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Measuring Mesothelin Protein Level in Endoscopic Ultrasound-Guided Fine Needle Aspiration Specimens-A Novel Method in Pancreatic Adenocarcinoma Detection
Abstracts
community-based freestanding endoscopy centers in 34 states, was searched for gastric specimens submitted clinically as polyp or nodule during a 12-month period (10/2006 to 9/2007). Diagnoses for each case were tabulated and relevant demographic, clinical, and histopathologic data were collected. Results: of 91,079 patients (mean age 56 years, range 0-107; 55,646 women, or 61.1%), 5,972 had at least one qualifying specimen. In 1,109 (18.6%) of these patients no histologic lesion met the criteria for polyp. Of 4,863 patients with at least one polyp (mean age 66.2 years, range 15-94), 3,293 were women (67.7%); sex data were unavailable for 2 patients. The total number of polyps was 5,081. There were 3,571 FGPs (71.2%); 863 (16.9%) hyperplastic polyps; and 466 (9.1%) instances of prominent foveolar hyperplasia/polypoid gastritis. There were 70 xanthomas (1.4%) and 49 adenomas (0.96%). Carcinoids, carcinomas, prominent lymphoid follicles, lymphomas, GISTs, lipomas, and pancreatic heterotopias were represented each less than 0.5%. Patients with polyps were older compared to the base population (56 vs. 66.2, p ! 0.001) and women were overrepresented (67.7% vs. 61.1%; p ! 0.001). Women with adenomas, carcinomas, and carcinoids were 5-8 years older then men, but numbers were too small for significance. Conclusions: in older studies 75% of gastric polyps were hyperplastic; polypoid gastritis was the second most frequent, while FGPs and adenomas were reportedly ‘‘common.’’ In our recent large study, FGPs (linked to PPI use and found almost exclusively in H. pylorinegative subjects) represented more than two thirds of all gastric polyps; in contrast, less than 17% were hyperplastic (related to atrophic gastritis); adenomas, precursors of gastric cancer and related to H. pylori infection, were found in less than 1% of our subjects. These shifts likely reflect the changing nosological and therapeutic patterns of gastric conditions in the United States.
666 Gene Analysis of Advanced Pancreatic Carcinoma Using EUSGuided FNA with Focused DNA Array: Possible Predictor of the Chemotherapeutic Efficacy Reiko Ashida, Bunzo Nakata, Minoru Shigekawa, Nobumasa Mizuno, Akira Sawaki, Kosei Hirakawa, Tetsuo Arakawa, Kenji Yamao Background: Endoscopic ultrasound (EUS) has evolved from EUS imaging to EUSguided fine-needle aspiration (FNA). EUS-guided FNA is now beyond cytology diagnosis and makes it possible to screen hundreds of genes simultaneously using cDNA microarray technique. The prediction of the effectiveness of anti-cancer agent is very important in the treatment of pancreatic carcinoma. The purpose of this study was to determine of the usefulness of Focused DNA Array (FDA) analysis using the pancreatic carcinoma tissue obtained by EUS-guided FNA for the prediction of chemotherapeutic effect. Methods: Pancreas tissues of 95 patients were obtained by EUS-guided FNA. mRNA was harvested from each sample and cDNA was composed by reverse transcription polymerase chain reaction (RT-PCR). Expression of mRNA was evaluated using FDA which was restricted to 133 genes including drug-resistance related genes. The expression of mRNA was measured as the relative value to house keeping gene, GAPDH. Results: 81 (85.3%) of 95 mRNA samples obtained by EUSguided FNA had adequate quantities and qualities for analysis. The mean amount of 81 mRNA samples was 0.80 0.18mg. Gemcitabine (GEM) monotherapy composed 1000 mg/m2 weekly administration for three weeks following one week rest was given for 49 patients. Thirty-five patients who had completed 2 courses or more were divided into the following two groups. Patients with partial response (PR) and those with stable disease (SD) whose tumor marker reduced by 50 % or more were classified as responders. The rest of the patients were classified as non-responders. The mRNA expression of deoxycytidine kinase (DCK), ENT1 and ENT2 which may act as GEM-sensitive factors, and dCMP deaminase (DCD), NT5, and RRM1 which may act as GEM-resistant factors were used for the following score analysis. The score for each gene was defined as relative values to the average expression of individual gene in 81 samples. The score for GEM-sensitivity was calculated as DCKþENT1þENT2-DCD-NT5-RRM1 gene scores. The score for GEM-sensitivity of 0.3 or more was seen in 8 (66.7%) of 12 responders. On the other hand, the gene score less than 0.3 was seen in 17 (73.9%) of 23 non-responder. (P Z 0.002). When the cut-off value of the score for GEM-sensitivity was optimally defined as 0.3, the sensitivity, specificity and accuracy were 67%, 74% and, 71%, respectively. Conclusion: The gene analysis using FDA might be useful to predict the chemothrapeutic efficacy for patients with advanced pancreatic cancer.
667 DNA Microsatellite Loss in Endoscopic Ultrasound-Guided Fine Needle Aspirate from Pancreatic Endocrine Tumors Is Associated with Increased Mortality Kenneth E. Fasanella, Kevin Mcgrath, Michael K. Sanders, Debra Brody, Robyn T. Domsic, Asif Khalid Background: Pancreatic endocrine tumor (PET) outcome depends on tumor size, presence of invasion or metastasis, Ki-67 index, mitoses per high power field and mutational damage. Most of this information is available only post-operatively. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is highly accurate in the diagnosis of PET, but does not provide prognostic information. We have evaluated the role of PET EUS-FNA microsatellite loss analysis in this context and reported that a fractional allelic loss (FAL) O 0.2 is associated with disease progression. We hypothesize that an FALO 0.2 will also be associated with
AB96 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
increased mortality. Methods: All patients diagnosed with PET at our institution with subsequent death or at least 1 year of follow up were included. We excluded patients with an unrelated malignancy or who died within one week of the procedure. Imaging and EUS characteristics, surgical pathology, microsatellite loss analysis results, and current clinical status were reviewed. Statistical analysis was performed using SAS 9.1. Comparison of continuous variables was performed with the Wilcoxon rank-sums. Logistic regression (LR) analysis was used to assess the association of high FAL to mortality. Kaplan-Meier (KM) survival curves were calculated with the previously-reported FAL value of O 0.2 and the upper tertile of FAL values, corresponding to R 0.33. Results: 41 patients were identified of which 33 met inclusion criteria. The mean age was 58, and 33% were female. Mean follow up was 30 months (median 28, 2-63). Microsatellite loss analysis was performed on 23 patients. Twelve patients had disease progression, and 9 died (8 diseasespecific). Median tumor size was 3.5 cm (2.5-8.5) in patients with disease progression, and 1.9 cm (0.8-4.5) in patients without progression (p Z 0.007). KM survival analysis revealed significant difference in survival between patients with FAL % 2.0 compared to O 2.0 (p Z 0.0003). Since this FAL value had perfect association with mortality, LR could not be performed. LR performed using the upper tertile of FAL (R 0.33) revealed patients were 20 times more likely to die (OR 20.0, 95% CI 1.15-395.0) after adjustment for age, and KM curves diverged significantly (p Z 0.01). Conclusions: PET EUS-FNA Microsatellite loss analysis provides prognostic information. An FAL O 2.0 is not only associated with disease progression but also mortality. We recommend this technique as an adjunct to routine PET EUS-FNA.
668 Measuring Mesothelin Protein Level in Endoscopic UltrasoundGuided Fine Needle Aspiration Specimens-A Novel Method in Pancreatic Adenocarcinoma Detection Dong Wang, Zhendong Jin, Zhaoshen Li, Feng Li Background and Aims: Endoscopic ultrasound guided fine needle aspiration (EUSFNA) has been a highly valuable technique for acquisition of cytologic specimens from the pancreatic adenocarcinoma. However EUS-FNA can miss 10-20% of pancreatic adenocarcinoma due to insufficient sample size in the setting of necrosis or sampling error. Furthermore chronic pancreatitis (CP) can have similar echosonographic appearances with those of pancreatic adenocarcinoma and therefore imposes a clinical challenge for endosonographers. Recent global gene expression profiling studies of pancreatic adenocarcinoma have employed SAGE, cDNA microarray, and oligonucleotide microarray technology to quantify gene expression in cancer cell lines as well as in human tissues. Several overexpressed genes including mesothelin have been identified by these techniques. In our study we attempted to investigate whether determination of mesothelin protein level in EUS-FNA pancreatic samples can be useful in detecting pancreatic adenocarcinoma and differentiating pancreatic adenocarcinoma from CP. Methods: Mesothelin protein levels in EUS-FNA of 18 patients with pancreatic adenocarcinoma and 7 chronic pancreatitis was quantitated by ELISA. Serum mesothelin protein levels of 55 patients (including the above 18 patients) with pancreatic adenocarcinoma and 20 (including the above 7) patients with chronic pancreatitis was measured by ELISA as well. Results: The level of mesothelin protein in EUS-FNA specimens of pancreatic adenocarcinoma (10.48 11.13 ng/ml) was significantly higher than that of chronic pancreatitis (1.00 0.72, p Z 0.016), but there was no significant difference in serum between the two groups (1.21 0.51 and 1.49 0.199, p Z 0.07). In pancreatic adenocarcinoma group we also found mesothelin protein in serum (1.21 0.51) was much lower than that in EUS-FNA sample (10.48 11.13, p ! 0.01). Conclusions: This novel method of measuring mesothelin protein level can be useful in detection of pancreatic adenocarcinoma and differentiation of malignant pancreatic tissue from chronic pancreatitis.
669 Standardized Weighted Criteria for EUS Features of Chronic Pancreatitis: The Rosemont Classification Lyndon V. Hernandez, Anand Sahai, William R. Brugge, Maurits J. Wiersema, Marc F. Catalano EUS is increasingly used in the diagnosis of chronic pancreatitis (CP). A number of publications from different countries have used different EUS terminology, features, and criteria for CP making it difficult to reproduce their findings and apply in clinical practice. Previous studies have also given equal weight to ductal and parenchymal features of CP without regard for its individual predictive value. Moreover, many experts believe that traditional criteria such as Cambridge Classification for CP are outdated and have lost its relevance. Thus, a need exists for a universally recognized nomenclature for EUS features of CP. AIM: To establish consensus-based criteria for EUS features of CP that will be useful for clinical practice and research. Methods: After a systematic review of the literature, a panel of 5 EUS experts presented a series of statements and questions to 45 internationally recognized endosonographers from North America and Japan to anonymously vote on terminology of EUS features, rank order, and category (Major versus Minor Criteria) of these features. Consensus was defined as O 2/3 agreement among participants. Authors of the most critical EUS articles on CP published from 1993 to 2007 attended this consensus meeting, which was held in Rosemont, Illinois in April 2007. Results: All 45 experts agreed that a grading system
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community-based freestanding endoscopy centers in 34 states, was searched for gastric specimens submitted clinically as polyp or nodule during a 12-month period (10/2006 to 9/2007). Diagnoses for each case were tabulated and relevant demographic, clinical, and histopathologic data were collected. Results: of 91,079 patients (mean age 56 years, range 0-107; 55,646 women, or 61.1%), 5,972 had at least one qualifying specimen. In 1,109 (18.6%) of these patients no histologic lesion met the criteria for polyp. Of 4,863 patients with at least one polyp (mean age 66.2 years, range 15-94), 3,293 were women (67.7%); sex data were unavailable for 2 patients. The total number of polyps was 5,081. There were 3,571 FGPs (71.2%); 863 (16.9%) hyperplastic polyps; and 466 (9.1%) instances of prominent foveolar hyperplasia/polypoid gastritis. There were 70 xanthomas (1.4%) and 49 adenomas (0.96%). Carcinoids, carcinomas, prominent lymphoid follicles, lymphomas, GISTs, lipomas, and pancreatic heterotopias were represented each less than 0.5%. Patients with polyps were older compared to the base population (56 vs. 66.2, p ! 0.001) and women were overrepresented (67.7% vs. 61.1%; p ! 0.001). Women with adenomas, carcinomas, and carcinoids were 5-8 years older then men, but numbers were too small for significance. Conclusions: in older studies 75% of gastric polyps were hyperplastic; polypoid gastritis was the second most frequent, while FGPs and adenomas were reportedly ‘‘common.’’ In our recent large study, FGPs (linked to PPI use and found almost exclusively in H. pylorinegative subjects) represented more than two thirds of all gastric polyps; in contrast, less than 17% were hyperplastic (related to atrophic gastritis); adenomas, precursors of gastric cancer and related to H. pylori infection, were found in less than 1% of our subjects. These shifts likely reflect the changing nosological and therapeutic patterns of gastric conditions in the United States.
666 Gene Analysis of Advanced Pancreatic Carcinoma Using EUSGuided FNA with Focused DNA Array: Possible Predictor of the Chemotherapeutic Efficacy Reiko Ashida, Bunzo Nakata, Minoru Shigekawa, Nobumasa Mizuno, Akira Sawaki, Kosei Hirakawa, Tetsuo Arakawa, Kenji Yamao Background: Endoscopic ultrasound (EUS) has evolved from EUS imaging to EUSguided fine-needle aspiration (FNA). EUS-guided FNA is now beyond cytology diagnosis and makes it possible to screen hundreds of genes simultaneously using cDNA microarray technique. The prediction of the effectiveness of anti-cancer agent is very important in the treatment of pancreatic carcinoma. The purpose of this study was to determine of the usefulness of Focused DNA Array (FDA) analysis using the pancreatic carcinoma tissue obtained by EUS-guided FNA for the prediction of chemotherapeutic effect. Methods: Pancreas tissues of 95 patients were obtained by EUS-guided FNA. mRNA was harvested from each sample and cDNA was composed by reverse transcription polymerase chain reaction (RT-PCR). Expression of mRNA was evaluated using FDA which was restricted to 133 genes including drug-resistance related genes. The expression of mRNA was measured as the relative value to house keeping gene, GAPDH. Results: 81 (85.3%) of 95 mRNA samples obtained by EUSguided FNA had adequate quantities and qualities for analysis. The mean amount of 81 mRNA samples was 0.80 0.18mg. Gemcitabine (GEM) monotherapy composed 1000 mg/m2 weekly administration for three weeks following one week rest was given for 49 patients. Thirty-five patients who had completed 2 courses or more were divided into the following two groups. Patients with partial response (PR) and those with stable disease (SD) whose tumor marker reduced by 50 % or more were classified as responders. The rest of the patients were classified as non-responders. The mRNA expression of deoxycytidine kinase (DCK), ENT1 and ENT2 which may act as GEM-sensitive factors, and dCMP deaminase (DCD), NT5, and RRM1 which may act as GEM-resistant factors were used for the following score analysis. The score for each gene was defined as relative values to the average expression of individual gene in 81 samples. The score for GEM-sensitivity was calculated as DCKþENT1þENT2-DCD-NT5-RRM1 gene scores. The score for GEM-sensitivity of 0.3 or more was seen in 8 (66.7%) of 12 responders. On the other hand, the gene score less than 0.3 was seen in 17 (73.9%) of 23 non-responder. (P Z 0.002). When the cut-off value of the score for GEM-sensitivity was optimally defined as 0.3, the sensitivity, specificity and accuracy were 67%, 74% and, 71%, respectively. Conclusion: The gene analysis using FDA might be useful to predict the chemothrapeutic efficacy for patients with advanced pancreatic cancer.
667 DNA Microsatellite Loss in Endoscopic Ultrasound-Guided Fine Needle Aspirate from Pancreatic Endocrine Tumors Is Associated with Increased Mortality Kenneth E. Fasanella, Kevin Mcgrath, Michael K. Sanders, Debra Brody, Robyn T. Domsic, Asif Khalid Background: Pancreatic endocrine tumor (PET) outcome depends on tumor size, presence of invasion or metastasis, Ki-67 index, mitoses per high power field and mutational damage. Most of this information is available only post-operatively. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is highly accurate in the diagnosis of PET, but does not provide prognostic information. We have evaluated the role of PET EUS-FNA microsatellite loss analysis in this context and reported that a fractional allelic loss (FAL) O 0.2 is associated with disease progression. We hypothesize that an FALO 0.2 will also be associated with
AB96 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
increased mortality. Methods: All patients diagnosed with PET at our institution with subsequent death or at least 1 year of follow up were included. We excluded patients with an unrelated malignancy or who died within one week of the procedure. Imaging and EUS characteristics, surgical pathology, microsatellite loss analysis results, and current clinical status were reviewed. Statistical analysis was performed using SAS 9.1. Comparison of continuous variables was performed with the Wilcoxon rank-sums. Logistic regression (LR) analysis was used to assess the association of high FAL to mortality. Kaplan-Meier (KM) survival curves were calculated with the previously-reported FAL value of O 0.2 and the upper tertile of FAL values, corresponding to R 0.33. Results: 41 patients were identified of which 33 met inclusion criteria. The mean age was 58, and 33% were female. Mean follow up was 30 months (median 28, 2-63). Microsatellite loss analysis was performed on 23 patients. Twelve patients had disease progression, and 9 died (8 diseasespecific). Median tumor size was 3.5 cm (2.5-8.5) in patients with disease progression, and 1.9 cm (0.8-4.5) in patients without progression (p Z 0.007). KM survival analysis revealed significant difference in survival between patients with FAL % 2.0 compared to O 2.0 (p Z 0.0003). Since this FAL value had perfect association with mortality, LR could not be performed. LR performed using the upper tertile of FAL (R 0.33) revealed patients were 20 times more likely to die (OR 20.0, 95% CI 1.15-395.0) after adjustment for age, and KM curves diverged significantly (p Z 0.01). Conclusions: PET EUS-FNA Microsatellite loss analysis provides prognostic information. An FAL O 2.0 is not only associated with disease progression but also mortality. We recommend this technique as an adjunct to routine PET EUS-FNA.
668 Measuring Mesothelin Protein Level in Endoscopic UltrasoundGuided Fine Needle Aspiration Specimens-A Novel Method in Pancreatic Adenocarcinoma Detection Dong Wang, Zhendong Jin, Zhaoshen Li, Feng Li Background and Aims: Endoscopic ultrasound guided fine needle aspiration (EUSFNA) has been a highly valuable technique for acquisition of cytologic specimens from the pancreatic adenocarcinoma. However EUS-FNA can miss 10-20% of pancreatic adenocarcinoma due to insufficient sample size in the setting of necrosis or sampling error. Furthermore chronic pancreatitis (CP) can have similar echosonographic appearances with those of pancreatic adenocarcinoma and therefore imposes a clinical challenge for endosonographers. Recent global gene expression profiling studies of pancreatic adenocarcinoma have employed SAGE, cDNA microarray, and oligonucleotide microarray technology to quantify gene expression in cancer cell lines as well as in human tissues. Several overexpressed genes including mesothelin have been identified by these techniques. In our study we attempted to investigate whether determination of mesothelin protein level in EUS-FNA pancreatic samples can be useful in detecting pancreatic adenocarcinoma and differentiating pancreatic adenocarcinoma from CP. Methods: Mesothelin protein levels in EUS-FNA of 18 patients with pancreatic adenocarcinoma and 7 chronic pancreatitis was quantitated by ELISA. Serum mesothelin protein levels of 55 patients (including the above 18 patients) with pancreatic adenocarcinoma and 20 (including the above 7) patients with chronic pancreatitis was measured by ELISA as well. Results: The level of mesothelin protein in EUS-FNA specimens of pancreatic adenocarcinoma (10.48 11.13 ng/ml) was significantly higher than that of chronic pancreatitis (1.00 0.72, p Z 0.016), but there was no significant difference in serum between the two groups (1.21 0.51 and 1.49 0.199, p Z 0.07). In pancreatic adenocarcinoma group we also found mesothelin protein in serum (1.21 0.51) was much lower than that in EUS-FNA sample (10.48 11.13, p ! 0.01). Conclusions: This novel method of measuring mesothelin protein level can be useful in detection of pancreatic adenocarcinoma and differentiation of malignant pancreatic tissue from chronic pancreatitis.
669 Standardized Weighted Criteria for EUS Features of Chronic Pancreatitis: The Rosemont Classification Lyndon V. Hernandez, Anand Sahai, William R. Brugge, Maurits J. Wiersema, Marc F. Catalano EUS is increasingly used in the diagnosis of chronic pancreatitis (CP). A number of publications from different countries have used different EUS terminology, features, and criteria for CP making it difficult to reproduce their findings and apply in clinical practice. Previous studies have also given equal weight to ductal and parenchymal features of CP without regard for its individual predictive value. Moreover, many experts believe that traditional criteria such as Cambridge Classification for CP are outdated and have lost its relevance. Thus, a need exists for a universally recognized nomenclature for EUS features of CP. AIM: To establish consensus-based criteria for EUS features of CP that will be useful for clinical practice and research. Methods: After a systematic review of the literature, a panel of 5 EUS experts presented a series of statements and questions to 45 internationally recognized endosonographers from North America and Japan to anonymously vote on terminology of EUS features, rank order, and category (Major versus Minor Criteria) of these features. Consensus was defined as O 2/3 agreement among participants. Authors of the most critical EUS articles on CP published from 1993 to 2007 attended this consensus meeting, which was held in Rosemont, Illinois in April 2007. Results: All 45 experts agreed that a grading system
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