RET Fusion Testing in Patients With NSCLC: The RETING Study.

Introduction: RET inhibitors with impressive overall response rates are now available for patients with NSCLC, yet the identification of RET fusions remains a difficult challenge. Most guidelines encourage the upfront use of next-generation sequencing (NGS), or alternatively, fluorescence in situ hybridization (FISH) or reverse transcriptase-polymerase chain reaction (RT-PCR) when NGS is not possible or available. Taken together, the suboptimal performance of single-analyte assays to detect RET fusions, although consistent with the notion of encouraging universal NGS, is currently widening some of the clinical practice gaps in the implementation of predictive biomarkers in patients with advanced NSCLC. Methods: This situation prompted us to evaluate several RET assays in a large multicenter cohort of RET fusion-positive NSCLC (n = 38) to obtain real-world data. In addition to RNA-based NGS (the criterion standard method), all positive specimens underwent break-apart RET FISH with two different assays and were also tested by an RT-PCR assay. Results: The most common RET partners were KIF5B (78.9%), followed by CCDC6 (15.8%). The two RET NGS-positive but FISH-negative samples contained a KIF5B(15)-RET(12) fusion. The three RET fusions not identified with RT-PCR were AKAP13(35)-RET(12), KIF5B(24)-RET(9) and KIF5B(24)-RET(11). All three false-negative RT-PCR cases were FISH-positive, exhibited a typical break-apart pattern, and contained a very high number of positive tumor cells with both FISH assays. Signet ring cells, psammoma bodies, and pleomorphic features were frequently observed (in 34.2%, 39.5%, and 39.5% of tumors, respectively). Conclusions: In-depth knowledge of the advantages and disadvantages of the different RET testing methodologies could help clinical and molecular tumor boards implement and maintain sensible algorithms for the rapid and effective detection of RET fusions in patients with NSCLC. The likelihood of RET false-negative results with both FISH and RT-PCR reinforces the need for upfront NGS in patients with NSCLC.

Anastomotic leak in colorectal cancer surgery: Contribution of gut microbiota and prediction approaches.

AIM: To monitor prospectively the occurrence of colorectal anastomotic leakage (CAL) in patients with colon cancer undergoing resectional surgery, characterizing the microbiota in both faeces and mucosal biopsies of anastomosis. In a second stage, we investigated the ability to predict CAL using machine learning models based on clinical data and microbiota composition. METHOD: A total of 111 patients were included, from whom a faecal sample was obtained, as well as biopsy samples from proximal and distal sites in the healthy margins of the tumour piece. The microorganisms present in the samples were investigated using microbial culture and 16S rDNA massive sequencing. Collagenase and protease production was determined, as well as the presence of genes responsible for expressing enzymes with these activities. Machine learning analyses were developed using clinical and microbiological data. RESULTS: The incidence of CAL was 9.0%, and CAL was associated with collagenase/protease-producing Enterococcus. Significant differences were found in the microbiota composition of proximal and distal biopsy samples, but not in faecal samples, among patients who developed CAL. Clinical predictors of CAL were 5-day C-reactive protein and heart disease, whereas 3-day C-reactive protein and diabetes were negative predictors. CONCLUSION: Biopsy samples from surgical margins, rather than faecal samples, are the most appropriate samples for exploring the contribution of the intestinal microbiota to CAL. Enterococci are only enriched in the anastomosis after surgery, and their collagenases and proteases are involved in the degradation of the anastomotic scar.

Treatment outcomes of advanced digestive well-differentiated grade 3 NETs.

There is no standardized treatment for grade 3 neuroendocrine tumors (G3 NETs). We aimed to describe the treatments received in patients with advanced G3 NETs and compare their efficacy. Patients with advanced digestive G3 NETs treated between 2010 and 2018 in seven expert centers were retrospectively studied. Pathological samples were centrally reviewed, and radiological data were locally reviewed. We analyzed RECIST-defined objective response (OR), tumor growth rate (TGR) and progression-free survival (PFS) obtained with first- (L1) or second-line (L2) treatments. We included 74 patients with advanced G3 NETs, mostly from the duodenal or pancreatic origin (71.6%), with median Ki-67 of 30%. The 126 treatments (L1 = 74; L2 = 52) included alkylating-based (n = 32), etoposide-platinum (n = 22) or adenocarcinoma-like (n = 20) chemotherapy, somatostatin analogs (n = 21), targeted therapies (n = 22) and liver-directed therapies (n = 7). Alkylating-based chemotherapy achieved the highest OR rate (37.9%) compared to other treatments (multivariable OR 4.22, 95% CI (1.5-12.2); P = 0.008). Adenocarcinoma-like and alkylating-based chemotherapies showed the highest reductions in 3-month TGR (P < 0.001 and P = 0.008, respectively). The longest median PFS was obtained with adenocarcinoma-like chemotherapy (16.5 months (9.0-24.0)) and targeted therapies (12.0 months (8.2-15.8)), while the shortest PFS was observed with somatostatin analogs (6.2 months (3.8-8.5)) and etoposide-platinum chemotherapy (7.2 months (5.2-9.1)). Etoposide-platinum CT achieved shorter PFS than adenocarcinoma-like (multivariable HR 3.69 (1.61-8.44), P = 0.002) and alkylating-based chemotherapies (multivariable HR 1.95 (1.01-3.78), P = 0.049). Overall, adenocarcinoma-like and alkylating-based chemotherapies may be the most effective treatments for patients with advanced G3 NETs regarding OR and PFS. Etoposide-platinum chemotherapy has poor efficacy in this setting.

Screening for ROS1 fusions in patients with advanced non-small cell lung carcinomas using the VENTANA ROS1 (SP384) Rabbit Monoclonal Primary Antibody.

Introduction: The development of several ROS1 inhibitors means that the importance of accurately identifying ROS1-positive lung cancer patients has never been greater. Therefore, it is crucial that ROS1 testing assays become more standardized.Areas covered: Based on primary literature, combined with personal diagnostic and research experience, this review provide a pragmatic update on the use of the recently released VENTANA ROS1 (SP384) Rabbit Monoclonal Primary Antibody.Expert opinion: This assay provides high sensitivity, so it is an excellent analytical option when screening for ROS1 fusions in patients with advanced non-small cell lung carcinomas.

Molecular Heterogeneity of High Grade Colorectal Adenocarcinoma.

High grade colorectal carcinomas (HG-CRCs), which comprise 15% of colorectal carcinomas, are underrepresented in reported molecular studies. Clinicopathological, immunohistochemical, and molecular features of 40 HG-CRCs are described. Moreover, glandular and solid areas of 25 tumors were separately analyzed. The expression of MLH1, PMS2, MSH2, MSH6, p53, E-cadherin, CDX2, CK20, CD8, PDL1, PAN-TRK, c-MET, SMARCB1, ARID1A, SMARCA2, and SMARCA4 was analyzed by immunohistochemistry. Promoter MLH1 methylation was analyzed in tumors with MLH1/PMS2 loss. Next-generation sequencing was used to screen 161 genes for hotspot mutations, copy number variations and gene fusions. In this series, 72.5% of HG-CRCs showed mismatch repair deficiency (MMRd). MMR deficient tumor and MMR proficient (MMRp) tumors showed striking molecular differences. Thus, whereas BRAF mutations were only observed in MMRd tumors, mutations in KRAS and TP53 were more frequent in MMR proficient tumors. Moreover, gene fusions (NTRK1 and MET) were detected only in MMRd tumors, whereas gene amplification (MYC, CCND1 and EGFR) predominated in MMRp/TP53-mutated tumors. Loss of expression of proteins involved in chromatin remodeling, such as ARID1A, was observed only in MMRd HG-CRCs, which also showed more frequently PD-L1 expression and a higher number of tumor infiltrating lymphocytes. The separate analysis of glandular and solid areas indicated that the clonal or subclonal nature of the molecular alterations also depended on MMR status. Mutations in genes such as TP53 and KRAS were always clonal in MMRp-CRCs but occurred as subclonal events in MMRd-CRCs. Gene amplification was implicated in the progression of MMRp tumors, but not in MMRd tumors, in which clonal diversity was due to accumulation of mutations in genes of different pathways such as NOTCH, MMR, or PIK3CA. In summary, intertumor and intratumor molecular heterogeneity in HG-CRCs is mainly due to MMR status.

Lumen-apposing metal stents versus biliary fully-covered metal stents for EUS-guided drainage of pancreatic fluid collections: a case control study: Meeting presentations: European Society of Gastrointestinal Endoscopy ESGE Days 2018.

Background and study aims Endoscopic ultrasound (EUS)-guided drainage has become first-line treatment for pancreatic fluid collections (PFC). The aim of this study was to compare the effectiveness and safety of biliary fully-covered self-expandable metal stents (BFCSEMS) and lumen-apposing metal stents with electrocautery (EC-LAMS). Patients and methods From April 2008 to March 2017, consecutive patients with symptomatic PFC drained under EUS-guidance with metal stents were included. Patients drained with EC-LAMS were considered the study group and those drained with BFCSEMS the control group. Two primary endpoints were evaluated: effectiveness (defined as reduction of ≥ 50 % of PFC size in cross-sectional imaging and improvement of symptoms 6 months after the transmural drainage) and safety. Results Thirty patients were drained with EC-LAMS and 60 patients with BFCSEMS. Patients and PFC baseline characteristics in both groups were similar. Use of a coaxial double pigtail plastic stent and a nasocystic lavage catheter was significantly less frequent in patients drained with EC-LAMS (33 % vs. 100 %, and 13 % vs. 58 %, respectively; P  < 0.0001). Technical success was 100 % in both groups. Procedure time was < 30 minutes in all patients drained with EC-LAMS and over 30 minutes in all patients drained with BFCSEMS ( P  = 0.0001). Clinical success was higher with a tendency to significance in patients drained with EC-LAMS (96 % vs. 82 %, P  = 0.055) and the adverse event rate was lower (4 % vs. 18 %, P  = 0.04). No case of procedure-related mortality was recorded. Conclusions EC-LAMS and BFCSEMS are both effective for EUS-guided drainage of PFC. However, EC-LAMS requires less time to be performed and appears to be safer.

Validación clínica del test Endofaster(R) como método diagnóstico rápido de la infección por Helicobacter pylori / No disponible

INTRODUCCIÓN: el objetivo fue evaluar la exactitud diagnóstica de Endofaster(R) para la detección de Helicobacter pylori. MÉTODOS: se realizó estudio histológico de biopsias gástricas (patrón oro) y aspirado del jugo gástrico para análisis por Endofaster(R) (negativo si la concentración de amonio fue < 57 ppm, positivo si > 67 ppm y débilmente positivo entre 57-67). RESULTADOS: ochenta y seis pacientes fueron incluidos y Endofaster(R) fue positivo en el 33,7%, débilmente positivo en el 11,6% y negativo en el 54,7%. Las biopsias fueron positivas en el 38,4%. Se alcanzó una precisión del 81,4% y Kappa = 0.57. CONCLUSIONES: Endofaster(R) permitiría un diagnóstico rápido de la infección con una buena precisión diagnóstica (AUROC = 0.81)

No disponible

Clinical validation of Endofaster® for a rapid diagnosis of Helicobacter pylori infection.

BACKGROUND: this study aimed to evaluate the diagnostic accuracy of the Endofaster® for the detection of Helicobacter pylori. METHODS: during upper gastrointestinal endoscopy, gastric juice was aspirated to perform an analysis using the Endofaster®. This test was considered as positive when the ammonium concentration was > 67 ppm, negative when < 57 ppm and weakly positive between 57 and 67. Biopsy specimens were also taken as the gold standard. RESULTS: among the 86 patients enrolled in the study, the Endofaster® result was positive in 23.7%, negative in 54.7% and weakly positive in 11.6%, whereas infection was detected via histology in 38.4% of patients. The accuracy was 81.4%, with a Kappa value of 0.57. CONCLUSIONS: the Endofaster® could be useful to perform a rapid diagnosis of Helicobacter pylori infection (area under the curve = 0.81).

Characteristics and consequences of missed gastric cancer: A multicentric cohort study.

BACKGROUND: Missed gastric cancer (MGC) is poorly documented in Mediterranean populations. AIMS: (1) To assess the rate, predictors and survival of MGC. (2) To compare MGC and non-MGC tumors. METHODS: This is a retrospective-cohort study conducted at four centers. MGC was defined as cancer detected within three years after negative esophagogastroduodenoscopy. Gastric adenocarcinomas diagnosed between 2008-2015 were included. Patients with no follow-up were excluded. RESULTS: During the study period 123,395 esophagogastroduodenoscopies were performed, with 1374 gastric cancers being diagnosed (1.1%). A total of 1289 gastric cancers were finally included. The overall rate of MGC was 4.7% (61/1289, 3.7-6%). A negative esophagogastroduodenoscopy in MGC patients was independently associated with PPI therapy (p < 0.001), previous Billroth II anastomosis (p = 0.002), and lack of alarm symptoms (p < 0.001). The most frequent location for MGC was the gastric body(52.4%). MGCs were smaller than non-MGCs (31 vs 41 mm, p = 0.047), more often flat or depressed (p = 0.003) and less likely to be encountered as advanced disease. Overall 2-year survival was similar between MGC (34.1%) and Non-MGC (35.3 %) (p = 0.59). CONCLUSION: MGC accounted for nearly five percent of newly-diagnosed gastric adenocarcinomas. Overall survival was poor and not different between MGC and non-MGC.

Evaluación prospectiva y controlada de las características técnicas de un nuevo ecoendoscopio de punción frontal / A prospective, controlled assessment of the technical characteristics of a novel forward-viewing echoendoscope

Introducción: la ultrasonografía endoscópica (USE) es una técnica de gran utilidad en el diagnóstico y tratamiento de distintas patologías del tracto digestivo. Objetivo: evaluar de forma prospectiva la utilidad clínica de un nuevo ecoendoscopio de visión frontal (FV-CLA). Métodos: estudio observacional transversal. Todos los pacientes sometidos a una USE durante un periodo de dos meses fueron evaluados para su inclusión en el estudio. Se analizaron de forma sistemática todas las estaciones mediastínicas, perigástricas y periduodenales (evaluando la facilidad de obtener los cortes ultrasonográficos y la calidad de los mismos) y se realizó punción de las lesiones indicadas clínicamente. Resultados: se incluyeron un total de 45 pacientes. La exploración ecoendoscópica pudo ser completada en el 100% de los pacientes, registrándose dos complicaciones menores. La manejabilidad del ecoendoscopio fue catalogada como sobresaliente; la visibilidad global del plano USE, como notable; y tan solo la visualización USE de las estaciones 4L y 5 fue puntuada como insuficiente. La visualización del páncreas y del resto de las estaciones USE fue puntuada como sobresaliente o notable. La facilidad de realizar punción, incluso desde la segunda porción duodenal, fue puntuada como notable o sobresaliente. Conclusión: el FV-CLA permite realizar una exploración completa y de calidad en el tracto digestivo superior, incluyendo punciones. Existen algunas estaciones mediastínicas que parecen poco accesibles para este nuevo aparato. Sería interesante validar la utilidad del FV-CLA en la terapéutica guiada por USE

Introduction: endoscopic ultrasound (EUS) is a highly useful technique for the diagnosis and management of different gastrointestinal (GI) tract conditions. Objective: to prospectively assess the clinical usefulness of a novel forward-viewing echoendoscope (FV-CLA). Methods: this was a cross-sectional observational study. All patients that underwent EUS over a two-month period were considered for the study. All mediastinal, perigastric and periduodenal stations were consistently assessed with a rating from 0 to 10 points with regard to the ease to obtain ultrasonographic sections and the quality of ultrasound images. The identified lesions were punctured when clinically indicated. Results: a total of 45 patients were included. EUS was completed in 100% of patients, with two minor complications recorded. Echoendoscope maneuverability was graded as "A" (9-10 points), overall plane visibility was graded as "B" (7-8 points) and only stations 4L and 5 visualization were graded as "D" (< 7 points). Visualization of the pancreas and the rest of the EUS stations were rated as excellent or very good. The feasibility to perform EUS-FNA, even from the second portion of the duodenum, was graded excellent or very good. Conclusion: the FV-CLA allows a complete, high-quality examination of the upper GI tract, including EUS-FNA punctures. Some mediastinal stations are hardly accessible with this new device. A formal validation of the FV-CLA for EUS-guided therapy would be of interest

A prospective, controlled assessment of the technical characteristics of a novel forward-viewing echoendoscope.

INTRODUCTION: endoscopic ultrasound (EUS) is a highly useful technique for the diagnosis and management of different gastrointestinal (GI) tract conditions. OBJECTIVE: to prospectively assess the clinical usefulness of a novel forward-viewing echoendoscope (FV-CLA). METHODS: this was a cross-sectional observational study. All patients that underwent EUS over a two-month period were considered for the study. All mediastinal, perigastric and periduodenal stations were consistently assessed with a rating from 0 to 10 points with regard to the ease to obtain ultrasonographic sections and the quality of ultrasound images. The identified lesions were punctured when clinically indicated. RESULTS: a total of 45 patients were included. EUS was completed in 100% of patients, with two minor complications recorded. Echoendoscope maneuverability was graded as "A" (9-10 points), overall plane visibility was graded as "B" (7-8 points) and only stations 4L and 5 visualization were graded as "D" (< 7 points). Visualization of the pancreas and the rest of the EUS stations were rated as excellent or very good. The feasibility to perform EUS-FNA, even from the second portion of the duodenum, was graded excellent or very good. CONCLUSION: the FV-CLA allows a complete, high-quality examination of the upper GI tract, including EUS-FNA punctures. Some mediastinal stations are hardly accessible with this new device. A formal validation of the FV-CLA for EUS-guided therapy would be of interest.

Aligning digital CD8+ scoring and targeted next-generation sequencing with programmed death ligand 1 expression: a pragmatic approach in early-stage squamous cell lung carcinoma.

AIMS: To study programmed death ligand 1 (PD-L1) expression, tumour-infiltrating T lymphocytes (TILs) and the molecular context in patients with early-stage squamous cell lung carcinomas (SCCs). METHODS AND RESULTS: The study included samples from 40 patients (discovery cohort) and 29 patients (validation cohort) diagnosed with early-stage SCC. PD-L1 immunohistochemistry (IHC) was performed with three commercially available clones (E1L3N, SP263 and SP142). CD8+ TILs were scored with a digital algorithm. All tumours were analysed with targeted next-generation sequencing (NGS). Additionally, TP53 mutations were investigated with direct sequencing. In both cohorts, we observed a significant association between CD8+ TILs density and high PD-L1 IHC expression in tumour cells (TCs). Furthermore, high SP142 PD-L1 expression in immune cells (ICs) was also associated significantly with CD8+ TILs density. Therefore, CD8+ TILs density discriminated between patients with high versus low PD-L1 IHC expression with excellent sensitivity and specificity. Interestingly, the highest percentages of PD-L1-positive TCs with the three antibodies were found in samples with cyclin-dependent kinase 6 (CDK6) amplification, with high amplification of proto-oncogene C-Myc (CMYC) or with cyclin D1-PI3 kinase subunit alpha (CCND1-PIK3CA) co-amplification. High SP142 PD-L1 IHC expression in ICs showed a non-significant correlation with TP53 mutations. Conversely, most cases with fibroblast growth factor receptor 1 (FGFR1) amplification were negative for all PD-L1 clones. CONCLUSIONS: Our preliminary results support the use of digital CD8+ TILs scoring and targeted NGS alongside PD-L1 expression. The approach presented herein could help define patients with SCCs candidates to immune checkpoints inhibitors.

Linfadenitis periportal tuberculosa: un reto diagnóstico / Tuberculous periportal lymphadenitis: A diagnostic challenge

No disponible

Pilomatrix carcinoma: a rare cause of facial tumor.

Pilomatrix carcinoma is a rare malignant tumor that originates from hair matrix cells. It is not usually considered in a differential diagnosis owing to its low incidence. We present a case of this uncommon entity and review the literature.

HAART is associated with lower hepatic necroinflammatory activity in HIV-hepatitis C virus-coinfected patients with CD4 cell count of more than 350 cells/microl at the time of liver biopsy.

OBJECTIVE: To evaluate the impact of HAART on the liver damage of HIV-hepatitis C virus (HCV)-coinfected patients with relatively preserved immune status. DESIGN: Cross-sectional study of liver biopsies. METHODS: HIV-HCV-coinfected patients who underwent liver biopsies and had a CD4 cell count of at least 350 cells/microl at the time of liver biopsy were included. Exclusion criteria included positive hepatitis B surface antigen and prior anti-HCV therapy. Necroinflammatory activity and fibrosis was scored by the Scheuer fibrosis staging system. Steatosis was scored according to the percentage of hepatocytes affected. Logistic regression analysis was used to assess determinants of necroinflammatory activity of at least 3. RESULTS: One hundred and nineteen HIV-HCV coinfected patients were included. In the univariate analysis, alcohol abuse, serum alanine aminotransferase levels, steatosis and a high fibrosis score were significantly associated with higher necroinflammatory activity. In the multivariate analysis, a high level of alanine aminotransferase, advanced fibrosis and absence of HAART were associated with higher necroinflammatory activity. CONCLUSION: Use of HAART was associated with lower levels of necroinflammatory activity. Necroinflammatory activity was strongly associated with higher fibrosis scores. These results suggest that HAART might decrease hepatitis C activity in HIV-HCV-coinfected patients with CD4 cell count of more than 350 cells/microl.