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Background: Several studies have demonstrated targeted next-generation sequencing (NGS) of biliary brushings and/or biopsy specimens can improve the identification of neoplastic bile duct strictures. However, these reports have largely been limited to retrospective analyses, single institutional experiences, and/or utilized NGS panels that were insufficiently comprehensive to account for the diversity of neoplasms that can cause a neoplastic stricture. The aim of this study was to prospectively evaluate NGS on a multi-institutional cohort of patients with a bile duct stricture in real-time.

Methods: Among seven institutions within a 3-year period, 1208 biliary specimens from 754 patients were submitted for targeted NGS that included two panels: a 28-gene NGS panel with 167 fusion genes (n=218) and a 161-gene NGS panel with 823 fusion genes (n=536). The NGS results were correlated with clinical presentation, history of primary sclerosing cholangitis (PSC), pathologic findings and follow-up. A stricture was designated as benign or neoplastic based on diagnostic pathology and/or a clinical course of >12 months.

Results: The sensitivity and specificity of NGS of biliary specimens for neoplasia were 82% and 96%, respectively. In comparison, pathologic evaluation had a sensitivity of 49% and a specificity of 100%. The combination of NGS and pathologic evaluation improved the sensitivity of both assays to 88%. Moreover, the addition of NGS to pathologic evaluation improved the sensitivity of biliary brushings from 36% to 84% and biliary biopsies from 47% to 87%. An expanded NGS panel (161 genes and 823 fusion genes) also showed improved sensitivity from 73% to 87% over a more limited panel (28 genes and 167 fusion genes). Repeat pathologic and NGS testing was performed for 118 patients and overall sensitivity increased to 91% but maintained a high specificity of 94%. Among 96 PSC patients, NGS had an 84% sensitivity as compared to pathologic evaluation with a 30% sensitivity. Of note, no statistically significant differences were observed in the performance of NGS based on the location of the patient’s stricture.

Conclusions: Through a prospective, multi-institutional study, the combination of NGS and pathologic evaluation of both biliary brushings and biopsy specimens improved the detection of neoplastic bile duct strictures. Furthermore, targeted NGS increased the sensitivity of identifying neoplasia in PSC patients.

Introduction: Cytologic evaluation of bile duct brushings (BDBs) is one of the most challenging tasks for cytopathologists, associated with low sensitivity and poor interobserver agreement. To address these difficulties, our group developed an artificial intelligence (AI) model to assist in the reading of BDB whole slide images (WSIs). This recent work demonstrated that AI-computer aided diagnosis (CADx) and AI-computer aided detection (CADe) tools matched the diagnostic accuracy of cytopathologists. The aim of this trial is to assess the efficiency and accuracy of an application housing the AI.

Methods: All consecutive BDB WSIs placed into a digital WSI database in October 2022 were identified, extracted, and uploaded to the application. The application scores each WSI as “positive” or “negative” for malignancy and then further prioritizes and ranks each WSI by the AI-CADx based on likelihood of malignancy. The AI-CADe prioritizes individual tiles/subregions by the likelihood that they contain malignant cytologic material. Users select any WSI and then evaluate the AI-prioritized list of tiles aided by the ability to freely navigate the WSI. Users label tiles as well as the entire WSI as “benign,” “atypical,” “suspicious,” or “malignant” (Figure 1A-B). User WSI labels of “benign,” “atypical,” and “suspicious” were considered “negative” and labels of “malignant” were considered “positive.” Users were blinded to all patient information.

AI-CADx, AI-enhanced cytopathologist interpretation (AI-CADe), and the official clinical cytopathologist interpretation (OCI) were compared. All WSI and patient data were reviewed by a multidisciplinary panel using a priori gold standard (GS) criteria to determine the presence or absence of malignancy for each WSI. The multidisciplinary panel was blinded to the user and AI-CADx interpretations.

Results: Of the 84 WSI uploaded, the panel identified 57 (67.9%) WSI as having a GS diagnosis labelled as “positive” (N=15, 26.3%) and “negative” (N=42, 73.7%). The GS WSIs were evaluated using the application by 4 blinded cytopathologists. While WSIs generated on average 141,950 tiles each, on average users evaluated only 10.6 tiles/WSI (10.2 tiles/neg WSI vs 11.7 tiles/pos WSI; p = 0.135), requiring only an average of 84.1 seconds of total WSI evaluation (79.3 seconds/neg WSI vs 93.7 seconds/pos WSI); p = 0.346). Overall accuracy of GS WSI interpretation for the OCI, AI-CADx, and AI-CADe were similar (80.7%, 75.4%, and 80.7%, respectively). Additional performance characteristics are reported in Table 1.

Discussion: Our trial shows that use of an AI-enhanced application allows cytopathologists to perform a targeted and abbreviated review of select WSI subregions, while maintaining their interpretive accuracy. In the future, user annotations of WSI and tiles could assist in training the AI and further improve performance.

<b>Figure 1A-B. </b>Images of the web-based AI-enhanced application. Panel A demonstrates the home page of the application that prioritizes all the WSI in the database based on the CADx-determined likelihood of malignancy. WSI names bordered in red are indicative of those WSI meeting the CADx score threshold for malignancy whereas WSI names bordered in green do not meet the score threshold. Panel B demonstrates the user view after selecting a particular WSI. From this page users can navigate and zoom in on subregions of the WSI (<i>left</i>), annotate a list of AI-CADe prioritized tiles (<i>middle </i>and <i>right</i>), and provide an overall interpretation of the WSI.

Figure 1A-B. Images of the web-based AI-enhanced application. Panel A demonstrates the home page of the application that prioritizes all the WSI in the database based on the CADx-determined likelihood of malignancy. WSI names bordered in red are indicative of those WSI meeting the CADx score threshold for malignancy whereas WSI names bordered in green do not meet the score threshold. Panel B demonstrates the user view after selecting a particular WSI. From this page users can navigate and zoom in on subregions of the WSI (left), annotate a list of AI-CADe prioritized tiles (middle and right), and provide an overall interpretation of the WSI.

<b>Table 1</b>. Comparison of performance characteristics for AI-CADe, CADx, and OCI on a cohort of BDB WSI.

Table 1. Comparison of performance characteristics for AI-CADe, CADx, and OCI on a cohort of BDB WSI.

Background: The identification of reliable and sensitive clinical diagnostic biomarkers for malignant biliary strictures is currently an unmet clinical need. Recent studies have shown that the biliary tract is colonized by its unique set of microbes that may play a role in disease pathogenesis in bile ducts. In addition, early dysplasia and tumorigenesis have been shown to be associated with changes in nutrient utilization resulting in specific cellular metabolic profile. Our aim is to establish novel biliary microbiome and metabolomic signatures that can improve early cancer detection and improve endoscopic diagnosis of indeterminate biliary strictures. Methods: In this prospective study, bile was obtained from patients with native papilla undergoing ERCP for indication of biliary obstruction with suspicion of new pancreatic cancer or cholangiocarcinoma (n=11), benign biliary diseases (i.e. choledocholithiasis, sphincter of oddi dysfunction) (n=17) and primary sclerosing cholangitis (PSC) (n=4). Bacterial DNA was extracted from bile samples and 16S rRNA sequencing was performed on V3-V4 hypervariable regions. Data analysis and visualization were performed on QIIME2 pipeline. Comprehensive hydrophilic metabolomics utilizing liquid chromatography mass spectrometry was performed on bile samples. Data analysis was done with MetaboAnalyst R package. Results: Multivariable analysis revealed significant differences in beta diversity at the genus level (p<0.05) in patients with malignant biliary strictures compared to with benign disease and PSC, demonstrating that bile microbiomes are distinct in pancreaticobiliary malignancies (Fig. 1). Analysis of the microbiome (ANCOM) showed that organisms of the genus Peptostreptococcus and Eubacterium were significantly differentially increased abundance in bile of patients with malignant strictures compared to patients with PSC and benign biliary disease respectively (p=0.002, etc). Metabolomics data demonstrated 37 statistically significant (p<0.05) differentially abundant metabolites between the groups (Fig.2). Principle-component analysis of bile metabolomics revealed a clear separation between patients with new pancreaticobiliary malignancy compared to patients with benign disease, demonstrating that bile metabolomic profiles are distinct in pancreaticobiliary malignancy (Fig. 2). Conclusion: Our results reveal the bile microbial composition and metabolomic profiles are distinct in patients with malignant biliary strictures compared to patients with PSC and benign biliary disease. This suggests that the biliary microbiome and metabolome can be used to identify malignant biliary strictures, complementary to other testable markers. Thus, bile multi-omics holds the potential to enhance future endoscopic evaluation of interminate biliary strictures and improve diagnosis of pancreaticobiliary malignancies.

Bile microbiome composition and functional profile is distinct in patients with malignant biliary strictures compared patients with benign biliary disease and PSC. A) Alpha diversity calculated using Shannon diversity index. B) Beta diversity calculated using Bray-Curtis distance. C) & D) Analysis of the microbiome composition (ANCOM) reveals that organisms of the genus Eubacterium and Peptostreptococcus are enriched in bile of patients with malignant strictures compared to that of benign biliary disease and PSC respectively. * p<0.05 in PERMANOVA.

<b>The bile metabolome is distinct in human pancreaticobiliary malignancies</b> A) Volcano plot depicting the top significantly upregulated metabolites (red) and downregulated metabolites (blue). PCA performed on the biliary metabolites of patients with malignant stricture compared to benign biliary disease.

The bile metabolome is distinct in human pancreaticobiliary malignancies A) Volcano plot depicting the top significantly upregulated metabolites (red) and downregulated metabolites (blue). PCA performed on the biliary metabolites of patients with malignant stricture compared to benign biliary disease.

Background & Aims: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts. Patients with PSC have a lifetime incidence of cholangiocarcinoma (CCA) as high as 13-15%, which is much higher than the general population. Addition of per-oral cholangioscopy (POCS) to an indicated endoscopic retrograde cholangiography (ERC) could potentially improve prognostication of progression to CCA via direct visualization of the bile duct lumen. This study aimed to assess the ability of POCS to identify 12-month CCA incidence in patients with PSC and an indication for ERC.

Methods: Forty-two consecutive patients with PSC, an indication for ERC, and no history of liver transplantation were enrolled at 5 centers in 4 countries. Of these, 36 in whom a cholangioscope could be advanced into the bile duct were included in the analysis. During the index procedure, POCS was performed before any planned therapeutic maneuvers using the SpyGlass DS Access and Delivery Catheter and SpyBite (Max) Biopsy Forceps (Boston Scientific Corporation, Marlborough, MA, USA). Patients were followed for 12 months post-POCS. The primary endpoint was ability of POCS visualization with POCS-guided biopsy to identify CCA during the study period. Secondary endpoints included repeat ERC, liver transplantation, and POCS-related serious adverse events (SAEs).

Results: Patients had a mean age of 43.5±15.6 years and 61.1% were male. The most common indications for ERC were worsening symptoms (55.6%), abnormal liver biochemistry (47.2%) or suspicion of malignancy or stricture (41.7%). POCS visualization was rated excellent or good in 97.2%. Three patients had cytological diagnosis of CCA at the index procedure. Two of 3 POCS visual impressions and all 3 SpyBite biopsies were consistent with CCA (Table). No additional patients were diagnosed with CCA within a median follow-up of 11.3 months (range 0.6-13.7). Four patients (11.1%) received repeat ERC for dilation or stricture sampling. Four patients (11.1%) had liver transplantation, one 131 days after CCA diagnosis at the index procedure, and three at 103, 299, and 317 days after benign POCS cytology findings at the index procedure. Two patients (5.5%) had POCS-related SAEs, which included one mild and one moderate case of post-ERC pancreatitis resolved without sequelae within 8 days. No cholangitis occurred after the procedure. No patients died during the study.

Conclusion: In this series, POCS added to an indicated ERC in patients with PSC accurately identified the presence or absence of CCA, with some patients receiving a repeat procedure. POCS-related SAEs were infrequent. Future research on the merits of POCS in this patient population is warranted. (Funded by Boston Scientific Corporation; ClinicalTrials.gov number, NCT03766035).

<b>POCS with biopsy versus ERC with brush cytology for 3 cases of cholangiocarcinoma</b>

POCS with biopsy versus ERC with brush cytology for 3 cases of cholangiocarcinoma

Background and Aims: Indirect diagnostic modalities are unsatisfactory for detecting intraductal neoplasm of the bile duct (IN-B), which can also be detected by peroral cholangioscopy (POC) with narrow-band imaging (NBI). We investigated the POC findings of IN-B and developed a feasible endoscopic classification system.
Methods: Consecutive 471 patients who underwent direct POC from April 2008 to July 2020 were enrolled. Intraductal superficial lesions of the bile duct (ISL-Bs) were classified according to the surface structure and microvascular pattern on POC with NBI and correlated to histologic findings after POC-guided forceps biopsy (POC-FB) or surgery. The primary outcome was the detection rate of IN-Bs, and the secondary outcomes were the associations of POC findings with IN-B, the technical success rates of POC and POC-FB, and adverse events (AEs).
Results: Direct POC was successful in 458 of 471 patients (97.2%). Among the patients, 131 (27.8%) exhibited ISL-Bs. The technical success rate of POC-FB was 94.7% (124 of 131). Among the 124 patients who underwent POC-FB, IN-B was revealed in 54 (43.5%), for a detection rate of 11.8% (54 of 458). Papillary lesion (P = 0.005), nodular lesion (P = 0.001), and regularly or irregularly dilated and tortuous vessels (P = 0.007; P = 0.001) were POC findings associated with IN-B. The area under the receiver operating characteristic curve of the novel classification system was 0.901.
Conclusions: POC with NBI can be useful for the detection of IN-Bs. Our novel classification system based on both surface structure and microvascular pattern enables differentiation of IN-B from ISL-Bs.

Sang-Heum Park

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