Kinzler
- Department of Oncology, the Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nickolas Papadopoulos
- Department of Oncology, the Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bert Vogelstein
- Department of Oncology, the Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sanford D Markowitz
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio; Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Chetan Bettegowda
- Department of Oncology, the Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph E Willis
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio; Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Pathology, Case Western Reserve University, Cleveland, Ohio
| | - Amitabh Chak
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio; Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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21
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Dbouk M, Brewer Gutierrez OI, Lennon AM, Chuidian M, Shin EJ, Kamel IR, Fishman EK, He J, Burkhart RA, Wolfgang CL, Hruban RH, Goggins MG, Canto MI. Guidelines on management of pancreatic cysts detected in high-risk individuals: An evaluation of the 2017 Fukuoka guidelines and the 2020 International Cancer of the Pancreas Screening (CAPS) consortium statements. Pancreatology 2021; 21:613-621. [PMID: 33593706 DOI: 10.1016/j.pan.2021.01.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/10/2021] [Accepted: 01/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Objectives: Pancreatic cysts are frequently detected in high-risk individuals (HRI) undergoing surveillance for pancreatic cancer. The International Cancer of the Pancreas Screening (CAPS) Consortium developed consensus recommendations for surgical resection of pancreatic cysts in HRI that are similar to the Fukuoka guidelines used for the management of sporadic cysts. We compared the performance characteristics of CAPS criteria for pancreatic cyst management in HRI with the Fukuoka guidelines originally designed for the management of cysts in non-HRI. METHODS Using prospectively collected data from CAPS studies, we determined for each patient with resected screen-detected cyst(s) whether Fukuoka guidelines or CAPS consensus statements would have recommended surgery. We compared sensitivity, specificity, PPV, NPV, and Receiver Operator Characteristics (ROC) curves of these guidelines at predicting the presence of high-grade dysplasia or invasive cancer in pancreatic cysts. RESULTS 356/732 HRI had ≥ one pancreatic cyst detected; 24 had surgery for concerning cystic lesions. The sensitivity, specificity, PPV, and NPV for the Fukuoka criteria were 40%, 85%, 40%, and 85%, while those of the CAPS criteria were 60%, 85%, 50%, 89%, respectively. ROC curve analyses showed no significant difference between the Fukuoka and CAPS criteria. CONCLUSIONS In HRI, the CAPS and Fukuoka criteria are moderately specific, but not sufficiently sensitive for detecting advanced neoplasia in cystic lesions. New approaches are needed to guide the surgical management of cystic lesions in HRI.
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Affiliation(s)
- Mohamad Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Olaya I Brewer Gutierrez
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anne Marie Lennon
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Miguel Chuidian
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Eun Ji Shin
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ihab R Kamel
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Richard A Burkhart
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael G Goggins
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Marcia Irene Canto
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Kenner B, Chari ST, Kelsen D, Klimstra DS, Pandol SJ, Rosenthal M, Rustgi AK, Taylor JA, Yala A, Abul-Husn N, Andersen DK, Bernstein D, Brunak S, Canto MI, Eldar YC, Fishman EK, Fleshman J, Go VLW, Holt JM, Field B, Goldberg A, Hoos W, Iacobuzio-Donahue C, Li D, Lidgard G, Maitra A, Matrisian LM, Poblete S, Rothschild L, Sander C, Schwartz LH, Shalit U, Srivastava S, Wolpin B. Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review. Pancreas 2021; 50:251-279. [PMID: 33835956 PMCID: PMC8041569 DOI: 10.1097/mpa.0000000000001762] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Despite considerable research efforts, pancreatic cancer is associated with a dire prognosis and a 5-year survival rate of only 10%. Early symptoms of the disease are mostly nonspecific. The premise of improved survival through early detection is that more individuals will benefit from potentially curative treatment. Artificial intelligence (AI) methodology has emerged as a successful tool for risk stratification and identification in general health care. In response to the maturity of AI, Kenner Family Research Fund conducted the 2020 AI and Early Detection of Pancreatic Cancer Virtual Summit (www.pdac-virtualsummit.org) in conjunction with the American Pancreatic Association, with a focus on the potential of AI to advance early detection efforts in this disease. This comprehensive presummit article was prepared based on information provided by each of the interdisciplinary participants on one of the 5 following topics: Progress, Problems, and Prospects for Early Detection; AI and Machine Learning; AI and Pancreatic Cancer-Current Efforts; Collaborative Opportunities; and Moving Forward-Reflections from Government, Industry, and Advocacy. The outcome from the robust Summit conversations, to be presented in a future white paper, indicate that significant progress must be the result of strategic collaboration among investigators and institutions from multidisciplinary backgrounds, supported by committed funders.
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Affiliation(s)
| | - Suresh T. Chari
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - David S. Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephen J. Pandol
- Basic and Translational Pancreas Research Program, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Anil K. Rustgi
- Division of Digestive and Liver Diseases, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | | | - Adam Yala
- Department of Electrical Engineering and Computer Science
- Jameel Clinic, Massachusetts Institute of Technology, Cambridge, MA
| | - Noura Abul-Husn
- Division of Genomic Medicine, Department of Medicine, Icahn School of Medicine, Mount Sinai, New York, NY
| | - Dana K. Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Marcia Irene Canto
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yonina C. Eldar
- Department of Math and Computer Science, Weizmann Institute of Science, Rehovot, Israel
| | - Elliot K. Fishman
- Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, MD
| | | | - Vay Liang W. Go
- UCLA Center for Excellence in Pancreatic Diseases, University of California, Los Angeles, Los Angeles, CA
| | | | - Bruce Field
- From the Kenner Family Research Fund, New York, NY
| | - Ann Goldberg
- From the Kenner Family Research Fund, New York, NY
| | | | - Christine Iacobuzio-Donahue
- David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debiao Li
- Biomedical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Anirban Maitra
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Lawrence H. Schwartz
- Department of Radiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Uri Shalit
- Faculty of Industrial Engineering and Management, Technion—Israel Institute of Technology, Haifa, Israel
| | - Sudhir Srivastava
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Brian Wolpin
- Gastrointestinal Cancer Center, Dana-Farber Cancer Institute, Boston, MA
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Dbouk M, Brewer Guiterrez O, Trindade AJ, Diehl DL, Kwon RS, Thosani NC, Khara HS, Benias PC, Kerdsirichairat T, Canto MI. Initial multicenter experience with nitrous oxide cryoballoon for treatment of flat duodenal adenomas (with video). Gastrointest Endosc 2021; 93:240-246. [PMID: 32511958 DOI: 10.1016/j.gie.2020.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS EMR is the preferred endoscopic therapy for duodenal adenomas (DAs) but is associated with an overall adverse event rate of 26%. Cryotherapy using a Cryoballoon Focal Ablation System (CbFAS) can safely and effectively eradicate esophageal intestinal metaplasia. We report our first experience with cryoballoon ablation for treatment of flat DAs. METHODS This was an American, multicenter, retrospective study involving 5 centers. DAs (Paris 0-IIa and 0-IIb) were treated with nitrous oxide for 5 to 12 seconds using CbFAS. Follow-up EGD was performed at 3 to 12 months. RESULTS Seventeen DAs (mean size, 22.7 ± 14.3 mm; 12 tubular, 5 tubulovillous) from 13 patients (mean age, 66.5 ± 9.99 years; 61.5% males) were included in the study. Thirteen of 17 DAs (76.5%) had failed previous treatment, and 4 of 17 (23.5%) were treatment naÏve. All procedures were technically successful and achieved a >50% decrease in size after cryoballoon ablation There was no increase in size or progression of disease for any lesions. Overall, treatment was completed in 15 of 17 patients, and recurrence-free survival was achieved in 12 of 17 (71%) after a median follow-up of 15.5 months (interquartile range [IQR], 6.8-19.4). The median cryoablation time per polyp was 4 minutes (IQR, 1-7.5 minutes), and the median total procedure time was 25 minutes (IQR, 22-30.5 minutes). There were no intra- or postprocedural adverse events. CONCLUSIONS Nitrous oxide cryoballoon ablation of nonpolypoid DAs is feasible, with promising safety and efficacy.
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Affiliation(s)
- Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olaya Brewer Guiterrez
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nirav C Thosani
- Division of Gastroenterology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Harshit S Khara
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Petros C Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Tossapol Kerdsirichairat
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Canto MI, Trindade AJ, Abrams J, Rosenblum M, Dumot J, Chak A, Iyer P, Diehl D, Khara HS, Corbett FS, McKinley M, Shin EJ, Waxman I, Infantolino A, Tofani C, Samarasena J, Chang K, Wang B, Goldblum J, Voltaggio L, Montgomery E, Lightdale CJ, Shaheen NJ. Multifocal Cryoballoon Ablation for Eradication of Barrett's Esophagus-Related Neoplasia: A Prospective Multicenter Clinical Trial. Am J Gastroenterol 2020; 115:1879-1890. [PMID: 33156107 DOI: 10.14309/ajg.0000000000000822] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Ablation of Barrett's esophagus (BE) is the preferred approach for the treatment of neoplasia without visible lesions. Limited data on cryoballoon ablation (CBA) suggest its potential clinical utility. We evaluated the safety and efficacy of CBA in a multicenter study of patients with neoplastic BE. METHODS In a prospective clinical trial, 11 academic and community centers recruited consecutive patients with BE of 1-6 cm length and low-grade dysplasia, high-grade dysplasia (HGD), or intramucosal adenocarcinoma (ImCA) confirmed by central pathology. Patients with symptomatic pre-existing strictures or visible BE lesions had dilation or endoscopic mucosal resection (EMR), respectively, before enrollment. A nitrous oxide cryoballoon focal ablation system was used to treat all visible columnar mucosa in up to 5 sessions. Study end points included complete eradication of all dysplasia (CE-D) and intestinal metaplasia (CE-IM) at 1 year. RESULTS One hundred twenty patients with BE with ImCA (20%), HGD (56%), or low-grade dysplasia (23%) were enrolled. In the intention-to-treat analysis, the CE-D and CE-IM rates were 76% and 72%, respectively. In the per-protocol analysis (94 patients), the CE-D and CE-IM rates were 97% and 91%, respectively. Postablation pain was mild and short lived. Fifteen subjects (12.5%) developed strictures requiring dilation. One patient (0.8%) with HGD progressed to ImCA, which was successfully treated with EMR. Another patient (0.8%) developed gastrointestinal bleeding associated with clopidogrel use. One patient (0.8%) had buried BE with HGD in 1 biopsy, not confirmed by subsequent EMR. DISCUSSION In patients with neoplastic BE, CBA was safe and effective. Head-to-head comparisons between CBA and other ablation modalities are warranted (clinicaltrials.gov registration NCT02514525).
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Affiliation(s)
- Marcia Irene Canto
- Department of Medicine (Gastroenterology), Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Arvind J Trindade
- Division of Gastroenterology at the Zucker School of Medicine of Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Julian Abrams
- Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Michael Rosenblum
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, USA
| | - John Dumot
- Division of Gastroenterology at University Hospitals of Cleveland Medical Center, Cleveland, Ohio, USA
| | - Amitabh Chak
- Division of Gastroenterology at University Hospitals of Cleveland Medical Center, Cleveland, Ohio, USA
| | - Prasad Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Diehl
- Division of Gastroenterology, Geisinger Medical Center, Danby Pennsylvania, USA
| | - Harshit S Khara
- Division of Gastroenterology, Geisinger Medical Center, Danby Pennsylvania, USA
| | - F Scott Corbett
- Florida Digestive Health Specialists, Sarasota, Florida, USA
| | - Matthew McKinley
- Division of Gastroenterology at the Zucker School of Medicine of Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Eun Ji Shin
- Department of Medicine (Gastroenterology), Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Irving Waxman
- Division of Gastroenterology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Anthony Infantolino
- Division of Gastroenterology, Jefferson Medical Center, Philadelphia, Pennsylvania, USA
| | - Christina Tofani
- Division of Gastroenterology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jason Samarasena
- Division of Gastroenterology, University of California Irvine Medical Center, Irvine, California, USA
| | - Kenneth Chang
- Division of Gastroenterology, University of California Irvine Medical Center, Irvine, California, USA
| | - Bingkai Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, USA
| | - John Goldblum
- Department of Pathology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Lysandra Voltaggio
- Department ofPathology, Johns Hopkins Medical Institutions Baltimore Maryland, USA
| | - Elizabeth Montgomery
- Department ofPathology, Johns Hopkins Medical Institutions Baltimore Maryland, USA
| | - Charles J Lightdale
- Division of Gastroenterology at the Zucker School of Medicine of Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
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Gawron AJ, Bell R, Dayyeh BKA, Buckley FP, Chang K, Dunst CM, Edmundowicz SA, Jobe B, Lipham JC, Lister D, Canto MI, Smith MS, Starpoli AA, Triadafilopoulos G, Watson TJ, Wilson E, Pandolfino JE, Kaizer A, Van De Voorde Z, Yadlapati R. Surgical and endoscopic management options for patients with GERD based on proton pump inhibitor symptom response: recommendations from an expert U.S. panel. Gastrointest Endosc 2020; 92:78-87.e2. [PMID: 32007519 PMCID: PMC7321870 DOI: 10.1016/j.gie.2020.01.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The objective of this study was to examine expert opinion and agreement on the treatment of distinct GERD profiles from surgical and therapeutic endoscopy perspectives. METHODS We used the RAND/University of California, Los Angeles Appropriateness Method over 6 months (July 2018 to January 2019) to assess the appropriateness of antireflux interventions among foregut surgeons and therapeutic gastroenterologists. Patients with primary atypical or extraesophageal symptoms were not considered. Patient scenarios were grouped according to their symptom response to proton pump inhibitor (PPI) therapy. The primary outcome was appropriateness of an intervention. RESULTS Antireflux surgery with laparoscopic fundoplication (LF) and magnetic sphincter augmentation (MSA) were ranked as appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. Radiofrequency energy was not ranked as appropriate for complete or partial responders. There was lack of agreement between surgery and interventional gastroenterology groups on the appropriateness of LF and MSA for PPI nonresponders. Rankings for PPI nonresponders were similar when results from impedance-pH testing on PPI therapy were available, except that LF and MSA were not ranked as appropriate for PPI nonresponders if the impedance-pH study was negative. CONCLUSIONS This work highlights areas of agreement for invasive therapeutic approaches for GERD and provides impetus for further interdisciplinary collaboration and trials to compare and generate novel and effective treatment approaches and care pathways, including the role of impedance-pH testing in PPI nonresponders.
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Affiliation(s)
- Andrew J. Gawron
- University of Utah, Salt Lake City UT, Salt Lake City VA Medical
Center
| | - Reginald Bell
- Institute of Esophageal and Reflux Surgery, Denver CO
| | | | | | | | | | | | | | | | - Dan Lister
- Arkansas Heartburn Treatment Center, Heber Springs, AR
| | | | - Michael S. Smith
- Mount Sinai West & Mount Sinai St. Luke’s Hospitals,
New York, NY New York, NY
| | | | | | | | - Erik Wilson
- University of Texas McGovern Medical School, Houston, TX
| | | | | | | | - Rena Yadlapati
- University of Colorado, Aurora, CO; University of California San
Diego, San Diego, CA
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26
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Aslanian HR, Lee JH, Canto MI. AGA Clinical Practice Update on Pancreas Cancer Screening in High-Risk Individuals: Expert Review. Gastroenterology 2020; 159:358-362. [PMID: 32416142 DOI: 10.1053/j.gastro.2020.03.088] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 12/12/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association Institute Clinical Practice Update is to describe the indications for screening for pancreas cancer in high-risk individuals. METHODS The evidence reviewed in this work is based on reports of pancreas cancer screening studies in high-risk individuals and expert opinion. BEST PRACTICE ADVICE 1: Pancreas cancer screening should be considered in patients determined to be at high risk, including first-degree relatives of patients with pancreas cancer with at least 2 affected genetically related relatives. BEST PRACTICE ADVICE 2: Pancreas cancer screening should be considered in patients with genetic syndromes associated with an increased risk of pancreas cancer, including all patients with Peutz-Jeghers syndrome, hereditary pancreatitis, patients with CDKN2A gene mutation, and patients with 1 or more first-degree relatives with pancreas cancer with Lynch syndrome, and mutations in BRCA1, BRCA2, PALB2, and ATM genes. BEST PRACTICE ADVICE 3: Genetic testing and counseling should be considered for familial pancreas cancer relatives who are eligible for surveillance. A positive germline mutation is associated with an increased risk of neoplastic progression and may also lead to screening for other relevant associated cancers. BEST PRACTICE ADVICE 4: Participation in a registry or referral to a pancreas Center of Excellence should be pursued when possible for high-risk patients undergoing pancreas cancer screening. BEST PRACTICE ADVICE 5: Clinicians should not screen average-risk individuals for pancreas cancer. BEST PRACTICE ADVICE 6: Pancreas cancer screening in high-risk individuals should begin at age 50 years, or 10 years younger than the initial age of familial onset. Screening should be initiated at age 40 years in CKDN2A and PRSS1 mutation carriers with hereditary pancreatitis and at age 35 years in the setting of Peutz-Jeghers syndrome. BEST PRACTICE ADVICE 7: Magnetic resonance imaging and endoscopic ultrasonography (EUS) should be used in combination as the preferred screening modalities in individuals undergoing pancreas cancer screening. BEST PRACTICE ADVICE 8: The target detectable pancreatic neoplasms are resectable stage I pancreatic ductal adenocarcinoma and high-risk precursor neoplasms, such as intraductal papillary mucinous neoplasms with high-grade dysplasia and some enlarged pancreatic intraepithelial neoplasias. BEST PRACTICE ADVICE 9: Screening intervals of 12 months should be considered when there are no concerning pancreas lesions, with shortened intervals and/or the performance of EUS in 6-12 months directed towards lesions determined to be low risk (by a multidisciplinary team). EUS evaluation should be performed within 3-6 months for indeterminate lesions and within 3 months for high-risk lesions, if surgical resection is not planned. New-onset diabetes in a high-risk individual should lead to additional diagnostic studies or change in surveillance interval. BEST PRACTICE ADVICE 10: Decisions regarding therapy directed towards abnormal findings detected during screening should be made by a dedicated multidisciplinary team together with the high-risk individual and their family. BEST PRACTICE ADVICE 11: Surgical resection should be performed at high-volume centers. BEST PRACTICE ADVICE 12: Clinicians should consider discontinuing pancreas cancer screening in high-risk individuals when they are more likely to die of non-pancreas cancer-related causes due to comorbidity and/or are not candidates for pancreas resection. BEST PRACTICE ADVICE 13: The limitations and potential risks of pancreas cancer screening should be discussed with patients before initiating a screening program.
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Affiliation(s)
| | - Jeffrey H Lee
- University of Texas, MD Anderson Cancer Center, Houston, Texas
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27
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Canto MI, Kerdsirichairat T, Yeo CJ, Hruban RH, Shin EJ, Almario JA, Blackford A, Ford M, Klein AP, Javed AA, Lennon AM, Zaheer A, Kamel IR, Fishman EK, Burkhart R, He J, Makary M, Weiss MJ, Schulick RD, Goggins MG, Wolfgang CL. Surgical Outcomes After Pancreatic Resection of Screening-Detected Lesions in Individuals at High Risk for Developing Pancreatic Cancer. J Gastrointest Surg 2020; 24:1101-1110. [PMID: 31197699 PMCID: PMC6908777 DOI: 10.1007/s11605-019-04230-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/10/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Screening high-risk individuals (HRI) can detect potentially curable pancreatic ductal adenocarcinoma (PDAC) and its precursors. We describe the outcomes of high-risk individuals (HRI) after pancreatic resection of screen-detected neoplasms. METHODS Asymptomatic HRI enrolled in the prospective Cancer of the Pancreas Screening (CAPS) studies from 1998 to 2014 based on family history or germline mutations undergoing surveillance for at least 6 months were included. Pathologic diagnoses, hospital length of stay, incidence of diabetes mellitus, operative morbidity, need for repeat operation, and disease-specific mortality were determined. RESULTS Among 354 HRI, 48 (13.6%) had 57 operations (distal pancreatectomy (31), Whipple (20), and total pancreatectomy (6)) for suspected pancreatic neoplasms presenting as a solid mass (22), cystic lesion(s) (25), or duct stricture (1). The median length of stay was 7 days (IQR 5-11). Nine of the 42 HRI underwent completion pancreatectomy for a new lesion after a median of 3.8 years (IQR 2.5-7.6). Postoperative complications developed in 17 HRI (35%); there were no perioperative deaths. New-onset diabetes mellitus after partial resection developed in 20% of HRI. Fourteen PDACs were diagnosed, 11 were screen-detected, 10 were resectable, and 9 had an R0 resection. Metachronous PDAC developed in remnant pancreata of 2 HRI. PDAC-related mortality was 4/10 (40%), with 90% 1-year survival and 60% 5-year survival, respectively. CONCLUSIONS Screening HRI can detect PDAC with a high resectability rate. Surgical treatment is associated with a relatively short length of stay and low readmission rate, acceptable morbidity, zero 90-day mortality, and significant long-term survival. CLINICAL TRIAL REGISTRATION NUMBER NCT2000089.
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Affiliation(s)
- Marcia Irene Canto
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Tossapol Kerdsirichairat
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Charles J. Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eun Ji Shin
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jose Alejandro Almario
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amanda Blackford
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Madeline Ford
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Alison P. Klein
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ammar A. Javed
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne Marie Lennon
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Atif Zaheer
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ihab R. Kamel
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Elliot K. Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard Burkhart
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Martin Makary
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Matthew J. Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | - Michael G. Goggins
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland,Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Christopher L. Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Abe T, Koi C, Kohi S, Song KB, Tamura K, Macgregor-Das A, Kitaoka N, Chuidian M, Ford M, Dbouk M, Borges M, He J, Burkhart R, Wolfgang CL, Klein AP, Eshleman JR, Hruban RH, Canto MI, Goggins M. Gene Variants That Affect Levels of Circulating Tumor Markers Increase Identification of Patients With Pancreatic Cancer. Clin Gastroenterol Hepatol 2020; 18:1161-1169.e5. [PMID: 31676359 PMCID: PMC7166164 DOI: 10.1016/j.cgh.2019.10.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/24/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Levels of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and cancer antigen 125 (CA-125) in blood are used as markers to determine the response of patients with cancer to therapy, but are not used to identify patients with pancreatic cancer. METHODS We obtained blood samples from 504 patients undergoing pancreatic surveillance from 2002 through 2018 who did not develop pancreatic cancer and measured levels of the tumor markers CA19-9, CEA, CA-125, and thrombospondin-2. Single-nucleotide polymorphisms (SNPs) in FUT3, FUT2, ABO, and GAL3ST2 that have been associated with levels of tumor markers were used to establish SNP-defined ranges for each tumor marker. We also tested the association between additional SNPs (in FUT6, MUC16, B3GNT3, FAM3B, and THBS2) with levels of tumor markers. To calculate the diagnostic specificity of each SNP-defined range, we assigned the patients under surveillance into training and validation sets. After determining the SNP-defined ranges, we determined the sensitivity of SNP-adjusted tests for the tumor markers, measuring levels in blood samples from 245 patients who underwent resection for pancreatic ductal adenocarcinoma (PDAC) from 2010 through 2017. RESULTS A level of CA19-9 that identified patients with PDAC with 99% specificity had 52.7% sensitivity. When we set the cut-off levels of CA19-9 based on each SNP, the test for CA19-9 identified patients with PDAC with 60.8% sensitivity and 98.8% specificity. Among patients with FUT3 alleles that encode a functional protein, levels of CA19-9 greater than the SNP-determined cut-off values identified 66.4% of patients with PDAC, with 99.3% specificity. In the validation set, levels of CEA varied among patients with vs without SNP in FUT2, by blood group, and among smokers vs nonsmokers; levels of CA-125 varied among patients with vs without the SNP in GAL3ST2. The use of the SNPs to define the ranges of CEA and CA-125 did not significantly increase the diagnostic accuracy of the assays for these proteins. Combining data on levels of CA19-9 and CEA, CA19-9 and CA-125, or CA19-9 and thrombospondin-2 increased the sensitivity of detection of PDAC, but slightly reduced specificity. CONCLUSIONS Including information on SNPs associated with levels of CA19-9, CEA, and CA-125 can improve the diagnostic accuracy of assays for these tumor markers in the identification of patients with PDAC. Clinicaltrials.gov no: NCT02000089.
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Affiliation(s)
- Toshiya Abe
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Chiho Koi
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Shiro Kohi
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ki-Byung Song
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Koji Tamura
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne Macgregor-Das
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Naoki Kitaoka
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Miguel Chuidian
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Madeline Ford
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mohamad Dbouk
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Borges
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard Burkhart
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Alison P Klein
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - James R Eshleman
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Marcia Irene Canto
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Goggins
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland.
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29
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Purkayastha BPD, Chan ER, Ravillah D, Ravi L, Gupta R, Canto MI, Wang JS, Shaheen NJ, Willis JE, Chak A, Varadan V, Guda K. Genome-Scale Analysis Identifies Novel Transcript-Variants in Esophageal Adenocarcinoma. Cell Mol Gastroenterol Hepatol 2020; 10:652-654.e17. [PMID: 32344180 PMCID: PMC7474160 DOI: 10.1016/j.jcmgh.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 01/12/2023]
Key Words
- bm, barrett’s metaplasia
- bp, base pair
- col10a1, collagen x alpha 1 chain precursor gene
- eac, esophageal adenocarcinoma
- gast, normal gastric
- hgd, barrett’s with high grade dysplasia
- pcr, polymerase chain reaction
- qpcr, quantitative pcr
- race, rapid amplification of cdna ends
- shrna, short hairpin rna
- sq, normal esophageal squamous
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Affiliation(s)
- B P D Purkayastha
- Division of General Medical Sciences-Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - E R Chan
- Institute for Computational Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - D Ravillah
- Division of General Medical Sciences-Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - L Ravi
- Division of General Medical Sciences-Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - R Gupta
- Division of Gastroenterology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - M I Canto
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - J S Wang
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - N J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - J E Willis
- Department of Pathology, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - A Chak
- Division of Gastroenterology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - V Varadan
- Division of General Medical Sciences-Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - K Guda
- Division of General Medical Sciences-Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Pathology, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
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30
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Sanaei O, Fernández-Esparrach G, De La Serna-Higuera C, Carrara S, Kumbhari V, El Zein MH, Ismail A, Ginès A, Sendino O, Montenegro A, Repici A, Rahal D, Brewer Gutierrez OI, Moran R, Yang J, Parsa N, Paiji C, Aghaie Meybodi M, Shin EJ, Lennon AM, Kalloo AN, Singh VK, Canto MI, Khashab MA. EUS-guided 22-gauge fine needle biopsy versus single-incision with needle knife for the diagnosis of upper gastrointestinal subepithelial lesions: a randomized controlled trial. Endosc Int Open 2020; 8:E266-E273. [PMID: 32118100 PMCID: PMC7035036 DOI: 10.1055/a-1075-1900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/18/2019] [Indexed: 12/18/2022] Open
Abstract
Background and study aims EUS-FNA has suboptimal accuracy in diagnosing gastrointestinal subepithelial tumors (SETs). EUS-guided 22-gauge fine needle biopsy (EUS-FNB) and single-incision with needle knife (SINK) were proposed to increase accuracy of diagnosis. This study aimed to prospectively compare the diagnostic accuracy and safety of EUS-FNB with SINK in patients with upper gastrointestinal SETs. Patients and methods All adult patients referred for EUS evaluation of upper gastrointestinal SETs ≥ 15 mm in size were eligible for inclusion. Patients were randomized to undergo EUS-FNB or SINK. Lesions were sampled with a 22-gauge reverse beveled core needle in the EUS-FNB group and by a conventional needle-knife sphincterotome and biopsy forceps in the SINK group. Patients were blinded to the technique used. The primary outcome was diagnostic accuracy. Secondary outcomes included adverse events, histological yield and procedure duration. Study enrollment was terminated early due to poor recruitment. Results A total of 56 patients (31 male (55.37 %); mean age, 67.41 ± 12.70 years) were randomized to either EUS-FNB (n = 26) or SINK (n = 30). Technical success was 96.15 % and 96.66 %, respectively. The majority of lesions were gastrointestinal stromal tumors (51.78 %). No significant difference was found between EUS-FNB and SINK in terms of diagnostic accuracy for a malignant or benign disease (76 % vs. 89.28 %, respectively; P = 0.278). The rate of adverse events (none severe) was also comparable (7.69 % vs. 10 %, respectively; P = 1.0) including two abdominal pain episodes in the EUS-FNB group compared to two delayed bleeding (one requiring hospitalization and radiologic embolization) and 1 abdominal pain in the SINK group. Conclusion EUS-FNB and SINK are equally effective techniques for upper gastrointestinal SETs sampling. SINK can be associated with mild to moderate delayed bleeding.
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Affiliation(s)
- Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Gastroenterology Department, ICMDiM, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | | | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Rozzano, Italy
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Mohamad H. El Zein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Angels Ginès
- Endoscopy Unit, Gastroenterology Department, ICMDiM, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Oriol Sendino
- Endoscopy Unit, Gastroenterology Department, ICMDiM, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Andrea Montenegro
- Endoscopy Unit, Gastroenterology Department, ICMDiM, Hospital Clinic, University of Barcelona, Catalonia, Spain
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Rozzano, Italy
| | - Daoud Rahal
- Department of Pathology, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Olaya I. Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Nasim Parsa
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Christopher Paiji
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Mohamad Aghaie Meybodi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Anne Marie Lennon
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
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31
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Goggins M, Overbeek KA, Brand R, Syngal S, Del Chiaro M, Bartsch DK, Bassi C, Carrato A, Farrell J, Fishman EK, Fockens P, Gress TM, van Hooft JE, Hruban RH, Kastrinos F, Klein A, Lennon AM, Lucas A, Park W, Rustgi A, Simeone D, Stoffel E, Vasen HFA, Cahen DL, Canto MI, Bruno M. Management of patients with increased risk for familial pancreatic cancer: updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium. Gut 2020; 69:7-17. [PMID: 31672839 PMCID: PMC7295005 DOI: 10.1136/gutjnl-2019-319352] [Citation(s) in RCA: 287] [Impact Index Per Article: 71.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 09/05/2019] [Accepted: 09/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM The International Cancer of the Pancreas Screening Consortium met in 2018 to update its consensus recommendations for the management of individuals with increased risk of pancreatic cancer based on family history or germline mutation status (high-risk individuals). METHODS A modified Delphi approach was employed to reach consensus among a multidisciplinary group of experts who voted on consensus statements. Consensus was considered reached if ≥75% agreed or disagreed. RESULTS Consensus was reached on 55 statements. The main goals of surveillance (to identify high-grade dysplastic precursor lesions and T1N0M0 pancreatic cancer) remained unchanged. Experts agreed that for those with familial risk, surveillance should start no earlier than age 50 or 10 years earlier than the youngest relative with pancreatic cancer, but were split on whether to start at age 50 or 55. Germline ATM mutation carriers with one affected first-degree relative are now considered eligible for surveillance. Experts agreed that preferred surveillance tests are endoscopic ultrasound and MRI/magnetic retrograde cholangiopancreatography, but no consensus was reached on how to alternate these modalities. Annual surveillance is recommended in the absence of concerning lesions. Main areas of disagreement included if and how surveillance should be performed for hereditary pancreatitis, and the management of indeterminate lesions. CONCLUSIONS Pancreatic surveillance is recommended for selected high-risk individuals to detect early pancreatic cancer and its high-grade precursors, but should be performed in a research setting by multidisciplinary teams in centres with appropriate expertise. Until more evidence supporting these recommendations is available, the benefits, risks and costs of surveillance of pancreatic surveillance need additional evaluation.
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Affiliation(s)
- Michael Goggins
- Pathology, Medicine Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Randall Brand
- Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sapna Syngal
- GI Cancer Genetics and Prevention Program, Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Marco Del Chiaro
- Department of Surgery, Division of Surgical Oncology, Denver, Colorado, USA
| | - Detlef K Bartsch
- Division of Visceral, Thoracic and Vascular Surgery, University of Marburg, Marburg, Germany
| | - Claudio Bassi
- Department of Surgey, University of Verona, Verona, Italy
| | | | - James Farrell
- Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Elliot K Fishman
- The Russell H Morgan Department of Radiology and Radiological Science, Baltimore, Maryland, USA
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Thomas M Gress
- Gastroenterology, Endocrinology, Metabolism and Infectiology, University of Marburg, Marburg, Germany
| | - Jeanin E van Hooft
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - R H Hruban
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York City, New York, USA,Division of Digestive and Liver Diseases, Columbia University, New York City, New York, USA
| | - Allison Klein
- Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Aimee Lucas
- Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Walter Park
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York City, New York, USA
| | - Anil Rustgi
- Division of Digestive and Liver Diseases, Columbia University, New York City, New York, USA
| | - Diane Simeone
- New York University Medical Center, New York City, New York, USA
| | | | - Hans F A Vasen
- Gastroenterology and Hepatology, Leiden University, Leiden, The Netherlands
| | - Djuna L Cahen
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Marco Bruno
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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32
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Konings ICAW, Canto MI, Almario JA, Harinck F, Saxena P, Lucas AL, Kastrinos F, Whitcomb DC, Brand RE, Lachter J, Malleo G, Paiella S, Syngal S, Saltzman JR, Stoffel EM, van Hooft JE, Hruban RH, Poley JW, Fockens P, Goggins MG, Bruno MJ. Surveillance for pancreatic cancer in high-risk individuals. BJS Open 2019; 3:656-665. [PMID: 31592073 PMCID: PMC6773633 DOI: 10.1002/bjs5.50180] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/02/2019] [Indexed: 12/26/2022] Open
Abstract
Background Surveillance of individuals at high risk of pancreatic ductal adenocarcinoma (PDAC) and its precursors might lead to better outcomes. The aim of this study was to determine the prevalence and outcomes of PDAC and high-risk neoplastic precursor lesions among such patients participating in surveillance programmes. Methods A multicentre study was conducted through the International CAncer of the Pancreas Screening (CAPS) Consortium Registry to identify high-risk individuals who had undergone pancreatic resection or progressed to advanced PDAC while under surveillance. High-risk neoplastic precursor lesions were defined as: pancreatic intraepithelial neoplasia (PanIN) 3, intraductal papillary mucinous neoplasia (IPMN) with high-grade dysplasia, and pancreatic neuroendocrine tumours at least 2 cm in diameter. Results Of 76 high-risk individuals identified in 11 surveillance programmes, 71 had undergone surgery and five had been diagnosed with inoperable PDAC. Of the 71 patients who underwent resection, 32 (45 per cent) had PDAC or a high-risk precursor (19 PDAC, 4 main-duct IPMN, 4 branch-duct IPMN, 5 PanIN-3); the other 39 patients had lesions thought to be associated with a lower risk of neoplastic progression. Age at least 65 years, female sex, carriage of a gene mutation and location of a lesion in the head/uncinate region were associated with high-risk precursor lesions or PDAC. The survival of high-risk individuals with low-risk neoplastic lesions did not differ from that in those with high-risk precursor lesions. Survival was worse among patients with PDAC. There was no surgery-related mortality. Conclusion A high proportion of high-risk individuals who had surgical resection for screening- or surveillance-detected pancreatic lesions had a high-risk neoplastic precursor lesion or PDAC at the time of surgery. Survival was better in high-risk individuals who had either low- or high-risk neoplastic precursor lesions compared with that in patients who developed PDAC.
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Affiliation(s)
- I C A W Konings
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - M I Canto
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - J A Almario
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - F Harinck
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - P Saxena
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.,Department of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - A L Lucas
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - F Kastrinos
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
| | - D C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - R E Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - J Lachter
- Department of Gastroenterology, Rambam Healthcare Campus, Haifa, Israel
| | - G Malleo
- Department of General Surgery, University Hospital of Verona, Verona, Italy
| | - S Paiella
- Department of General Surgery, University Hospital of Verona, Verona, Italy
| | - S Syngal
- Department of Gastroenterology, Brigham and Women's Hospital and Population Sciences Division, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - J R Saltzman
- Department of Gastroenterology, Brigham and Women's Hospital and Population Sciences Division, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - E M Stoffel
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - J E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - R H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - J W Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Goggins
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Ngamruengphong S, Kamal A, Akshintala V, Hajiyeva G, Hanada Y, Chen YI, Sanaei O, Fluxa D, Haito Chavez Y, Kumbhari V, Singh VK, Lennon AM, Canto MI, Khashab MA. Prevalence of metastasis and survival of 788 patients with T1 rectal carcinoid tumors. Gastrointest Endosc 2019; 89:602-606. [PMID: 30447216 DOI: 10.1016/j.gie.2018.11.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 11/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Prevalence of rectal carcinoids is increasing, partly because of increased colorectal cancer screening. Local excision (endoscopic or transanal excision) is usually performed for small (<1-2 cm) rectal carcinoids, but data on clinical outcomes from large population-based U.S. studies are lacking. The aims of this study were to determine the prevalence of metastasis of resected small rectal carcinoid tumors using a large national cancer database and to evaluate the long-term survival of patients after local resection as compared with radical surgery. METHODS The Surveillance Epidemiology and End Results database was used to identify 788 patients with rectal T1 carcinoids <2 cm in size. Prevalence of metastases at initial diagnosis and risk factors for metastases were analyzed. Cancer-specific survival (CSS) was calculated. RESULTS A total of 727 patients (92.3%) had tumors ≤10 mm in diameter and 61 (7.7%) had tumors 11 to 19 mm. Overall, 12 patients (1.5%) had metastasis at the time of diagnosis with prevalence of 1.1% in lesions ≤10 mm and 6.6% in lesions 11 to 19 mm (P = .01). Survival of patients with T1 rectal carcinoids without metastasis was significantly better than those with metastasis (5-year CSS of 100% vs 78%, P < .001). Of 559 patients with T1N0M0 rectal carcinoids ≤10 mm, 5-year CSS was 100% in both groups who underwent local excision and those who underwent radical surgery. CONCLUSIONS Larger T1 rectal carcinoid tumors (11-19 mm) have significantly higher risk of lymph node metastases compared with those ≤10 mm. Survival is worse with metastatic disease. Local therapy is adequate for T1N0M0 rectal carcinoids ≤10 mm in size with excellent long-term outcomes.
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Affiliation(s)
| | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Venkata Akshintala
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Gulara Hajiyeva
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yuri Hanada
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniela Fluxa
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yamile Haito Chavez
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anne Marie Lennon
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcia Irene Canto
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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34
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Canto MI, Almario JA, Schulick RD, Yeo CJ, Klein A, Blackford A, Shin EJ, Sanyal A, Yenokyan G, Lennon AM, Kamel IR, Fishman EK, Wolfgang C, Weiss M, Hruban RH, Goggins M. Risk of Neoplastic Progression in Individuals at High Risk for Pancreatic Cancer Undergoing Long-term Surveillance. Gastroenterology 2018; 155:740-751.e2. [PMID: 29803839 PMCID: PMC6120797 DOI: 10.1053/j.gastro.2018.05.035] [Citation(s) in RCA: 251] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 04/09/2018] [Accepted: 05/18/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Screening of individuals who have a high risk of pancreatic ductal adenocarcinoma (PDAC), because of genetic factors, frequently leads to identification of pancreatic lesions. We investigated the incidence of PDAC and risk factors for neoplastic progression in individuals at high risk for PDAC enrolled in a long-term screening study. METHODS We analyzed data from 354 individuals at high risk for PDAC (based on genetic factors of family history), enrolled in Cancer of the Pancreas Screening cohort studies at tertiary care academic centers from 1998 through 2014 (median follow-up time, 5.6 years). All subjects were evaluated at study entry (baseline) by endoscopic ultrasonography and underwent surveillance with endoscopic ultrasonography, magnetic resonance imaging, and/or computed tomography. The primary endpoint was the cumulative incidence of PDAC, pancreatic intraepithelial neoplasia grade 3, or intraductal papillary mucinous neoplasm with high-grade dysplasia (HGD) after baseline. We performed multivariate Cox regression and Kaplan-Meier analyses. RESULTS During the follow-up period, pancreatic lesions with worrisome features (solid mass, multiple cysts, cyst size > 3 cm, thickened/enhancing walls, mural nodule, dilated main pancreatic duct > 5 mm, or abrupt change in duct caliber) or rapid cyst growth (>4 mm/year) were detected in 68 patients (19%). Overall, 24 of 354 patients (7%) had neoplastic progression (14 PDACs and 10 HGDs) over a 16-year period; the rate of progression was 1.6%/year, and 93% had detectable lesions with worrisome features before diagnosis of the PDAC or HGD. Nine of the 10 PDACs detected during routine surveillance were resectable; a significantly higher proportion of patients with resectable PDACs survived 3 years (85%) compared with the 4 subjects with symptomatic, unresectable PDACs (25%), which developed outside surveillance (log rank P < .0001). Neoplastic progression occurred at a median age of 67 years; the median time from baseline screening until PDAC diagnosis was 4.8 years (interquartile range, 1.6-6.9 years). CONCLUSIONS In a long-term (16-year) follow-up study of individuals at high-risk for PDAC, we found most PDACs detected during surveillance (9/10) to be resectable, and 85% of these patients survived for 3 years. We identified radiologic features associated with neoplastic progression.
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Affiliation(s)
- Marcia Irene Canto
- Department of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Jose Alejandro Almario
- Department of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions,Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | | | | | - Alison Klein
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Amanda Blackford
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Eun Ji Shin
- Department of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Abanti Sanyal
- The Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health
| | - Gayane Yenokyan
- The Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health
| | - Anne Marie Lennon
- Department of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Ihab R. Kamel
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Elliot K. Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Christopher Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Matthew Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
| | - Michael Goggins
- Department of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions,Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions
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35
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Canto MI, Shaheen NJ, Almario JA, Voltaggio L, Montgomery E, Lightdale CJ. Multifocal nitrous oxide cryoballoon ablation with or without EMR for treatment of neoplastic Barrett's esophagus (with video). Gastrointest Endosc 2018; 88:438-446.e2. [PMID: 29626424 DOI: 10.1016/j.gie.2018.03.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/25/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic cryotherapy can eradicate neoplastic Barrett's esophagus (BE). A new contact cryoballoon focal ablation system (CbFAS)) freezes esophageal mucosa with nitrous oxide. We studied the safety and efficacy of CbFAS for complete eradication of neoplastic Barrett's esophagus. METHODS In a prospective clinical trial, consecutive BE patients with confirmed neoplasia (low-grade dysplasia [LGD], high-grade dysplasia [HGD], and/or intramucosal adenocarcinoma [ImCA]), at least 1 cm of BE, with or without prior ablation, were treated with a dose 10 seconds of spray per site. EMR was performed for nodular lesions. Treatments were repeated every 10 to 12 weeks until complete eradication, with a maximum of 5 treatments. Primary outcomes were complete eradication of all dysplasia (CE-D) and complete eradication of intestinal metaplasia (CE-IM) at 1 year (intention-to-treat analysis). RESULTS Forty-one assessable patients (22 treatment naive, 19 previously ablated) with LGD (n = 13), HGD (n = 23), or ImCA (n = 5) were treated. The median procedure time was 30 minutes. The median number of ablation procedures for CE-IM was 3 (interquartile range, 2-4). Overall 1-year CE-D and CE-IM rates were 95% and 88%, respectively. CE-D rate was significantly lower (67%) in those with ultra-long BE compared with those with <8 cm (100%, P = .02). Median pain scores were zero at day 1. Four patients (9.7%) developed mild dysphagia from stenoses requiring dilation. One patient on aspirin developed upper GI bleeding that did not require therapy. CONCLUSIONS Multifocal nitrous oxide cryotherapy using CbFAS is a promising, highly effective, and safe endoscopic treatment for primary or rescue therapy of BE-associated neoplasia and IM. (Clinical trial registration number: NCT02534233.).
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Affiliation(s)
- Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology, University North Carolina, Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jose Alejandro Almario
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lysandra Voltaggio
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Elizabeth Montgomery
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Charles J Lightdale
- Digestive and Liver Disease, Columbia University Medical Center, New York, New York, USA
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36
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Abu Dayyeh B, Murad MH, Bazerbachi F, Buttar NS, Akshintala V, Canto MI, Chang KJ. Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: Misleading Ranking Probabilities in Network Meta-analysis. Gastroenterology 2018; 155:935-936. [PMID: 30092187 DOI: 10.1053/j.gastro.2018.02.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/12/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Barham Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Navtej S Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Venkat Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology & Hepatology, Department of Medicine, UC Irvine School of Medicine, Irvine, California
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37
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Affiliation(s)
- Marcia Irene Canto
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Elizabeth Montgomery
- Department of Pathology, Johns Hopkins Medical Institutions, Johns Hopkins Hospital, Baltimore, Maryland, USA
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38
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Chan MQ, Blum AE, Chandar AK, Emmons AMLK, Shindo Y, Brock W, Falk GW, Canto MI, Wang JS, Iyer PG, Shaheen NJ, Grady WM, Abrams JA, Thota PN, Guda KK, Chak A. Association of sporadic and familial Barrett's esophagus with breast cancer. Dis Esophagus 2018; 31:doy007. [PMID: 29528378 PMCID: PMC6005759 DOI: 10.1093/dote/doy007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC). Based on striking aggregation of breast cancer and BE/EAC within families as well as shared risk factors and molecular mechanisms of carcinogenesis, we hypothesized that BE may be associated with breast cancer. Pedigree analysis of families identified prospectively at multiple academic centers as part of the Familial Barrett's Esophagus Consortium (FBEC) was reviewed and families with aggregation of BE/EAC and breast cancer are reported. Additionally, using a matched case-control study design, we compared newly diagnosed BE cases in Caucasian females with breast cancer (cases) to Caucasian females without breast cancer (controls) who had undergone upper endoscopy (EGD). Two familial pedigrees, meeting a stringent inclusion criterion, manifested familial aggregation of BE/EAC and breast cancer in an autosomal dominant inheritance pattern with incomplete penetrance. From January 2008 to October 2016, 2812 breast cancer patient charts were identified, of which 213 were Caucasian females who underwent EGD. Six of 213 (2.82%) patients with breast cancer had pathology-confirmed BE, compared to 1 of 241 (0.41%) controls (P-value < 0.05). Selected families with BE/EAC show segregation of breast cancer. A breast cancer diagnosis is marginally associated with BE. We postulate a common susceptibility between BE/EAC and breast cancer.
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Affiliation(s)
- M Q Chan
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - A E Blum
- University Hospitals Cleveland Medical Center, Cleveland, Ohio,Louis Stokes VA Medical Center, Cleveland, Ohio
| | - A K Chandar
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Y Shindo
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - W Brock
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - G W Falk
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - M I Canto
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J S Wang
- Washington University School of Medicine, St. Louis, Missouri
| | - P G Iyer
- Mayo Clinic, Rochester, Minnesota
| | - N J Shaheen
- University of North Carolina, Chapel Hill, North Carolina
| | - W M Grady
- University of Washington Medical Center, Seattle, Washington
| | - J A Abrams
- Columbia University Medical Center, New York, New York
| | - P N Thota
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - K K Guda
- Case Comprehensive Cancer Center, Cleveland, Ohio
| | - A Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio,Case Comprehensive Cancer Center, Cleveland, Ohio,Address correspondence to: Amitabh Chak, Professor of Medicine, Director,
Clinical Research, Division of Gastroenterology, Wearn 242, University Hospitals Cleveland
Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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39
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Canto MI, Montgomery E. Wide-area transepithelial sampling with 3-dimensional cytology: Does it detect more dysplasia or yield more hype? Gastrointest Endosc 2018; 87:356-359. [PMID: 29406925 DOI: 10.1016/j.gie.2017.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 11/04/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Marcia Irene Canto
- Department of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland, USA
| | - Elizabeth Montgomery
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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40
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Canto MI, Abrams JA, Künzli HT, Weusten B, Komatsu Y, Jobe BA, Lightdale CJ. Nitrous oxide cryotherapy for treatment of esophageal squamous cell neoplasia: initial multicenter international experience with a novel portable cryoballoon ablation system (with video). Gastrointest Endosc 2018; 87:574-581. [PMID: 28720474 DOI: 10.1016/j.gie.2017.07.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 07/10/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Early esophageal squamous cell neoplasia (ESCN) can be successfully treated by EMR, endoscopic submucosal dissection (ESD), or radiofrequency ablation. A new portable, battery-powered cryotherapy system using nitrous oxide (cryoballoon focal ablation system [CbFAS]) has been used for Barrett's esophagus. It consists of a small hand-held device containing liquid nitrous oxide, which converts to gas within a low-pressure-compliant through-the-scope balloon and freezes targeted mucosa in contact with the balloon. This study evaluated the feasibility of endoscopic eradication of early ESCN with the CbFAS. METHODS Patients with early ESCN (defined as low-grade intraepithelial neoplasia [LGIN], high-grade intraepithelial neoplasia [HGIN], or early T1 squamous mucosal cancer) were treated with the CbFAS. After chromoendoscopy, all Lugol's unstained lesions (USLs) were targeted with 8, 10, or 12 seconds of ice per site, and treatment was repeated until biopsy samples demonstrated eradication of ESCN. Postprocedure adverse events were recorded. RESULTS Ten patients (4 men; median age, 69.5 years) with LGIN (n=2), HGIN (n=7), or esophageal squamous cell carcinoma (ESCC; n=1, after EMR) in 24 USLs were treated. The median maximum diameter of the largest USL was 1.5 cm (interquartile range, 1-2 cm), and median total length of all neoplastic USLs was 2 cm (range, 1-10 cm). Patients with focal disease received a median of 2 cryoablations, whereas 4 patients with large and/or multifocal circumferential neoplasia had 6 to 12 ablations per procedure. The median procedure time was 34 minutes (range, 18-57 minutes). Treatment was completed in all patients. No major adverse events occurred. Four patients developed mild self-limited chest pain requiring narcotic analgesics immediately after the procedure. Two patients who received circumferential ablation developed a stricture responding to dilation, with no recurrence. Complete endoscopic and pathologic response was achieved in all patients at 3 months. One year follow-up biopsy specimens in 7 patients showed no USL or ESCN. All patients were disease free at last visit, with a median follow-up time of 10.7 months (interquartile range, 4-14 months). CONCLUSIONS We report the first application of nitrous cryoballoon ablation for curative treatment of early primary or recurrent ESCN. Our initial experience suggests that efficacy is high and the safety profile is reasonable. Prospective trials are needed to optimize cryogen dosimetry and assess safety and efficacy.
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Affiliation(s)
- Marcia Irene Canto
- Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Julian A Abrams
- Digestive and Liver Disease, Columbia University Medical Center, New York, New York, USA
| | - Hannah T Künzli
- Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, the Netherlands
| | - Bas Weusten
- Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, the Netherlands
| | - Yoshihiro Komatsu
- Department of Surgery, Alleghany Health Network, Pittsburgh, Pennsylvania, USA
| | - Blair A Jobe
- Department of Surgery, Alleghany Health Network, Pittsburgh, Pennsylvania, USA
| | - Charles J Lightdale
- Digestive and Liver Disease, Columbia University Medical Center, New York, New York, USA
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Suenaga M, Yu J, Shindo K, Tamura K, Almario JA, Zaykoski C, Witmer PD, Fesharakizadeh S, Borges M, Lennon AM, Shin EJ, Canto MI, Goggins M. Pancreatic Juice Mutation Concentrations Can Help Predict the Grade of Dysplasia in Patients Undergoing Pancreatic Surveillance. Clin Cancer Res 2018; 24:2963-2974. [PMID: 29301828 DOI: 10.1158/1078-0432.ccr-17-2463] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/15/2017] [Accepted: 12/29/2017] [Indexed: 12/21/2022]
Abstract
Purpose: The measurement of mutations in pancreatic juice samples collected from the duodenum during endoscopic ultrasound (EUS) may improve the diagnostic evaluation of patients undergoing pancreatic surveillance. Our aim was to evaluate the accuracy of using pancreatic juice mutation concentrations to predict the presence and histologic grade of neoplasia in the pancreas.Experimental Design: Digital next-generation sequencing (NGS) of pancreatic juice DNA using a targeted 12-gene panel was performed on 67 patients undergoing pancreatic evaluation during EUS, including patients with pancreatic ductal adenocarcinoma, patients who subsequently underwent pancreatic resection for precursor lesions, patients undergoing surveillance for their familial/inherited susceptibility to pancreatic cancer, and normal pancreas disease controls.Results: Patients with pancreatic cancer or high-grade dysplasia as their highest grade lesion had significantly higher pancreatic juice mutation concentrations than all other subjects (mean/SD digital NGS score; 46.6 ± 69.7 vs. 6.2 ± 11.6, P = 0.02). Pancreatic juice mutation concentrations distinguished patients with pancreatic cancer or high-grade dysplasia in their resection specimen from all other subjects with 72.2% sensitivity and 89.4% specificity [area under the curve (AUC) = 0.872]. Mutant TP53/SMAD4 concentrations could distinguish patients with pancreatic cancer or high-grade dysplasia in their resection specimen from all other subjects with 61.1% sensitivity and 95.7% specificity (AUC = 0.819). Among 31 high-risk individuals under surveillance, 2 of the 3 individuals with most abnormal pancreatic juice mutation profiles also had the most abnormalities on pancreatic imaging.Conclusions: Pancreatic juice mutation analysis using digital NGS has potential diagnostic utility in the evaluation of patients undergoing pancreatic surveillance. Clin Cancer Res; 24(12); 2963-74. ©2018 AACRSee related commentary by Lipner and Yeh, p. 2713.
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Affiliation(s)
- Masaya Suenaga
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jun Yu
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Koji Shindo
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Koji Tamura
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jose Alejandro Almario
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Christopher Zaykoski
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - P Dane Witmer
- Center for Inherited Disease Research (CIDR), Baltimore, Maryland
| | - Shahriar Fesharakizadeh
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Borges
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne-Marie Lennon
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eun-Ji Shin
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Marcia Irene Canto
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael Goggins
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland. .,Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
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42
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Suenaga M, Sadakari Y, Almario JA, Borges M, Lennon AM, Shin EJ, Canto MI, Goggins M. Using an endoscopic distal cap to collect pancreatic fluid from the ampulla (with video). Gastrointest Endosc 2017; 86:1152-1156.e2. [PMID: 28259593 PMCID: PMC5581309 DOI: 10.1016/j.gie.2017.02.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Duodenal collections of pancreatic fluid can be used as a source of mutations and other markers of pancreatic ductal neoplasia, but admixing pancreatic juice with duodenal contents lowers the concentrations of mutations. Collecting pancreatic fluid directly from the ampulla could yield a purer sample of pancreatic fluid. METHODS We used an endoscopic distal cap attachment to "cap" the ampulla and collect secretin-stimulated pancreatic fluid samples for 5 minutes from 81 patients undergoing pancreatic evaluation as part of the Cancer of the Pancreas Screening studies. We compared mutation concentrations (K-ras and GNAS) measured by droplet-digital PCR (ddPCR) in "cap-collected juice" samples to those found in juice samples obtained from 77 patients collected by aspiration from the duodenal lumen without capping the ampulla. RESULTS Among all subjects, mutation concentrations were higher in pancreatic juice samples collected using the endoscopic cap method (median, .028%; IQR, 0-.077) compared with the noncap-collected (median, .019%; IQR, 0-.044; P = .055). Among pancreatic juice samples with detectable mutations, mutation concentrations were higher in the cap-collected juice samples than in those collected without the cap (.055%; IQR, .026-.092 vs .032%; IQR, .020-.066; P = .031). CONCLUSIONS Collecting pancreatic juice directly from the ampulla using an endoscopic distal cap yields higher concentrations of pancreatic fluid mutations.
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Affiliation(s)
- Masaya Suenaga
- Department of Pathology, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
| | - Yoshihiko Sadakari
- Department of Pathology, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
| | - Jose Alejandro Almario
- Department of Pathology, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
| | - Michael Borges
- Department of Pathology, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
| | - Anne-Marie Lennon
- Department of Medicine, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
- Department of Surgery, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
| | - Eun-Ji Shin
- Department of Medicine, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
| | - Marcia Irene Canto
- Department of Medicine, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
- Department of Oncology, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
| | - Michael Goggins
- Department of Pathology, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
- Department of Medicine, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
- Department of Oncology, The Sol Goldman Pancreatic, Cancer Research Center, Johns Hopkins Medical Institutions
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Epstein JA, Cosby H, Falk GW, Khashab MA, Kiesslich R, Montgomery EA, Wang JS, Canto MI. Columnar islands in Barrett's esophagus: Do they impact Prague C&M criteria and dysplasia grade? J Gastroenterol Hepatol 2017; 32:1598-1603. [PMID: 28116788 DOI: 10.1111/jgh.13744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 01/16/2017] [Accepted: 01/18/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM The standard for classifying Barrett's metaplasia on endoscopy, the Prague C&M criteria, ignores all islands of metaplastic-appearing tissue. The aims of the present study were to measure the prevalence of columnar islands, quantify their impact on metaplasia extent, and determine if they harbor advanced dysplasia. METHODS Data from two prospective patient cohorts were retrospectively analyzed. They included adults who underwent upper endoscopy to evaluate for gastroesophageal reflux disease, Barrett's esophagus (BE), dysplasia, or adenocarcinoma between 2003 and 2012 at tertiary care centers in the USA and Germany. The BE pattern, location, and pathology were examined. The extent of BE as defined by the Prague criteria (disregarding the location of islands) was compared with the complete maximal extent of BE (incorporating the location of islands). RESULTS A total of 555 patients underwent endoscopy (mean age 60.1 years, 67.2% male, 91.9% white). Among those patients, 191 (34.4%) showed metaplastic-appearing mucosa in islands. Endoscopically, in 101 (52.9%) cases, islands were proximal to the farthest segment of BE as defined by the Prague M location. Histologically, intestinal metaplasia was confirmed in 60 (58.8%) of the 102 esophagogastroduodenoscopies (EGDs) where islands were biopsied. In 41 (40.2%) cases, the histologically confirmed BE islands extended farther than the maximal segment based on the Prague criteria. Pathology from biopsies of islands either changed the diagnosis or worsened the BE dysplasia grade in 16 (15.7%) of the 102 patients. CONCLUSIONS Columnar islands are commonly seen on EGD. The Prague C&M criteria may underestimate the maximal extent of BE and overlook the area of highest dysplasia grade.
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Affiliation(s)
- Jeremy A Epstein
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Hilary Cosby
- Department of Medicine, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Gary W Falk
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | | | - Jean S Wang
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marcia Irene Canto
- Department of Medicine, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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44
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Yu J, Sadakari Y, Shindo K, Suenaga M, Brant A, Almario JAN, Borges M, Barkley T, Fesharakizadeh S, Ford M, Hruban RH, Shin EJ, Lennon AM, Canto MI, Goggins M. Digital next-generation sequencing identifies low-abundance mutations in pancreatic juice samples collected from the duodenum of patients with pancreatic cancer and intraductal papillary mucinous neoplasms. Gut 2017; 66:1677-1687. [PMID: 27432539 PMCID: PMC5243915 DOI: 10.1136/gutjnl-2015-311166] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/27/2016] [Accepted: 05/19/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Secretin-stimulated pancreatic juice contains DNA shed from cells lining the pancreatic ducts. Genetic analysis of this fluid may form a test to detect pancreatic ductal neoplasia. DESIGN We employed digital next-generation sequencing ('digital NGS') to detect low-abundance mutations in secretin-stimulated juice samples collected from the duodenum of subjects enrolled in Cancer of the Pancreas Screening studies at Johns Hopkins Hospital. For each juice sample, digital NGS necessitated 96 NGS reactions sequencing nine genes. The study population included 115 subjects (53 discovery, 62 validation) (1) with pancreatic ductal adenocarcinoma (PDAC), (2) intraductal papillary mucinous neoplasm (IPMN), (3) controls with non-suspicious pancreata. RESULTS Cases with PDAC and IPMN were more likely to have mutant DNA detected in pancreatic juice than controls (both p<0.0001); mutant DNA concentrations were higher in patients with PDAC than IPMN (p=0.003) or controls (p<0.001). TP53 and/or SMAD4 mutations were commonly detected in juice samples from patients with PDAC and were not detected in controls (p<0.0001); mutant TP53/SMAD4 concentrations could distinguish PDAC from IPMN cases with 32.4% sensitivity, 100% specificity (area under the curve, AUC 0.73, p=0.0002) and controls (AUC 0.82, p<0.0001). Two of four patients who developed pancreatic cancer despite close surveillance had SMAD4/TP53 mutations from their cancer detected in juice samples collected over 1 year prior to their pancreatic cancer diagnosis when no suspicious pancreatic lesions were detected by imaging. CONCLUSIONS The detection in pancreatic juice of mutations important for the progression of low-grade dysplasia to high-grade dysplasia and invasive pancreatic cancer may improve the management of patients undergoing pancreatic screening and surveillance.
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Affiliation(s)
- Jun Yu
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yoshihiko Sadakari
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Koji Shindo
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Masaya Suenaga
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron Brant
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose Alejandro Navarro Almario
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Borges
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas Barkley
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shahriar Fesharakizadeh
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Madeline Ford
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anne Marie Lennon
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcia Irene Canto
- Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Goggins
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Medicine, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
Pancreatic cancer (PC) is a highly fatal disease that can only be cured by complete surgical resection. However, most patients with PC have unresectable disease at the time of diagnosis, highlighting the need to detect PC and its precursor lesions earlier in asymptomatic patients. Screening is not cost-effective for population-based screening of PC. Individuals with genetic risk factors for PC based on family history or known PC-associated genetic syndromes, however, can be a potential target for PC screening programs. This article provides an overview of the epidemiology and genetic background of familial PC and discusses diagnostic and management approaches.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Blalock 407, Baltimore, MD 21287, USA
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Blalock 407, Baltimore, MD 21287, USA.
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46
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Masica DL, Dal Molin M, Wolfgang CL, Tomita T, Ostovaneh MR, Blackford A, Moran RA, Law JK, Barkley T, Goggins M, Irene Canto M, Pittman M, Eshleman JR, Ali SZ, Fishman EK, Kamel IR, Raman SP, Zaheer A, Ahuja N, Makary MA, Weiss MJ, Hirose K, Cameron JL, Rezaee N, He J, Joon Ahn Y, Wu W, Wang Y, Springer S, Diaz LL, Papadopoulos N, Hruban RH, Kinzler KW, Vogelstein B, Karchin R, Lennon AM. A novel approach for selecting combination clinical markers of pathology applied to a large retrospective cohort of surgically resected pancreatic cysts. J Am Med Inform Assoc 2017; 24:145-152. [PMID: 27330075 PMCID: PMC5201184 DOI: 10.1093/jamia/ocw069] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/02/2016] [Accepted: 04/07/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Our objective was to develop an approach for selecting combinatorial markers of pathology from diverse clinical data types. We demonstrate this approach on the problem of pancreatic cyst classification. MATERIALS AND METHODS We analyzed 1026 patients with surgically resected pancreatic cysts, comprising 584 intraductal papillary mucinous neoplasms, 332 serous cystadenomas, 78 mucinous cystic neoplasms, and 42 solid-pseudopapillary neoplasms. To derive optimal markers for cyst classification from the preoperative clinical and radiological data, we developed a statistical approach for combining any number of categorical, dichotomous, or continuous-valued clinical parameters into individual predictors of pathology. The approach is unbiased and statistically rigorous. Millions of feature combinations were tested using 10-fold cross-validation, and the most informative features were validated in an independent cohort of 130 patients with surgically resected pancreatic cysts. RESULTS We identified combinatorial clinical markers that classified serous cystadenomas with 95% sensitivity and 83% specificity; solid-pseudopapillary neoplasms with 89% sensitivity and 86% specificity; mucinous cystic neoplasms with 91% sensitivity and 83% specificity; and intraductal papillary mucinous neoplasms with 94% sensitivity and 90% specificity. No individual features were as accurate as the combination markers. We further validated these combinatorial markers on an independent cohort of 130 pancreatic cysts, and achieved high and well-balanced accuracies. Overall sensitivity and specificity for identifying patients requiring surgical resection was 84% and 81%, respectively. CONCLUSIONS Our approach identified combinatorial markers for pancreatic cyst classification that had improved performance relative to the individual features they comprise. In principle, this approach can be applied to any clinical dataset comprising dichotomous, categorical, and continuous-valued parameters.
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Affiliation(s)
- David L Masica
- *Drs Masica and Dal Molin contributed equally as first authors
- Department of Biomedical Engineering and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, Maryland
- Departments of the Sol Goldman Pancreatic Cancer Research Center
| | - Marco Dal Molin
- *Drs Masica and Dal Molin contributed equally as first authors
- Departments of Pathology
- Departments of the Sol Goldman Pancreatic Cancer Research Center
| | - Christopher L Wolfgang
- Departments of Surgery
- Departments of Oncology
- Departments of the Sol Goldman Pancreatic Cancer Research Center
| | - Tyler Tomita
- Department of Biomedical Engineering and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | | | - Michael Goggins
- Departments of Medicine
- Departments of Oncology
- Departments of the Sol Goldman Pancreatic Cancer Research Center
| | | | - Meredith Pittman
- Departments of Pathology
- Departments of the Sol Goldman Pancreatic Cancer Research Center
| | - James R Eshleman
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yuxuan Wang
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Simeon Springer
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Luis L Diaz
- Departments of Surgery
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Nickolas Papadopoulos
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ralph H Hruban
- Departments of Pathology
- Departments of Oncology
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kenneth W Kinzler
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Bert Vogelstein
- Departments of the Sol Goldman Pancreatic Cancer Research Center
- Departments of the Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Rachel Karchin
- †Drs Lennon and Karchin contributed equally as senior authors
- Department of Biomedical Engineering and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, Maryland
- Departments of Oncology
- Departments of the Sol Goldman Pancreatic Cancer Research Center
| | - Anne Marie Lennon
- †Drs Lennon and Karchin contributed equally as senior authors
- Departments of Surgery
- Departments of Medicine
- Departments of the Sol Goldman Pancreatic Cancer Research Center
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Overbeek KA, Cahen DL, Canto MI, Bruno MJ. Surveillance for neoplasia in the pancreas. Best Pract Res Clin Gastroenterol 2016; 30:971-986. [PMID: 27938791 PMCID: PMC5552042 DOI: 10.1016/j.bpg.2016.10.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/25/2016] [Accepted: 10/31/2016] [Indexed: 01/31/2023]
Abstract
Despite its low incidence in the general population, pancreatic cancer is one of the leading causes of cancer-related mortality. Survival greatly depends on operability, but most patients present with unresectable disease. Therefore, there is great interest in the early detection of pancreatic cancer and its precursor lesions by surveillance. Worldwide, several programs have been initiated for individuals at high risk for pancreatic cancer. Their first results suggest that surveillance in high-risk individuals is feasible, but their effectiveness in decreasing mortality remains to be proven. This review will discuss which individuals are eligible for surveillance, which lesions are aimed to be detected, and which surveillance modalities are being used in current clinical practice. Furthermore, it addresses the management of abnormalities found during surveillance and topics for future research.
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Affiliation(s)
- Kasper A. Overbeek
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands,Corresponding author. Fax: +31 10 703 03 31
| | - Djuna L. Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St., Blalock 407, Baltimore, MD, 21287, USA
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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48
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El Zein M, Kumbhari V, Ngamruengphong S, Carson KA, Stein E, Tieu A, Chaveze Y, Ismail A, Dhalla S, Clarke J, Kalloo A, Canto MI, Khashab MA. Learning curve for peroral endoscopic myotomy. Endosc Int Open 2016; 4:E577-82. [PMID: 27227118 PMCID: PMC4874807 DOI: 10.1055/s-0042-104113] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 02/12/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Although peroral endoscopic myotomy (POEM) is being performed more frequently, the learning curve for gastroenterologists performing the procedure has not been well studied. The aims of this study were to define the learning curve for POEM and determine which preoperative and intraoperative factors predict the time that will be taken to complete the procedure and its different steps. PATIENTS AND METHODS Consecutive patients who underwent POEM performed by a single expert gastroenterologist for the treatment of achalasia or spastic esophageal disorders were included. The POEM procedure was divided into four steps: mucosal entry, submucosal tunneling, myotomy, and closure. Nonlinear regression was used to determine the POEM learning plateau and calculate the learning rate. RESULTS A total of 60 consecutive patients underwent POEM in an endoscopy suite. The median length of procedure (LOP) was 88 minutes (range 36 - 210), and the mean (± standard deviation [SD]) LOP per centimeter of myotomy was 9 ± 5 minutes. The total operative time decreased significantly as experience increased (P < 0.001), with a "learning plateau" at 102 minutes and a "learning rate" of 13 cases. The mucosal entry, tunneling, and closure times decreased significantly with experience (P < 0.001). The myotomy time showed no significant decrease with experience (P = 0.35). When the mean (± SD) total procedure times for the learning phase and the corresponding comparator groups were compared, a statistically significant difference was observed between procedures 11 - 15 and procedures 16 - 20 (15.5 ± 2.4 min/cm and 10.1 ± 2.7 min/cm, P = 0.01) but not thereafter. A higher case number was significantly associated with a decreased LOP (P < 0.001). CONCLUSION In this single-center retrospective study, the minimum threshold number of cases required for an expert interventional endoscopist performing POEM to reach a plateau approached 13.
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Affiliation(s)
- Mohamad El Zein
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathryn A. Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ellen Stein
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alan Tieu
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yamile Chaveze
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amr Ismail
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Dhalla
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - John Clarke
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anthony Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcia Irene Canto
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen A. Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA,Corresponding author Mouen Khashab, MD Division of Gastroenterology and Hepatology Johns Hopkins Hospital1800 Orleans Street, Suite 7125BBaltimore, MD 21287USA+1-443-683-8335
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Schölvinck DW, Künzli HT, Kestens C, Siersema PD, Vleggaar FP, Canto MI, Cosby H, Abrams JA, Lightdale CJ, Tejeda-Ramirez E, DeMeester SR, Greene CL, Jobe BA, Peters J, Bergman JJGHM, Weusten BLAM. Treatment of Barrett's esophagus with a novel focal cryoablation device: a safety and feasibility study. Endoscopy 2015; 47:1106-12. [PMID: 26158241 DOI: 10.1055/s-0034-1392417] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Currently, eradication of Barrett's epithelium is preferably achieved using radiofrequency ablation (RFA) or spray cryoablation (SCA). However, both modalities suffer from drawbacks such as the need for sizing, multiple deployment steps, large controller units (RFA), imprecise dosing and need for gas-venting (SCA). The new Cryoballoon Focal Ablation System (CbFAS) may address these limitations. This study assessed the safety, feasibility, and dose response of the CbFAS in patients with flat Barrett's epithelium with or without dysplasia. PATIENTS AND METHODS In this multicenter, prospective non-randomized trial, 39 patients were each treated with one or two ablations of 6, 8, or 10 seconds. Symptoms were assessed immediately and 2 days post-cryoablation. Follow-up endoscopy was performed 6-8 weeks post-procedure to assess response. Outcome parameters were incidence of adverse events, pain, esophageal stricture formation, and ablation response by cryogen dose. RESULTS Of 62 ablations, 56 (10 with 6 seconds, 28 with 8 seconds, 18 with 10 seconds) were successfully performed. Six ablations failed because of device malfunction (n=3) and procedural or anatomic issues (n=3). Median procedure time was 7 minutes (interquartile range [IQR] 4-10). No major adverse events occurred; six patients experienced a minor mucosal laceration requiring no intervention. Mild pain was reported by 27% of patients immediately after cryoablation and by 14% after 2 days. No strictures were evident at follow-up. Full squamous regeneration was seen in 47 treated areas (6 [60%] of the 6-second areas; 23 [82%] of the 8-second areas; 18 [100%] of 10-second areas). CONCLUSIONS Focal cryoablation of Barrett's epithelium with the CbFAS is feasible and safe, resulting in squamous regeneration in the majority of patients.
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Affiliation(s)
| | | | | | | | | | | | - Hilary Cosby
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | | | | | | | | | - Blair A Jobe
- Canonsburg General Hospital, Canonsburg, Pennsylvania, USA
| | - Jeff Peters
- University of Rochester, Rochester, New York, USA
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50
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Springer S, Wang Y, Molin MD, Masica DL, Jiao Y, Kinde I, Blackford A, Raman SP, Wolfgang CL, Tomita T, Niknafs N, Douville C, Ptak J, Dobbyn L, Allen PJ, Klimstra DS, Schattner MA, Schmidt CM, Yip-Schneider M, Cummings OW, Brand RE, Zeh HJ, Singhi AD, Scarpa A, Salvia R, Malleo G, Zamboni G, Falconi M, Jang JY, Kim SW, Kwon W, Hong SM, Song KB, Kim SC, Swan N, Murphy J, Geoghegan J, Brugge W, Fernandez-Del Castillo C, Mino-Kenudson M, Schulick R, Edil BH, Adsay V, Paulino J, van Hooft J, Yachida S, Nara S, Hiraoka N, Yamao K, Hijioka S, van der Merwe S, Goggins M, Canto MI, Ahuja N, Hirose K, Makary M, Weiss MJ, Cameron J, Pittman M, Eshleman JR, Diaz LA, Papadopoulos N, Kinzler KW, Karchin R, Hruban RH, Vogelstein B, Lennon AM. A combination of molecular markers and clinical features improve the classification of pancreatic cysts. Gastroenterology 2015; 149:1501-10. [PMID: 26253305 PMCID: PMC4782782 DOI: 10.1053/j.gastro.2015.07.041] [Citation(s) in RCA: 291] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 06/28/2015] [Accepted: 07/22/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The management of pancreatic cysts poses challenges to both patients and their physicians. We investigated whether a combination of molecular markers and clinical information could improve the classification of pancreatic cysts and management of patients. METHODS We performed a multi-center, retrospective study of 130 patients with resected pancreatic cystic neoplasms (12 serous cystadenomas, 10 solid pseudopapillary neoplasms, 12 mucinous cystic neoplasms, and 96 intraductal papillary mucinous neoplasms). Cyst fluid was analyzed to identify subtle mutations in genes known to be mutated in pancreatic cysts (BRAF, CDKN2A, CTNNB1, GNAS, KRAS, NRAS, PIK3CA, RNF43, SMAD4, TP53, and VHL); to identify loss of heterozygozity at CDKN2A, RNF43, SMAD4, TP53, and VHL tumor suppressor loci; and to identify aneuploidy. The analyses were performed using specialized technologies for implementing and interpreting massively parallel sequencing data acquisition. An algorithm was used to select markers that could classify cyst type and grade. The accuracy of the molecular markers was compared with that of clinical markers and a combination of molecular and clinical markers. RESULTS We identified molecular markers and clinical features that classified cyst type with 90%-100% sensitivity and 92%-98% specificity. The molecular marker panel correctly identified 67 of the 74 patients who did not require surgery and could, therefore, reduce the number of unnecessary operations by 91%. CONCLUSIONS We identified a panel of molecular markers and clinical features that show promise for the accurate classification of cystic neoplasms of the pancreas and identification of cysts that require surgery.
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Affiliation(s)
- Simeon Springer
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Yuxuan Wang
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Marco Dal Molin
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Pathology, The Johns Hopkins University, Baltimore, MD, USA
| | - David L. Masica
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD, USA,The Johns Hopkins Medical Institutions and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Yuchen Jiao
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Isaac Kinde
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Amanda Blackford
- Department of Biostatistics and Bioinformatics, The Johns Hopkins University, Baltimore, MD, USA
| | - Siva P. Raman
- Department of Radiology, The Johns Hopkins University, Baltimore, MD, USA
| | - Christopher L. Wolfgang
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA,Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
| | - Tyler Tomita
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD, USA,The Johns Hopkins Medical Institutions and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Noushin Niknafs
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD, USA,The Johns Hopkins Medical Institutions and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Christopher Douville
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD, USA,The Johns Hopkins Medical Institutions and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Janine Ptak
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Lisa Dobbyn
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Peter J. Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer Center
| | | | - Mark A. Schattner
- Department of Gastroenterology, Memorial Sloan-Kettering Cancer Center
| | | | | | | | | | | | | | - Aldo Scarpa
- ARC-Net Research Centre ad Department of Pathology and Diagnostics, University and Hospital Trust of Verona, Italy,Department of Pathology, General Surgery B, University and Hospital Trust of Verona, Italy
| | - Roberto Salvia
- Department of Surgery, University and Hospital Trust of Verona, Negrar, Italy
| | - Giuseppe Malleo
- Department of Surgery, University and Hospital Trust of Verona, Negrar, Italy
| | - Giuseppe Zamboni
- Department of Pathology, General Surgery B, University and Hospital Trust of Verona, Italy,Department of Pathology, Ospedale Sacro Cuore-Don Calabraia, Negrar, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Department of Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Byung Song
- Department of Hepatobiliary and Pancreas Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Department of Hepatobiliary and Pancreas Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Niall Swan
- Department of Histopathology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Jean Murphy
- Department of Histopathology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Justin Geoghegan
- Department of Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - William Brugge
- Department of Gastroenterology, Massachusetts General Hospital
| | | | | | | | | | | | - Jorge Paulino
- Department of Pathology, Centro Hepatobiliopancreático e Transplantação – Hospital Curry Cabral, Lisbon, Portugal
| | - Jeanin van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Netherlands
| | - Shinichi Yachida
- Department of Hepatobiliary and Pancreatic Surgery, Pathology and Cancer Genomics, National Cancer Center Hospital and National Cancer Center Research Institute, Tokyo, Japan
| | - Satoshi Nara
- Department of Hepatobiliary and Pancreatic Surgery, Pathology and Cancer Genomics, National Cancer Center Hospital and National Cancer Center Research Institute, Tokyo, Japan
| | - Nobuyoshi Hiraoka
- Department of Hepatobiliary and Pancreatic Surgery, Pathology and Cancer Genomics, National Cancer Center Hospital and National Cancer Center Research Institute, Tokyo, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susuma Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | | | - Michael Goggins
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA,Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Marcia Irene Canto
- Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Martin Makary
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Matthew J. Weiss
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - John Cameron
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Meredith Pittman
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Pathology, The Johns Hopkins University, Baltimore, MD, USA
| | - James R. Eshleman
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Luis A. Diaz
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
| | - Nickolas Papadopoulos
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Kenneth W. Kinzler
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Rachel Karchin
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD, USA,Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA,The Johns Hopkins Medical Institutions and the Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Ralph H. Hruban
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA,Department of Pathology, The Johns Hopkins University, Baltimore, MD, USA,Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
| | - Bert Vogelstein
- The Ludwig Center and Howard Hughes Medical Institute at the Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, MD, USA,The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Anne Marie Lennon
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University, Baltimore, Maryland; Department of Surgery, The Johns Hopkins University, Baltimore, Maryland; Department of Medicine, The Johns Hopkins University, Baltimore, Maryland.
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