Clinical Trials Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 28, 2019; 25(36): 5530-5542
Published online Sep 28, 2019. doi: 10.3748/wjg.v25.i36.5530
Genomic profile concordance between pancreatic cyst fluid and neoplastic tissue
Arthur Laquière, Arnaud Lagarde, Bertrand Napoléon, Raphaël Bourdariat, Alexandre Atkinson, Gianfranco Donatelli, Bernard Pol, Laurence Lecomte, Laurence Curel, Romina Urena-Campos, Thierry Helbert, Vincent Valantin, François Mithieux, Jean Pascal Buono, Philippe Grandval, Sylviane Olschwang
Arthur Laquière, Laurence Lecomte, Romina Urena-Campos, Department of Gastroenterology, Saint Joseph Hospital, Marseille 13008, France
Arnaud Lagarde, Alexandre Atkinson, Philippe Grandval, Sylviane Olschwang, Aix-Marseille Univ, INSERM, MMG, Marseille 13385, France
Arnaud Lagarde, AP-HM, Conception Hospital, Marseille 13385, France
Bertrand Napoléon, Raphaël Bourdariat, François Mithieux, RGDS, Jean Mermoz Hospital, Lyon 69008, France
Gianfranco Donatelli, RGDS, Les Peupliers Hospital, Paris 75013, France
Bernard Pol, Department of Digestive Surgery, Saint-Joseph Hospital, Marseille 13008, France
Laurence Curel, Department of Clinical Research, Saint Joseph Hospital, Marseille 13008, France
Thierry Helbert, Vincent Valantin, Sylviane Olschwang, European Hospital, Marseille 13003, France
Jean Pascal Buono, Pathological Anatomy and Cytology, MEDIPATH, Eguilles 13510, France
Philippe Grandval, Sylviane Olschwang, AP-HM, Timone Hospital, Marseille 13005, France
Sylviane Olschwang, RGDS, Clairval Hospital, Marseille 13009, France
Author contributions: Laquière AE and Lagarde A provided equal contributions to the study and the article; All authors met the three conditions of authorship published by the ICMJE: Substantial contribution to conception and design, data acquisition analysis, and interpretation/drafting the article, and making critical revisions/final approval of the final version.
Institutional review board statement: This study has been reviewed by the institutional review board of the Saint Joseph Hospital.
Clinical trial registration statement: This study is registered at https://clinicaltrials.gov/ct2/show/NCT03305146?term=cyst+gen&rank=1. The registration identification number is [NCT03305146].
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment. All involved persons (subjects or legally authorized representative) gave their written informed consent prior to study inclusion.
Conflict-of-interest statement: The authors do not have any conflicts of interest to disclose.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Arthur Laquière, MD, Hepatogastroenterologist, Department of Gastroenterology, Saint Joseph Hospital, 26 bd de Louvain, Marseille 13008, France. alaquiere@gmail.com
Telephone: +33-4-91801822 Fax: +33-4-91806912
Received: April 30, 2019
Peer-review started: April 30, 2019
First decision: May 30, 2019
Revised: July 16, 2019
Accepted: August 19, 2019
Article in press: Auguet 19, 2019
Published online: September 28, 2019
ARTICLE HIGHLIGHTS
Research background

DNA mutational analysis of pancreatic cystic fluid (CF) is a useful adjunct to the evaluation of pancreatic cysts. KRAS/GNAS or RAF/PTPRD/CTNNB1/RNF43 mutations are highly specific to precancerous or advanced neoplasia. Several studies recently demonstrated the ability of next-generation sequencing (NGS) analysis to detect DNA mutations in pancreatic CF, but few studies have yet to perform a systematic comparative analysis between pancreatic CF and neoplastic surgical tissue (NT). The value of CF-NGS analysis indicators for determining surgical resection requires evaluation.

Research motivation

The main subject of this study is to evaluate the diagnostic performance of some specific mutations in CF, and to establish a concordance of detected mutations in CF and NT. The key problem to be solved was to appropriately select patients for preventive pancreatic surgery. It is very important to solve this problem in the future to avoid unnecessary procedures. Future research will be targeted to assess and validate this new technique of non-cancerous cyst prognosis.

Research objectives

The primary objective of this pilot prospective study was to determine the mutational concordance in the molecular biology analysis of paired DNA samples from CF and pancreatic tumor NT. The secondary objective was to analyze specific mutations (KRAS, GNAS, RAF, PTPRD, CTNNB1, RNF43, POLD1, and TP53) to correlate their presence with a final cancer diagnosis. The sensitivity and specificity of the DNA mutational analysis in CF was also evaluated for pancreatic cysts requiring surgery.

Research methods

Patients requiring surgery for high-risk pancreatic cysts were included in a multicenter prospective pilot study. DNA from CF (collected by Endoscopic Ultrasound-Guided Fine Needle Aspiration Biopsy (EUS-FNA)) and NT (collected by surgery) were analyzed by NGS. The primary objective was to compare the mutation profiles of paired DNA samples. The secondary objective was to correlate the presence of specific mutations (KRAS/GNAS, RAF/PTPRD/CTNNB1/RNF43/POLD1/TP53) with a final cancer diagnosis. Sensitivity and specificity were also evaluated.

Research results

Between December 2016 and October 2017, 20 patients were included in this pilot study. Surgery was delayed for three patients. Concordant CF-NT genotypes were found in 15/17 paired DNA, with a higher proportion of mutated alleles in CF than in NT. NGS was possible for all pancreatic CF collected by EUS-FNA. In two cases, the presence of a KRAS/GNAS mutation was discordant between CF and NT. In three patients with NT or pancreatic cysts with high-grade dysplasia, no mutations were found. The sensitivity and specificity of KRAS/GNAS mutations in CF to predict an appropriate indication for surgical resection were 0.78 and 0.62, respectively. The sensitivity and specificity of RAF/PTPRD/CTNNB1/RNF43/POLD1/TP53 mutations in CF were 0.55 and 1.0, respectively.

Research conclusions

The main goal of this study was to confirm the concordance between CF and NT mutations. The prognosis of pancreatic cysts can be evaluated by analyzing CF mutations. KRAS, GNAS, RAF, PTPRD, CTNNB1, RNF43, POLD1, and TP53 mutations are good indicators of cyst malignant degeneration risks. This study offers the opportunity to accurately assess pancreatic cyst prognosis using a minimally invasive technique. The new hypothesis assessed in this study is that CF mutations are good indicators of malignant degeneration risks. The new methods proposed in this study involve DNA extraction from a body fluid other than blood. The POLD1 gene might be of interest in the evaluation of the malignant degeneration risks of pancreatic cysts. We confirmed that CF mutations are good indicators of malignant risk. In the future, all patients with pancreatic cysts could benefit from CF analysis collected by EUS-FNA.

Research perspectives

All of the collected CF samples were able to be genetically analyzed. The mutations selected for evaluation (KRAS, GNAS, RAF, PTPRD, CTNNB1, RNF43, POLD1, and TP53) were not sufficient and did not provide excellent diagnostic performance. Additional mutations should be identified in the future to improve this diagnostic performance. Future national multicentric research is being implemented, with the collection of all pancreatic cysts of 12 mm-diameter and over. Future research should use the same methodology with comparative CF and NT analyses, but conducted on a larger scale and including the analysis of a higher number of mutations.