BACKGROUND:Human epidermal growth factor receptor 2 (HER2) aberrations, such as protein overexpression and amplification of the HER2 gene (ERBB2), are well-established in breast and gastroesophageal adenocarcinomas. However, ERBB2 oncogenic variants occur in 3.5% of all solid tumors with possible therapeutic implications. This study investigates the treatment efficacy and mutational landscape of patients with ERBB2-mutated cancers receiving HER2-targeted therapy. METHODS:Nineteen patients with refractory solid tumors harboring ERBB2 oncogenic variants were enrolled in the Copenhagen Prospective Personalized Oncology trial and received HER2-targeted treatment. Whole-exome sequencing, ctDNA analysis, and imaging were conducted at baseline, during treatment, and upon progression. Descriptive statistics were employed due to the exploratory nature of the study. RESULTS:HER2-targeted treatment yielded a 37% overall response rate, a 68% disease control rate, and a median progression-free survival of 4.4 months. A tendency was observed toward higher overall response rate (60%) in patients harboring ERBB2 oncogenic variants located in the tyrosine kinase domain. Clonality of ERBB2 oncogenic variants was linked with treatment efficacy, underscoring the reduced effect when targeting subclonal mutations. Sequential ctDNA analysis of ERBB2 oncogenic variants demonstrated correlation with treatment response. CONCLUSION:In this heterogeneous cohort of patients harboring ERBB2 oncogenic variants, HER2-targeted therapy demonstrated clinical efficacy. Mutational analysis revealed the importance of clonal ERBB2 oncogenic variants and identified factors influencing treatment outcomes. Limitations include a small sample size as well as heterogeneity in treatment regimens and cancer types.

Background and Aims:The regenerative capacity of the pancreas diminishes with age. Understanding acinar cell responses to injury and the resolution of regenerative processes is crucial for tissue homeostasis. However, knowledge about the impact of aging on these processes remains limited. Methods:To investigate the influence of aging on pancreas regeneration, we established a cohort of young (7-14 weeks) and old (18 months) C57bl/6 mice. Experimental pancreatitis was induced using caerulein, and pancreas samples were collected at various time points after induction, covering acute damage response, inflammation, peak proliferation, and inflammation resolution. Our analysis involved immunohistochemistry, quantitative imaging, and gene expression analyses. Results:Our study revealed a significant decline in the regenerative capacity of the pancreas in old mice. Despite similar morphology and transcriptional profiles between the pancreas of young and old mice under homeostasis, the aged pancreas is primed to generate an exacerbated proinflammatory reaction in response to injury. Specifically, we observed notable upregulation of Junb expression in acinar cells and aberrant myofibroblast activation in the aged pancreas. Conclusion:The response of acinar cells to injury in the pancreas of aged mice is characterized by an increased susceptibility to inflammation and stromal reactions. Our findings uncover a pre-existing proinflammatory state in aged acinar cells, offering insights into potential strategies to prevent the onset of pancreatic insufficiency and the development of inflammatory conditions. These insights hold implications for preventing conditions such as chronic pancreatitis and pancreatic ductal adenocarcinoma.

BackgroundLiver granulomas have always been a diagnostic challenge for pathologists. They have been described in up to 15% of liver biopsies and can also be seen in liver allograft biopsy specimens, but there is a paucity of information regarding the prevalence and associated etiologic factors of granulomas in liver transplanted patients. The aim of this study is to shed light on the etiology of liver granulomas.MethodsLiver biopsies from liver transplanted patients, in the period from 01.01.2011 - 01.05.2017, were examined. We registered the histo-morphological characteristics and clinicopathological data of all biopsies and performed next-generation sequencing (NGS) to detect possible pathogens (bacteria, fungi, and parasites) in the biopsies containing granulomas.ResultsWe reviewed a total of 400 liver biopsies from 217 liver transplant patients. Of these, 131 liver biopsies (32.8%) from 98 patients (45.2%) revealed granulomas. Most were epithelioid granulomas located parenchymal and were detected in 115 (87.7%) biopsies. We also identified 10 cases (7.6%) with both lobular and portal granulomas and six biopsies (4.5%) with portal granulomas alone. In 54 biopsies (41.2%), granulomas were found in biopsies with acute cellular rejection (ACR). Fifty (51%) patients with granulomas underwent liver transplantation for autoimmune-related end-stage liver disease (AILD). The granulomas were found most frequently in the first six months after transplantation, where patients also more often were biopsied. NGS analysis did not reveal any potential infectious agent, and no significant differences were observed in the microbiological diversity (microbiome) between clinical- and granuloma characteristics concerning bacteria, fungi, and parasites.ConclusionOur study confirmed that granulomas are frequently seen in liver allograft biopsy specimens, and most often localized in the parenchyma, occurring in the first post-transplant period in patients with AILD, and often seen simultaneously with episodes of ACR. Neither a specific microbiological etiological agent nor a consistent microbiome was detected in any case.

Background: We have previously shown that detection of methylated ctDNA in the three genes c9orf50, KCNQ5, and CLIP4 is a highly sensitive method (named the TriMeth assay) to discriminate patients with colorectal cancer from healthy individuals (1). The publicly available Infinium HumanMethylation450K BreadChip DNA methylation array indicates that these three markers are also highly methylated in gastric and esophageal cancer. In this study, we investigate the ability of the TriMeth assay to detect ctDNA in patients with gastric and gastroesophageal junction (GEJ) adenocarcinomas. Methods: Purified DNA was extracted from tumor tissue and plasma from 63 patients with gastric/GEJ adenocarcinomas. Sodium bisulfite conversion was performed to distinguish methylated from unmethylated cytosines. Droplet digital PCR (ddPCR) with methylation-specific primers and probes was performed to detect hypermethylated sites in the three genes c9orf50, KCNQ5, and CLIP4. The TriMeth assay was considered positive if at least two out of three markers were methylated according to a predefined cut-off. Eleven plasma samples from healthy individuals were used as negative controls.Results: In tumor tissue, methylated copies were detected in all 29 surgical samples (100% sensitivity), with varying allele frequencies. In plasma, methylated copies were detected in 14 out of 18 samples (78% sensitivity) from patients with advanced disease, with varying sensitivity amongst the three markers (AUC for the three markers CLIP4, C9orf50, and KCNQ5 was 0.61, 0.86, and 0.94, respectively). In plasma from patients with resectable disease, methylated copies were detected in 10 of 17 samples (59% sensitivity), although only 7/17 (41% sensitivity) were positive according to the predefined cut-off. All 11 controls were negative for methylation signals (100% specificity). Conclusion and Further Perspectives: Using a pre-defined cut-off value, the TriMeth assay detected methylated DNA in all tumor samples. The sensitivity of the TriMeth assay in plasma was 78% in advanced disease and 41% in resectable disease. Further investigations of the TriMeth assay in patients with resectable gastric and GEJ adenocarcinomas are needed. We plan to validate the sensitivity of the TriMeth assay for treatment monitoring and detection of residual disease. References: 1. Jensen, S.Ø., et al. Novel DNA methylation biomarkers show high sensitivity and specificity for blood-based detection of colorectal cancer—a clinical biomarker discovery and validation study. Clin Epigenet 11, 158 (2019). https://doi.org/10.1186/s13148-019-0757-3 Citation Format: Cecilie Riis Iden, Nadia Øgaard, Sarah Østrup Jensen, Salah Mohammad Mustafa, Lise Barlebo Ahlborn, Jane Preuss Hasselby, Kristoffer Staal Rohrberg, Michael Patrick Achiam, Claus Lindbjerg Andersen, Morten Mau-Sørensen. DNA methylation markers for sensitive detection of circulating tumor DNA in plasma from patients with gastroesophageal adenocarcinomas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2290.

Background and Aims: Recent advances have introduced molecular subtyping of pancreatic cystic lesions (PCLs) as a possible amendment to the diagnostic algorithm. The study evaluated the feasibility and diagnostic accuracy of molecular analysis and subtyping of PCLs using the recently introduced EUS-guided through-the-needle-biopsy (TTNB) sampling. Methods: We prospectively included 101 patients in the study who presented with PCLs >15 mm in the largest cross-section. EUS-guided TTNB samples were obtained by a micro-biopsy forceps introduced through a 19-gauge needle. The TTNB samples were analyzed by next-generation sequencing (NGS) for point mutations in tumor suppressors and oncogenes using a 51-gene customized hotspot panel. Sensitivity and specificity were calculated with the histologic diagnosis as reference. Results: After initial microscopic evaluation of the samples, 91 patients had residual TTNB samples available for NGS. Of these, 49 harbored mutations, most frequently in KRAS and GNAS, reflecting an excess frequency of intraductal papillary mucinous neoplasms (IPMNs) in the study population. A sensitivity and specificity of 83.7% (95% confidence interval [CI], 70.3-92.7) and 81.8% (95% CI, 48.2-97.7), respectively, were demonstrated for the diagnosis of a mucinous cyst and 87.2% (95% CI, 74.2-95.2) and 84.6% (95% CI, 54.5-98.1) for the diagnosis of an IPMN. Conclusions: Thus, molecular analysis of TTNB samples by NGS has high sensitivity and specificity for diagnosing mucinous cysts and IPMNs. Although the procedure comes with a risk of adverse events of 9.9%, TTNB samples are a robust alternative to cyst fluid for a combined histologic and molecular diagnosis of PCLs. (Clinical trial registration number: NCT03578445.) (Gastrointest Endosc 2023;97:50-8.)

The antitumor activity of chitooligosaccharides has been suggested. This phase 2 trial evaluated the efficacy and safety of T-ChOS™, in addition to adjuvant chemotherapy, in patients after resection of pancreatic ductal adenocarcinoma (PDAC). In this single-center, randomized, double-blind, placebo-controlled trial using patients ≥18 years of age after complete macroscopic resection for PDAC, patients were randomly assigned (1:1) to either a continuous oral T-ChOS group or a placebo group, in combination with gemcitabine (GEM) and oral capecitabine (CAP), for a maximum of six cycles. The primary endpoint was disease-free survival (DFS). Recruitment was stopped prematurely in July 2018, with 21 of planned 180 patients included, due to poor accrual and because modified FOLFIRINOX replaced GEM/CAP for the target population. Nine patients received T-ChOS and twelve received the placebo. The median DFS was 10.8 months (95% CI 5.9–15.7) for the T-ChOS arm and 8.4 months (95% CI 0–21.5) in the placebo arm. Overall, seven patients (78%) in the T-ChOS arm and eight patients (67%) in the placebo arm experienced at least one grade 3–4 treatment-related adverse event, most frequently neutropenia. Altogether, the addition of T-ChOS to chemotherapy in patients after resection of PDAC seems safe. However, the clinical benefit cannot be assessed due to the premature cessation of the trial.

Gene alterations play a prominent role in driving cancer initiation and progression. Yet, mutations on oncogenes (those genes that promote tumorigenesis) only transform cells under certain cellular contexts. The mechanisms controlling neoplastic transformation (oncogenic competence) are poorly understood in pancreatic ductal adenocarcinoma (PDAC). Our laboratory investigates the interplay of mutations on the Kirsten Rat Sarcoma oncogene (Kras), developmental transcriptional programs, and the tissue microenvironment PDAC initiation. Our data demonstrate that Sox4 is necessary for the specification of cellular states in preinvasive cancer lesions and regulates the characteristics and cellular compositions of the tumor microenvironment in an autochthonous genetic model of PDAC. The pancreas has a remarkable ability to regenerate and recover from acute pancreatitis. In this process, acinar cells repress the expression of genes associated with acinar function and transiently activate a gene program that resembles pancreas progenitors of development. This mechanism, defined as cellular plasticity, alleviates tissue damage, stimulates acinar proliferation, and is necessary for pancreas regeneration. However, it makes the acinar cells competent to malignant transformation mediated by Kras. To investigate SOX4 function in pancreas regeneration and cancer, we used the KCacinar mouse model (Ptf1a-CreER; Kras G12DLSL). After injury, we observed a transient four-fold increase in the expression of SOX4, which correlates with the morphological and molecular evidence of cellular plasticity. KCacinar mice rapidly develop mucinous pancreatic intraepithelial neoplasias (PanINs) after caerulein-induced pancreatitis. Histological analysis KCAcinar Sox4-depleted pancreas (KCSAcinar) reveals a distinct cystic lesion lined by cuboidal or flattened epithelium with large irregular and hyperchromatic nuclei and absence of mucin-producing cells. Mice lacking Sox4 showed a significant reduction in the number of tuft cells. Furthermore, we observed an extensive reduction of the tumor stroma surrounding epithelial acinar-derived lesions in KCSAcinar compared to KC littermates. Next, we perform gene expression analysis of lesions 21 days after the induction of pancreatitis. Principal component analysis clusters the samples according to the genotype. Differential gene expression validated our histopathological analysis and showed a significant reduction in the expression of mucins and tuft cell markers. Cumulative, our data suggest that Sox4 is necessary for the specification of cellular states in the precursor lesions of PDAC, and that the cellular state of the tumor cell of origin determines the characteristics and cellular composition of the tumor microenvironment. Our work will continue to unravel the function of Sox4 in cancer initiation and the interaction of signaling pathways activated in pancreas regeneration with Kras mutations. Citation Format: Jonathan Baldan, Juan Camacho Roda, Charlotte Vestrup Rift, Jane Preuss Hasselby, Patrick Jacquemin, Ilse Rooman, Véronique Lefebvre, Luis Arnes. Sox4-dependent acinar cell plasticity in pancreatic regeneration and cancer initiation [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr B032.

Invasive intraductal papillary mucinous neoplasms (inv-IPMNs) have a better prognosis than regular pancreatic ductal adenocarcinoma (PDAC), but no association with status of surgical margins and microscopic infiltration patterns has previously been described. The aim of this study is to review patterns of invasion and the predictive value of clinical guidelines in terms of rates of resection of high-grade dysplasia (HGD) and cancer among intraductal papillary mucinous neoplasms (IPMNs). Consecutively, resected IPMNs between 2011 and 2017 were analyzed. Data were obtained from a prospectively maintained database. A total of 132 patients were identified. Out of these, 38 patients with inv-IPMNs, initially identified as solid lesions suspicious of cancer, were compared with a control group of 101 patients with ordinary PDAC. Lower rates of vascular invasion, perineural invasion, lymph node metastasis, advanced T stage, and R1 status were characteristic of the inv-IPMNs in addition to better overall survival (OS) for a low tumor stage. Furthermore, as novel findings, the PDACs presented with resection margin involvement of 3 or more positive margins (31.3% vs. 9.5%, p = 0.044), associated with poor OS. Of the patients presenting as pT3, the inv-IPMN less often invaded more than one extrapancreatic anatomical structure (40.1% vs. 63.9%, p = 0.03). Regarding the predictive value of clinical guidelines, the frequency of resected HGD in IPMNs with high-risk stigmata (n = 54) and IPMNs with worrisome features was 30.7%, and the frequency of invasive carcinoma was 5.7%. In conclusion, we report a low resection rate of high-risk IPMNs and present novel findings describing inv-IPMNs as a less infiltrative phenotype compared with regular PDAC.

Background In neonates, rhesus D alloimmunization despite anti-D immunoglobulin prophylaxis is rare and often unexplained. Rhesus D alloimmunization can lead to hemolytic disease of the newborn with anemia and unconjugated hyperbilirubinemia. In past reports, transient congenital hyperinsulinism has been described as a rare complication of rhesus D alloimmunization. Our case report illustrates that rhesus D alloimmunization can result in a pseudosyndrome with severe congenital hyperinsulinism, anemia, and conjugated hyperbilirubinemia, despite correctly administered anti-D immunoglobulin prophylaxis. Case presentation We report of a 36-year-old, Caucasian gravida 1, para 1 mother with A RhD negative blood type who received routine antenatal anti-D immunoglobulin prophylaxis. Her full term newborn boy presented with severe congenital hyperinsulinism, anemia, and conjugated hyperbilirubinemia up to 295 µmol/L (ref. < 9), accounting for 64% of the total bilirubin. Syndromic congenital hyperinsulinism was suspected. Examinations showed a positive direct antiglobulin test, initially interpreted as caused by irregular antibodies; diffuse congenital hyperinsulinism by 18F-DOPA positron emission tomography/computed tomography scan; normal genetic analyses for congenital hyperinsulinism; mildly elevated liver enzymes; delayed, but present bile excretion by Tc99m-hepatobiliary iminodiacetic acid scintigraphy; and cholestasis and mild fibrosis by liver biopsy. The maternal anti-D titer was 1:16,000 day 20 postpartum. Y-chromosome material in the mother’s blood could not be identified. This could, however, not exclude late intrapartum fetomaternal hemorrhage as the cause of immunization. No causative genetic findings were deetrmined by trio whole exome sequencing . The child went into clinical remission after 5.5 months. Conclusion Our case demonstrates that rhesus D alloimmunization may present as a pseudosyndrome with transient congenital hyperinsulinism, anemia, and inspissated bile syndrome with conjugated hyperbilirubinaemia, despite anti-D immunoglobulin prophylaxis, possibly due to late fetomaternal hemorrhage.

Objectives: To address the diagnostic accuracy of endoscopic ultrasound guided through-the-needle-biopsies (TTNBs) and simultaneously obtained cytology samples from pancreatic cysts compared to the final histopathological diagnosis of the surgical specimen, and to give an overview of ancillary tests performed on TTNBs. Methods: A literature search was conducted in MEDLINE, Embase and Scopus. Studies were included in the metaanalysis, if they had data for TTNB, cytology and a surgical specimen of pancreatic cysts as reference standard. The assessment of the risk of bias and quality of the included studies was conducted using the modified QUADAS2 tool. Results: Ten studies with 99 patients were included in the meta-analysis. Data regarding study design and clinicopathological features were extracted systematically. For TTNB, pooled sensitivity was 0.86 (95 % CI 0.62-0.96), specificity 0.95 (95 % CI 0.79-0.99) and area under the curve (AUC) 0.86 for the diagnosis of a mucinous cyst and pooled sensitivity was 0.78 (95 % CI 0.61-0.89), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.92 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.69 (95 % CI 0.50-0.83), specificity 0.47 (95 % CI 0.28-0.68) and AUC 0.49. For cytology performed simultaneously, pooled sensitivity was 0.46 (95 % CI 0.35-0.57), specificity 0.90 (95 % CI 0.46-0.99) and AUC 0.64 for the diagnosis of mucinous cysts, and pooled sensitivity was 0.38 (95 % CI 0.23-0.55), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.84 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.29 (95 % CI 0.21-0.39), specificity 0.45 (95 % CI 0.25-0.66) and AUC 0.30. Furthermore, immunohistochemical stains can be useful to establish the specific cyst subtype. Conclusions: TTNBs have a higher sensitivity and specificity than cytology for the diagnosis of mucinous cyst and high- risk cysts of the pancreas.

Background The limited data on the utility of endoscopic ultrasound (EUS)-guided through-the-needle biopsies (TTNBs) in patients with pancreatic cystic lesions (PCLs) originate mainly from retrospective studies. Our aim was to determine the clinical impact of TTNBs, their added diagnostic value, and the adverse event rate in a prospective setting. Methods This was a prospective, single-center, open-label controlled study. Between February 2018 and August 2019, consecutive patients presenting with a PCL of 15 mm or more and referred for EUS were included. Primary outcome was a change in clinical management of PCLs following TTNB compared with cross-sectional imaging and cytology. Adverse events were defined according to the ASGE lexicon. Results 101 patients were included. TTNBs led to a change in clinical management in 11.9% of cases (n = 12). Of these, 10 had serous cysts and surveillance was discontinued, while one of the remaining two cases underwent surgery following diagnosis of a mucinous cystic neoplasm. The diagnostic yield of TTNBs for a specific cyst diagnosis was higher compared with FNA cytology (69.3% vs. 20.8%, respectively; P<0.001). The adverse event rate was 9.9% (n =10; 95% confidence interval 5.4 %- 17.3 %), with the most common event being acute pancreatitis (n =9). Four of the observed adverse events were severe, including one fatal outcome. Conclusions TTNBs resulted in a change of clinical management in about one in every 10 patients; however, the associated adverse event risk was substantial. Further studies are warranted to elucidate in which subgroups of patients the clinical benefit outweighs the risks.

BACKGROUND:The standard treatment for gastroesophageal cancer is neoadjuvant chemotherapy, followed by surgery, which has been shown to increase survival compared with surgery alone. Evidence is mounting that characterization of the oncologically induced tumor regression is of prognostic importance. However, no consensus regarding the optimal system for describing tumor regression exists. Thus, this study aims to explore three validated/promising tumor regression systems with a focus on their interobserver reliability and usability.METHODS:We included 100 consecutive patients with gastroesophageal adenocarcinoma who had undergone neoadjuvant oncological treatment followed by surgery. The tumors underwent tumor regression grade (TRG) assessment according to the Standard Mandard-, Modified Mandard-, and Becker systems to assess the interobserver reliability between two consultant pathologists. The interobserver reliability was determined by both Fleiss kappa and weighted kappa metrics. Besides, a semi-quantitative usability questionary was completed and it was expanded with usability comments.RESULTS:The Fleiss kappa interobserver agreement was 0.67 [95% CI, 0.55-0.79], 0.88 [95% CI, 0.73-1.00], and 0.88 [95% CI, 0.73-1.00] for Standard Mandard-, Modified Mandard-, and the Becker systems, respectively. The weighted kappa (linear) was 0.80 [95% CI, 0.72-0.89], 0.91 [95% CI, 0.84-0.98], and 0.91 [95% CI, 0.84-0.98] for the Standard Mandard-, Modified Mandard-, and the Becker systems, respectively. The usability was scored on a scale of 8-24 by both raters. The systems were scored accordingly: 47 (Modified Mandard system), 43 (Becker system), and 37 (Standard Mandard system).CONCLUSION:The Modified Mandard- and Becker systems had excellent interobserver reliability and usability. However, the systems could be improved by a better characterization of the different tiers and tumor morphology.

Accurate data on HER2 positivity in esophageal squamous cell carcinoma patients (ESCC) is lacking. We conducted a systematic review and meta-analysis (Single Incidence Rates; metarate package, R) to examine the prevalence of HER2 in ESCC. Data on in situ hybridization (ISH) and immunohistochemistry (IHC) were extracted to derive pooled prevalence estimates, characteristics of the studies were extracted for subgroup analysis. Eighteen studies with 1505 patients were identified. HER2 gene amplification by ISH were prevalent in 10 % (95 % CI 6.9 %-15 %). Prevalence of HER2 overexpression (IHC3+) and borderline HER2 expression (IHC2+) were 6 % (95 % CI: 3.5 %-8.7 %) and 10 % (95 % CI: 6.0 %-17 %), respectively. An estimated 8.6 % (95 % CI: 5.5 %-13 %) of ESCC were HER2 positive using initial IHC followed by reflex ISH confirmation of borderline HER2 expression. In conclusion: Estimated prevalence of HER 2 positivity in ESCC were 10 % assessed by ISH and 8.6 % assessed by initial IHC followed by ISH.

Influenza virus and coronavirus pandemics regularly sweep the globe, at great cost of health and economy. Our aim was to conduct a PubMed search for autopsy studies on influenza and coronavirus to investigate the contribution of autopsies during pandemics, focussing on autopsy methods and procedures and the role of autopsy findings in pandemics. The retrieved autopsy studies generally relied on microscopy, polymerase chain reaction (PCR), immunostaining and electron microscopy. Most were small and reported on lung effects, including diffuse alveolar damage (DAD), pneumonia and tracheobronchitis. Antibiotic therapy has diminished a role for bacterial pneumonia, whereas obesity is an emerging risk factor. Autopsy studies have provided new insights into coronavirus disease 2019 (COVID-19) treatments like anti-coagulative therapy. Unfortunately, autopsies during pandemics are hampered by lack of guidelines, facilities and expertise for handling potentially infectious corpses and by widely varying recommendations for personal protective equipment and procedures. The Department of Forensic Pathology, at the Forensic Institute, at the University of Copenhagen in Denmark has, in collaboration with the Department of Pathology, Rigshospitalet, Copenhagen, initiated a prospective observational study on COVID-19-related deaths encompassing postmortem imaging, standardized autopsy procedures/reporting and extensive tissue sampling for histological, chemical, microbiological and genetic analysis. The study involves a diverse array of research groups at the University of Copenhagen, and the clinical field.

Background/Purpose Few clinically useful biomarkers are known to predict prognosis in patients with hepatocellular carcinoma (HCC). The aim of this study was to investigate the correlation between PPAR activity and ALDH7A1 expression and their prognostic significance using RNA sequencing in patients undergoing liver resection for HCC. Methods We included patients undergoing liver resection for HCC at a tertiary referral center for hepato-pancreato-biliary surgery between May 2014 and January 2018. PPAR activity and ALDH7A1 expression were evaluated by RNA sequencing and correlated with overall survival, recurrence and histological features. Results We included 52 patients with a median follow-up of 20.9 months, predominantly males (88.5%) with a single tumor (84.6%) in a non-cirrhotic liver (73.1%). Three-year overall survival was 48.6% in patients with a specific PPAR target gene expression profile (cancer cluster 3) compared with 81.7% in controls (P = .04, Log-rank test). This remained significant (odds ratio 14.02, 95% confidence interval 1.92-102.22,P = .009) when adjusted for age, cirrhosis, microvascular invasion, number of tumors and free resection margins. ALDH7A1 expression was not correlated with PPAR or any outcomes. Conclusion PPAR activity in a subset of tumor samples was associated with reduced overall survival indicating that PPAR may be a valuable prognostic biomarker.

Aims Intraductal papillary mucinous neoplasms (IPMNs) may be precursor lesions of pancreatic cancer. The path towards malignancy is associated with mutations in tumour suppressor—and oncogenes that may serve as biomarkers during diagnostic investigation. A novel micro forceps has made it possible to obtain biopsies from the cyst wall for analysis by next generation sequencing (NGS), providing an opportunity for early detection and intervention. However, the impact of spatial tumour heterogeneity on the representability of the biopsies has not been determined. The primary aim is to characterise the impact of molecular heterogeneity of the luminal cyst wall on tissue sampling strategies with small biopsies. Methods We performed NGS and immunohistochemical phenotyping on 18 resected IPMNs with varying degrees of dysplasia and for a subset, concomitant carcinoma, using a commercially available NGS-panel of 51 oncogenes. We simulated endoscopic biopsies by performing punch biopsies (PBs) of the cyst wall from resected specimens. Results In total, 127 NGS analyses were performed. Concomitant KRAS and GNAS was a common feature of the IPMNs. Mutations in KRAS and GNAS were associated with low-grade dysplasia whereas alterations in TP53, SMAD4, CDKN2A and PIK3CA were associated with high-grade dysplasia and/or carcinoma. The mutational analysis of the PBs from the cyst wall was compared with the whole lesion. No difference was detected between PBs and whole lesions when the cumulated mutational profile in increasing order of randomly performed PBs was compared. Conclusions Small IPMN biopsies from the cyst wall are adequate to yield a molecular diagnosis.

Abstract Background Macrophages play a significant role in liver disease development and progression. The macrophage activation marker soluble (s)CD163 is associated with severity and prognosis in a number of different acute and chronic liver diseases but has been only sparsely examined in Wilson’s disease (WD). We investigated sCD163 levels in patients with acute and chronic WD and hypothesized associations with liver disease phenotype and biochemical markers of liver injury. Methods We investigated sCD163 in two independent cohorts of WD patients: 28 patients with fulminant WD from the US Acute Liver Failure (ALF) Study Group registry and 147 patients with chronic disease from a German WD registry. We included a control group of 19 healthy individuals. Serum sCD163 levels were measured by ELISA. Liver CD163 expression was determined by immunohistochemistry. Results In the ALF cohort, median sCD163 was 10-fold higher than in healthy controls (14.6(2.5–30.9) vs. 1.5(1.0–2.7) mg/L, p < 0.001). In the chronic cohort, median sCD163 was 2.6(0.9–24.9) mg/L. There was no difference in sCD163 according to subgroups based on initial clinical presentation, i.e. asymptomatic, neurologic, hepatic, or mixed. Patients with cirrhosis at the time of diagnosis had higher sCD163 compared with those without cirrhosis (3.0(1.2–24.9) vs. 2.3(0.9–8.0) mg/L, p < 0.001); and both cohorts significantly lower than the ALF patients. Further, sCD163 correlated positively with ALT, AST, GGT and INR (rho = 0.27–0.53); and negatively with albumin (rho = − 0.37), (p ≤ 0.001, all). We observed immunohistochemical CD163 expression in liver tissue from ALF patients. Conclusions Although sCD163 is not specific for WD, it was elevated in WD patients, especially in those with ALF. Further, sCD163 was higher in patients with cirrhosis compared to patients without cirrhosis and associated with biochemical markers of liver injury and hepatocellular function. Thus, macrophage activation is evident in WD and associates with liver disease phenotype and biochemical parameters of liver disease. Our findings suggest that sCD163 may be used as a marker of liver disease severity in WD patients.

Background: Platinum-based chemotherapy is part of the standard treatment for patients with colorectal cancer. ERCC1 is a potential predictive biomarker for platinum-based chemotherapy. The aim of this study was to examine interobserver agreement on ERCC1 protein expression in primary colorectal cancer as well as corresponding liver metastasis. Furthermore, comparison of ERCC1-expression in primary tumor and the corresponding liver metastasis was performed. Methods: Forty patients with primary colorectal cancers and corresponding liver metastases were included. One slide was stained with the anti-ERCC1 antibody, 4F9 clone (DAKO) and evaluated by two gastrointestinal pathology consultants and a pathology registrar separately. Interobserver agreement was evaluated for primary tumors and liver metastases using kappa (K) statistics. Discordant scorings were reviewed, and consensus was obtained. The expression in primary tumor was compared with the corresponding liver metastases. Results: For the primary tumors agreement was found in 85% of the tumors corresponding to an unweighted kappa value of 0,79 (95% CI 0,64-0,94). For the liver metastases agreement was found in 76% corresponding to an unweighted kappa value of 0,64 (95% CI 0,49-0,79). When comparing primary tumors to the corresponding metastases, no concordance in ERCC1-expression was observed. Conclusion: Interobserver agreement of ERCC1 expression was good for both primary tumors and liver metastases, which is crucial for a potential predictive biomarker. As no concordance between primary tumor and liver metastases was found it seems to be of high importance to use tissue from actual tumor burden for evaluation of ERCC1 expression. Further studies and correlation to clinical outcome are warranted.

Pancreatic cystic lesions (PCLs) are often an incidental finding related to the increased use of cross-sectional imaging,1 and risk stratification and management are a challenge for the multidisciplinary team. EUS examination with FNA of cyst fluid for cytology serves as a cornerstone in the evaluation of PCLs with worrisome features.2 However, microscopic evaluation of cytology samples is a challenge for the pathologist, and the reported sensitivity for the differentiation between mucinous and nonmucinous cysts is as low as 54%.

We commend Rift et al1Rift C.V. Kovacevic B. Toxværd A. et al.EUS-guided through-the-needle biopsy of pancreatic cystic lesions: a pathologist’s guide for the endoscopist.Gastrointest Endosc. 2020; 92: 252-258Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar for their article that helps endosonographers and pathologists in handling and evaluating specimens we did not deal with before the availability of microforceps. Through-the-needle microforceps biopsy is a promising tool for the diagnosis of pancreatic cystic lesions.2Tacelli M, Celsa C, Magro B, et al. Diagnostic performance of endoscopic ultrasound through-the-needle microforceps biopsy of pancreatic cystic lesions: systematic review with meta-analysis. Dig Endosc. Epub 2020 Jan 8.Google Scholar,3Facciorusso A. Del Prete V. Antonino M. et al.Diagnostic yield of EUS-guided through-the-needle biopsy in pancreatic cysts: a meta-analysis.Gastrointest Endosc. 2020; 92: 1-8Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Although the device works similarly to standard endoscopic forceps, the specimens collected are much smaller, and the number of retrievable pieces is limited in relation to the complexity of the procedure. Therefore, the utmost care and attention must be paid in the handling of such samples. The article by Rift et al1Rift C.V. Kovacevic B. Toxværd A. et al.EUS-guided through-the-needle biopsy of pancreatic cystic lesions: a pathologist’s guide for the endoscopist.Gastrointest Endosc. 2020; 92: 252-258Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar is exhaustive, but we would like to add 2 practical tricks based on our experience in over 100 cases. First, to reduce the risk of losing material during specimen processing in the pathology laboratory, immediately after extracting the specimen from the microforceps jaws and before formalin fixation, we place it between 2 colored paper disks and then into a gauze envelope (Fig. 1).4Crino S.F. Bernardoni L. Brozzi L. et al.Association between macroscopically visible tissue samples and diagnostic accuracy of EUS-guided through-the-needle microforceps biopsy sampling of pancreatic cystic lesions.Gastrointest Endosc. 2019; 90: 933-943Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The paper-tissue complex is normally processed for paraffin inclusion. Small “white” samples obtained by through-the-needle microforceps biopsy will be easily recognized during microtome sectioning, thanks to the color of paper disks, which can be cut together with the sample without affecting the pathologic evaluation. Second, to save useful tissue, we suggest handling each specimen individually. If multiple specimens are embedded together in the same paraffin block, their levels at the microtome sectioning can be different, and some of the fragments may not be cut. Therefore, it would be necessary to cut numerous sections to examine all the fragments, resulting in a waste of tissue. Differently, when each sample is embedded and trimmed individually, tissue sections are more homogeneous with one another, with an overall higher number of slides potentially suitable for supplementary immunohistochemical stains (Fig. 2).Figure 2There is a possible waste of tissue when multiple specimens are included in the same paraffin block (upper panel). The inclusion of each specimen in a single paraffin block solves this problem (lower panel).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Dr Crinò is a consultant for Boston Scientific. The other authors disclosed no financial relationships. ResponseGastrointestinal EndoscopyVol. 92Issue 4PreviewWe appreciate the remarks by Crinó et al1 and their interest in our article.2 The advancement of new endoscopic tools of tissue procurement for the diagnosis of pancreatic cystic lesions makes considerable demands on both endosonographers and pathologists. Full-Text PDF