We describe a patient with biopsy-proven locally advanced pancreatic ductal adenocarcinoma (PDA) who underwent a modified course of gemcitabine and stereotactic body radiation therapy. Whole exome sequencing of this patient's tumor revealed a simple genome landscape with no evidence of mutations, copy number changes, or structural alterations in genes most commonly associated with PDA, i.e. KRAS, CDKN2A, TP53 or SMAD4. An analysis of germline DNA revealed no pathogenic variants of significance. Whole exome and whole genome sequencing identified a somatic mutation of RNF213 and an inversion/deletion of CTNNA2 as the genetic basis of this PDA. Although PDA is classically characterized by a predictable set of mutations, these data suggest that alternate genetic paths to PDA may exist, which can be associated with a more indolent clinical course.

We describe a patient with biopsy-proven locally advanced pancreatic ductal adenocarcinoma (PDA) who underwent a modified course of gemcitabine and stereotactic body radiation therapy. Whole exome sequencing of this patient's tumor revealed a simple genome landscape with no evidence of mutations, copy number changes, or structural alterations in genes most commonly associated with PDA, i.e. KRAS, CDKN2A, TP53 or SMAD4. An analysis of germline DNA revealed no pathogenic variants of significance. Whole exome and whole genome sequencing identified a somatic mutation of RNF213 and an inversion/deletion of CTNNA2 as the genetic basis of this PDA. Although PDA is classically characterized by a predictable set of mutations, these data suggest that alternate genetic paths to PDA may exist, which can be associated with a more indolent clinical course.

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