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Background: Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer related death in the US. Unfortunately, recent clinical trials using immunotherapy targeting the highly immunosuppressive tumor microenvironment have showed disappointing results, as there is no method to predict which patients will respond to therapy. More recently, the development of single cell technology has allowed for in-depth profiling at the cellular level using small amounts of tissue, raising the potential to develop precision medicine tools at time of endoscopic fine needle biopsy. Results: We performed single-cell RNA sequencing (scRNAseq) on endoscopic fine needle biopsies from 10 PDAC tumors at time of diagnostic endoscopic biopsy or 6 surgically resected tissues. We also sequenced 3 adjacent or normal pancreas tissues. We captured 8,521 cells from 3 surgical normal adjacent samples and 46,244 cells from PDAC tumors. Mapping of putative interactions between ligands and receptors demonstrated upregulation of key signaling pathways, including Hedgehog, NOTCH, and chemokine signaling within myeloid, epithelial, T, and NK cells. Differential expression analysis in cytotoxic CD8 T cells of PDA patients revealed increased expression of genes involved in T cell activation (GZMB, GZMA), exhaustion (GZMK, EOMES) as well as immune checkpoint pathway upregulation when compared to cytotoxic T cells in adjacent normal pancreatic tissue. Among the most significantly increased genes in CD8 T cells of PDAC tumor was the immune checkpoint TIGIT. Upon further analysis of the CD8 T cells, we found TIGIT was almost exclusively expressed in exhausted CD8 T cells, while other checkpoints such as PD-1 and LAG3 were equally distributed across effector and exhausted T cell populations. Interestingly, we were able to capture patient-specific heterogeneity of gene expression in T cells, suggesting the possibility of individualized T cell gene signatures present in PDAC tumors. We used mass cytometry and immunostaining to validate our transcript-based findings. Conclusion: Overall, we have successfully performed robust in-depth profiling using single-cell sequencing of PDAC tumors from fine needle biopsies. TIGIT, but not other immune checkpoints, correlates with T cells exhaustion in tumors, revealing an important biological function of this relatively understudied checkpoint. Analysis of our results identified patient-specific heterogeneity of key signaling pathways in different cell compartments of PDAC tumors that have to potential to be leveraged for precision medicine. Citation Format: Nina Steele, Eileen Carpenter, Samantha Kemp, Veerin Sirihorachai, Stephanie The, Lawrence Delrosario, Jenny Lazarus, El-ad Amir, Valerie Gunchick, Carlos Espinoza, Samantha Bell, Lindsey Harris, Valerie Irizarry-Negron, Dan Paglia, Justin Macchia, Fatima Lima, Angel Ka Yan Chu, Heather Schofield, Erik Jan Wamsteker, Richard Kwon, Allison Schulman, Anoop Prabhu, Ryan law, Arjun Sondhi, Katelyn Donahue, Hari Nathan, Clifford Cho, Michelle Anderson, Vaibhav Sahai, Costas Lyssiotis, Benjamin Allen, Arvind Rao, Weiping Zou, Filip Bednar, Timothy Frankel, Marina Pasca di Magliano. Multimodal mapping of the immune landscape in human pancreatic cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3442.

Efficacy of metal and plastic stents in unresectable complex hilar cholangiocarcinoma: a randomized controlled trial. Gastrointest Endosc 2012;76:93-9. 5. Mukai T, Yasuda I, Nakashima M, et al. Metallic stents are more efficacious than plastic stents in unresectable malignant hilar biliary strictures: a randomized controlled trial.

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Background: Heller myotomy (HM) is highly effective for achalasia treatment. Nonetheless, recurrent/persistent symptoms occur in 10-20% of patients. Management options include POEM, redo-HM, or pneumatic dilatation (PD). It is currently unknown which of these options is more effective. Aims: To compare the efficacy and safety of POEM, redo-HM, or PD in patients with previous failed HM. Methods: This was an international experience at 14 centers between 10/2010 and 11/2019. Adults with failed HM who underwent POEM, redo-HM, or PD were included. Technical success was defined as successful completion of the procedure. Clinical success was defined as a decrease in Eckardt score (ES) to 3 without the need for reinterventions. Adverse events (AEs) were graded according to the ASGE Lexicon/Clavien-Dindo classification. Results: A total of 162 patients (51% F, mean age 54yr) with failed HM were included, of whom 108 underwent POEM, 23 redo-HM, and 31 PD. The baseline mean ES was 6.1, 6.6 and 6.2 (pZ0.6), and baseline mean integrated relaxation pressure was 18.7, 16.1 and 22.0 (pZ0.5). Technical success was achieved in all patients. After a mean follow up of 16.9 months (14.4 POEM, 26.0 redo-HM, 18.4 PD), the POEM group had the lowest mean post treatment ES (1.8 vs 4.4 vs 5.0, p<0.001) and rate of clinical relapse (11.7% vs 68.1% vs 48.2%, pZ0.02). At 6-12 months follow up, clinical success was achieved in 90% of POEM patients, 60% redo-HM, and 50% PD (pZ0.01), and higher in the POEM group vs redo-HM (OR 6.01, pZ0.03). At 12-24 months follow up, 83.3% of POEM patients, 40% redo-HM, and 28.5% PD remained in clinical success (0.004), which was higher in the POEM group vs redo-HM (OR 4.5, pZ0.001) and lower in the PD group vs POEM (OR 0.17, pZ0.01). In patients with >24 months follow up (nZ41, mean 38.6 mo), 72.7% of POEM patients, 40% redo-HM and 22% PD remained in clinical success (pZ0.03), which was higher in the POEM group vs redo-HM (pZ0.07), and lower in the PD group vs POEM (OR 0.11, pZ0.02). Patients who underwent redo-HM experienced more AEs (26% vs 8% POEM vs 13% PD, pZ0.05). Based on Clavien-Dindo/ASGE Lexicon, redo-HM group experienced more grade 3 and 4 AEs (13% vs 1% POEM vs 0% PD, pZ0.02) and more severe AEs (9% vs 0% PEOM vs 0% PD; pZ0.007). The PD group had the shortest mean procedure time (31.1 min, p<001) and LOS (p<0.001). The redo-HM group had longer procedure duration (167 vs 84 min, p<0.001) and LOS (5 vs 2 d, p<00.1), compared with the POEM group (Table 1). Univariable logistic regression analysis demonstrated that patients who underwent retreatment with POEM have a higher likelihood of achieving clinical success compared with redo-HM (OR 7.6, p<0.001) (Table 2). Conclusion: POEM results in higher short/mid-term clinical success and lower rate of clinical relapse compared with alternative treatments in patients with failed HM.