FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer

Pancreatic cancer: failures and hopes-a review of new promising treatment approaches

Pancreatic cancer is a challenging disease with limited treatment options and a high mortality rate. Just few therapy advances have been made in recent years. Tumor microenvironment, immunosuppressive features and mutational status represent important obstacles in the improvement of survival outcomes. Up to now, first-line therapy did achieve a median overall survival of less than 12 months and this discouraging data lead clinicians all over the world to focus their efforts on various fields of investigation: 1) sequential cycling of different systemic therapy in order to overcome mechanisms of resistance; 2) discovery of new predictive bio-markers, in order to target specific patient population; 3) combination treatment, in order to modulate the tumor microenvironment of pancreatic cancer; 4) new modalities of the delivery of drugs in order to pass the physical barrier of desmoplasia and tumor stroma. This review shows future directions of treatment strategies in advanced pancreatic cancer through a deep analysis of these recent macro areas of research.

Neutrophil-to-apolipoprotein A1 ratio predicted the efficiency of chemotherapy in advanced pancreatic cancer

BACKGROUND

Identification of a biomarker predicting chemotherapy efficacy in patients with advanced pancreatic cancer (APC) is urgently needed. This study aimed to determine the association between the neutrophil-to-apolipoprotein A1 ratio (NEAPO) and chemotherapy efficacy in APC patients.

METHODS

This retrospective study involved 236 APC patients who underwent first-line chemotherapy, including FOLFIRINOX (FFX), nab-paclitaxel plus gemcitabine (AG), or SOXIRI. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of NEAPO, and patients were divided into low and high NEAPO groups. Kaplan-Meier curves and Cox regression analyses were used to evaluate the effect of NEAPO on overall survival (OS) and progression-free survival (PFS).

RESULTS

The optimal cutoff of NEAPO was 4.69. High NEAPO levels were associated with shorter OS (p = 0.046) and PFS (p = 0.001). In the NEAPO low subgroup, the median PFS of SOXIRI was longer than that in AG group (7.2 months vs. 5.5 months, p = 0.029), with no significant difference of PFS between SOXIRI and FFX (p = 0.691). There is a trend but not significant difference in PFS between AG and FFX (p = 0.096). The proportion of disease control rate (DCR) was higher in SOXIRI group. In the NEAPO high subgroup, there was no significant difference in PFS among the three regimens, while the DCR was higher in AG group.

CONCLUSIONS

NEAPO levels were significantly associated with OS, PFS and treatment response in APC patients who underwent chemotherapy and might be a useful biomarker for predicting chemotherapy efficacy.

Incidental germline findings during comprehensive genomic profiling of pancreatic and colorectal cancer: single-centre, molecular tumour board experience

Multidisciplinary molecular tumor boards (MTB) are already well established in many comprehensive cancer centers and play an important role in the individual treatment planning for cancer patients. Comprehensive genomic profiling of tumor tissue based on next-generation sequencing is currently performed for diagnostic and mainly predictive testing. If somatic genomic variants are identified, which are suspected to be pathogenic germline variants (PGVs), MTB propose genetic counseling and germline DNA testing. Commonly used comprehensive genomic profiling approaches of tumor tissue do not include a matched germline DNA control. Therefore, the detection of PGVs could be only predicted based on the content of tumor cells (CTC) in selected tumor area (%) and variant allele frequency score (%). For conclusion, the role of a medical geneticist is essential in these cases. The overall prevalence of PGVs in patients with pancreatic ductal adenocarcinoma (PDAC) and colorectal cancer (CRC) is approximately 10%. In this single-center study, we present 37 patients with PDAC and 48 patients with CRC who were presented at MTB and tested using the large combined DNA/RNA sequencing panel. Content of tumor cells and variant allele frequency scores were evaluated in all tested patients. In case of suspicion of PGV and no previous genetic testing based on the standard guidelines, genetic counseling was recommended regardless of age, sex, and family history. In the PDAC subgroup, five patients were recommended by MTB for genetic counseling based on suspicious genetic findings. Based on a medical geneticist's decision, germline DNA sequencing was performed in four of these cases, and all of them tested positive for PGV in the following genes: ATM, ATM, BRCA1, and BRCA2. In the CRC subgroup, no PGV was confirmed in the two patients genetically tested based on the MTB recommendations. Furthermore, we present data from our center's registry of patients with PDAC and CRC who underwent genetic counseling and germline DNA testing based on the standard screening criteria. Our data confirm that comprehensive genomic profiling of tumor tissue can identify patients with hereditary forms of PDAC, who could remain unidentified by standard screening for hereditary forms of cancer.

The nucleolin antagonist N6L and paclitaxel combination treatment could be a new promising therapeutic strategy for pancreatic ductal adenocarcinoma therapy

Pancreatic cancer (PCa) is one of the most devastating cancers with few clinical signs and no truly effective therapy. In recent years, our team has demonstrated that nucleolin antagonists such as N6L could be a therapeutic alternative for this disease. In order to study a possible clinic development of N6L (multivalent pseudopeptide), we undertook to study the effect of combination of N6L with chemotherapies classically used for PCa on the survival of pancreatic cancer cells. Thus, the combined effect of N6L with either gemcitabine, FOLFOX and paclitaxel (PTX) on the survival of PANC-1, Mia-PaCa-2 and BxPC3 was studied and shown additive effect. In addition, analysis of the data by Combenefit software indicates that there are synergistic effects between N6L and the 3 chemotherapy molecules tested with more sensitive effects with the N6L-PTX combination. This result was confirmed by associating N6L and paclitaxel on porous calcium carbonate particles loaded with cyclodextrin (CD) encapsulating PTX and carrying N6L at their surface. Porous calcium carbonate particles present highly benefits for biological purposes because of their large surface area and their high stability in neutral media. As for CD, it presents the advantage of owing hydrophilic exterior and a less polar cavity in the center. We have then combined the advantageous features of both porous and negatively charged surfaces of calcium carbonate (CaCO3) particles and host molecules CD for developing carrier enabling all at once the loading of PTX (hydrophobic drug) and N6L (cationic drug). This association generates water-soluble particles capable of targeting via N6L and delivering paclitaxel to tumor cells.

Integrated spatial morpho-transcriptomics predicts functional traits in pancreatic cancer

Analyses of patient-derived cell lines have greatly enhanced discovery of molecular biomarkers and therapeutic targets. However, characterization of cellular morphological properties is limited. We studied cell morphologies of human pancreatic adenocarcinoma (PDAC) cell lines and their associations with drug sensitivity, gene expression, and functional properties. By integrating live cell and spatial mRNA imaging, we identified KRAS inhibitor-induced morphological changes specific for drug-resistant cells that correlated with gene expression changes. We then categorized a large panel of patient-derived PDAC cell lines into morphological (e.g., polygonal, irregular, spheroid) and organizational (e.g., tightly aggregated, multilayered, dispersed) subtypes and found differences in gene expression, therapeutic targeting potential, and metastatic proclivity. In human PDAC tissues, we identified prognostic expression signatures associated with distinct cancer cell organization patterns. In summary, we highlight the potential of cell morphological information in rapid, cost-effective assays to aid precision oncology efforts leveraging patient-derived in vitro models and tissues.

State of the Art of Immune Checkpoint Inhibitors in Unresectable Pancreatic Cancer: A Comprehensive Systematic Review

Immune checkpoint inhibitors (ICIs) have transformed the therapeutic landscape for several malignancies, but their efficacy in unresectable pancreatic adenocarcinoma remains uncertain. This systematic review aimed to evaluate the effectiveness and safety of ICIs in this context, focusing on overall survival (OS), progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and toxicity. A comprehensive search of MEDLINE, EMBASE, CENTRAL, and Scopus identified 34 eligible studies, including randomized controlled trials and observational cohorts. Quantitative synthesis involved 21 studies comprising 937 patients, with additional qualitative analyses on biomarker-driven subgroups and early-phase trials. The median OS across studies was 8.65 months, while the median PFS was 2.55 months. The ORR and DCR were 16.2% and 50.3%, respectively, with grade ≥3 treatment-related adverse events occurring in 22% of patients. Promising outcomes were observed in MSI-H/dMMR populations, although these represented only 1-2% of cases. Combination strategies with chemotherapy demonstrated synergistic potential but lacked definitive evidence due to heterogeneity and the absence of phase III trials. ICIs showed a manageable toxicity profile, highlighting their feasibility in selected patients. Future research should focus on overcoming tumor microenvironment barriers and identifying biomarkers to optimize responsiveness and expand the applicability of ICIs in pancreatic cancer.

Humanized Anti-MUC16 Antibody-Conjugated Contrast Agents for Magnetic Resonance Imaging of Pancreatic Cancer

Background/Objectives: Pancreatic ductal adenocarcinoma (PDAC) is diagnosed at a late stage with distant metastasis in an overwhelming 50% of cases, and the prognosis is poor. Treating this extremely aggressive disease with standard-of-care therapies has led to modest benefits in overall survival, mainly due to a lack of targeted early treatment modalities, as early detection has not yet been possible. Mucin-16 (MUC16) is a glycoprotein overexpressed in more than 60% of patients with PDAC and is a tumor-specific biomarker. Methods: In this study, a magnetic resonance imaging (MRI) probe to facilitate the detection of early and late lesions of PDAC is developed by conjugating a MUC16-targeted humanized antibody (huAR9.6) with gadolinium. Results: In preclinical mouse models, this MUC16-targeted MRI probe demonstrates effective contrast enhancement in early lesions of PDAC in the subcutaneous setting and allows for the detection of late-stage pancreatic cancer tumors in an orthotopic model. The probe did not induce any toxicity in vital organs at the administered doses. Conclusions: This study establishes that synthesizing a MUC16-targeted MRI probe is feasible and allows for the better high-resolution contrast enhancement of MUC16+ PDAC lesions to facilitate detection and possibly better treatment strategies.

Efficacy and safety of triplet regimen capecitabine, oxaliplatin, and irinotecan (XELOXIRI) as first-line chemotherapy for advanced pancreatic cancer

BACKGROUND

The 5-fuorouracil, oxaliplatin and irinotecan (FOLFOXIRI) regimen is the standard first-line treatment for advanced pancreatic cancer (APC). Capecitabine, an oral prodrug of 5-fluorouracil, offers a more convenient and potentially safer alternative. We evaluated the efficacy and safety of the XELOXIRI regimen (capecitabine, oxaliplatin, irinotecan) in Chinese patients with APC.

METHODS

This real-world study evaluated consecutive patients treated with the XELOXIRI regimen as first-line chemotherapy for APC at a national cancer center in China from August 2019 to June 2024. Treatment efficacy was assessed using the objective response rate (ORR), overall survival (OS), and progression-free survival (PFS), and safety was assessed using adverse events (AEs).

RESULTS

Fifty-six patients were enrolled (median age, 60 years [range, 33-71]; 35 males, 21 females). Seventeen had locally advanced unresectable disease and 39 had metastatic disease. After a median follow-up of 19.8 months, the ORR was 33.9% (95% confidence interval [CI]: 21.8-47.8), disease control rate was 82.1% (95% CI: 69.6-91.1), and median response duration was 6.2 months (95% CI: 3.6-NA). Six patients with locally advanced disease and one with lung metastasis underwent R0 resection, with one achieving a pathological complete response. Median OS for the entire cohort was 16.2 months (95% CI: 10.6-23.2) and median PFS was 6.3 months (95% CI: 5.3-9.0). OS rates at 6, 12, and 18 months were 92.2%, 56.7%, and 35.6%, respectively; PFS rates were 53.9%, 20.2%, and 6.7%. For those who underwent R0 resection, median OS was not reached and median PFS was 12.3 months (95% CI: 11.9-NA).Treatment-related AEs (TRAEs)occurred in 94.6% of patients, with Grade 3 or higher TRAEs in 44.6%. No Grade 5 TRAEs or treatment-related deaths were observed.

CONCLUSION

The XELOXIRI regimen demonstrated promising efficacy and manageable toxicity in the treatment of APC, providing a practical alternative to FOLFOXIRI, with similar outcomes and easier administration.

Hypoxia-induced MIR31HG expression promotes partial EMT and basal-like phenotype in pancreatic ductal adenocarcinoma based on data mining and experimental analyses

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is the most common and aggressive type of pancreatic cancer, with a five-year survival rate below 8%. Its high mortality is largely due to late diagnosis, metastatic potential, and resistance to therapy. Epithelial-mesenchymal transition (EMT) plays a key role in metastasis, enabling cancer cells to become mobile. Partial EMT, where cells maintain both epithelial and mesenchymal traits, is more frequent in tumors than complete EMT and contributes to cancer progression. The long non-coding RNA MIR31 host gene (MIR31HG) has recently emerged as a critical factor in PDAC oncogenesis. This study aimed to investigate MIR31HG's role in partial EMT and its association with the basal-like PDAC subtype.

METHODS

We analyzed the relationship between MIR31HG expression, partial EMT, and the basal-like subtype of PDAC by integrating data from public databases. We reanalyzed public data from PDAC patient-derived organoids to assess MIR31HG expression and gene signatures under hypoxic and normoxic conditions. RNA sequencing and bioinformatics analyses, including gene set enrichment analysis (GSEA), were used to investigate differentially expressed genes and pathway enrichments. EMT, partial EMT, and hypoxia scores were calculated based on the expression levels of specific gene sets.

RESULTS

We observed that MIR31HG overexpression strongly correlates with higher partial EMT scores and the stabilization of the epithelial phenotype in PDAC. MIR31HG is highly expressed in the basal-like subtype of PDAC, which exhibits partial EMT traits. Hypoxia, a hallmark of basal-like PDAC, was shown to significantly induce MIR31HG expression, thereby promoting the basal-like phenotype and partial EMT. In patient-derived organoids, hypoxic conditions increased MIR31HG expression and enhanced basal-like and partial EMT gene signatures, while normoxia reduced these expressions. These findings suggest that hypoxia-induced MIR31HG expression plays a crucial role in driving the aggressive basal-like subtype of PDAC.

CONCLUSIONS

Our results indicate that MIR31HG is crucial in regulating PDAC progression, particularly in the aggressive basal-like subtype associated with hypoxia and partial EMT. Targeting the MIR31HG-mediated network may offer a novel therapeutic approach to combat hypoxia-driven PDAC.

Hydrogel PCDME creates pancreatic cancer stem cells in OXPHOS metabolic state with TXNIP elevation

Pancreatic cancer is known as one of the poor prognostic cancers, and the most of patients are unable to undergo radical resection due to local progression or distant metastasis at initial diagnosis. In spite of the advancements in surgery and chemotherapy, there are many cases of recurrence after surgery or chemoradiotherapy mainly due to the presence of cancer stem cells (CSCs). CSCs are potential therapeutic target, but current issue is that an identification of CSCs is difficult since they are only present in a small number of tumor cells. Here we demonstrate that hydrogel PCDME can rapidly induce pancreatic cancer cell spheroids with elevated levels of stem cell markers including Sox2, Oct3/4, and Nanog, and the growth rate was reduced. CSCs showed activation of YAP/TAZ signaling, and microarray analysis showed markedly elevated expression of thioredoxin-interacting protein (TXNIP). Primary pancreatic cancer cells also increased TXNIP in addition to stemness markers on gel. In metabolic analysis, CSCs showed a shift of energy production from glycolysis to oxidative phosphorylation (OXPHOS). Furthermore, knockdown of TXNIP on PCDME gel using shRNAs decreased growth speed and in vivo tumorigenicity, suggesting that TXNIP may be involved in CSCs induction.

Arterial resection and divestment in pancreatic cancer surgery in the era of multidisciplinary treatment: decadal comparative study

BACKGROUND

The aim of this study was to investigate the feasibility and effectiveness of pancreatectomy with arterial resection/divestment for pancreatic cancer with arterial involvement in the modern era of multidisciplinary treatment.

METHODS

Patients who underwent pancreatectomy with arterial resection/pancreatectomy with arterial divestment for pancreatic cancer with arterial involvement from 2010 to 2021 were retrospectively analysed, and outcomes were compared between the former (2010-2015) and latter interval (2016-2021). Survivals were compared by univariable and multivariable analyses.

RESULTS

Among 203 patients included, 76 underwent pancreatectomy with arterial resection and 127 underwent pancreatectomy with arterial divestment. Compared with the former interval, more patients received preoperative chemotherapy (26.6% (n = 21) versus 95% (n = 118), P < 0.001), and underwent pancreatectomy with arterial resection (30.4% (n = 24) versus 41.9% (n = 52), P = 0.287) in the latter interval. The major morbidity rate and pancreatic fistula decreased in the latter interval (major morbidity rate: P = 0.040; pancreatic fistula: P = 0.006), even among patients undergoing pancreatectomy with arterial resection (major morbidity rate: P = 0.013; pancreatic fistula: P < 0.001). Patients in the latter interval had better overall survival (26.0 versus 48.2 months, P = 0.001), even among patients undergoing pancreatectomy with arterial resection (22.0 versus 45.1 months, P = 0.076).

CONCLUSIONS

Within the context of modern multidisciplinary treatment, radical resection including arterial resection should be justified for patients with pancreatic cancer with arterial involvement, considering the acceptable perioperative risk and prolonged survival.

Design and Evaluation of RNA Aptamer-Mediated Delivery of C/EBPβ siRNA for Oncological Therapy

The CCAAT/enhancer-binding protein beta (CEBPB or C/EBPβ) is a transcription factor that plays a critical role in cellular differentiation, metabolism, and immune response. Emerging evidence has highlighted its complex involvement in both solid and hematological cancers, such as hepatocellular carcinoma (HCC) and pancreatic ductal adenocarcinoma (PDAC), where it can act as an oncogene or a tumor suppressor, depending on the context. In this study, we describe the design and evaluation of a conjugate formed by a small interfering RNA (siRNA) for CEBPB and a transferrin receptor targeting aptamer (TfR-siCEBPB). The designed conjugate is active in human and mouse cells, by transfection and by passive uptake, demonstrating target engagement with strong downregulation of CEBPB mRNA transcript. In murine models of metastatic PDAC and cirrhotic HCC, treatment with TfR-siCEBPB was associated with reduction in tumor burden and improvement in liver function biomarkers. This novel aptamer conjugate allows delivery of targeted oligonucleotide therapy and is a promising therapeutic tool to take forward to human trials.

Gemcitabine and ATR inhibitors synergize to kill PDAC cells by blocking DNA damage response

The DNA-damaging agent Gemcitabine (GEM) is a first-line treatment for pancreatic cancer, but chemoresistance is frequently observed. Several clinical trials investigate the efficacy of GEM in combination with targeted drugs, including kinase inhibitors, but the experimental evidence for such rationale is often unclear. Here, we phenotypically screened 13 human pancreatic adenocarcinoma (PDAC) cell lines against GEM in combination with 146 clinical inhibitors and observed strong synergy for the ATR kinase inhibitor Elimusertib in most cell lines. Dose-dependent phosphoproteome profiling of four ATR inhibitors following DNA damage induction by GEM revealed a strong block of the DNA damage response pathway, including phosphorylated pS468 of CHEK1, as the underlying mechanism of drug synergy. The current work provides a strong rationale for why the combination of GEM and ATR inhibition may be useful for the treatment of PDAC patients and constitutes a rich phenotypic and molecular resource for further investigating effective drug combinations.

Prognostic Value of Residual Circulating Tumor DNA in Metastatic Pancreatic Ductal Adenocarcinoma

Background

Circulating tumor DNA (ctDNA) is a potential biomarker in pancreatic ductal adenocarcinoma (PDAC). However, studies on residual ctDNA in patients post-chemotherapy are limited. We assessed the prognostic value of residual ctDNA in metastatic PDAC relative to that of carbohydrate antigen 19-9 (CA19-9).

Methods

ctDNA analysis using a targeted next-generation sequencing panel was performed at baseline and during chemotherapy response evaluation in 53 patients. Progression-free survival (PFS) and overall survival (OS) were first evaluated based on ctDNA positivity at baseline. For further comparison, patients testing ctDNA-positive at baseline were subdivided based on residual ctDNA into ctDNA responders (no residual ctDNA post-chemotherapy) and ctDNA non-responders (residual ctDNA post-chemotherapy). Additional survival analysis was performed based on CA19-9 levels.

Results

The baseline ctDNA detection rate was 56.6%. Although clinical outcomes tended to be poorer in patients with baseline ctDNA positivity than in those without, the differences were not significant. Residual ctDNA post-chemotherapy was associated with reduced PFS and OS. The prognosis of ctDNA responders was better than that of non-responders but did not significantly differ from that of ctDNA-negative individuals (no ctDNA both at baseline and during post-chemotherapy). Compared with ctDNA responses to chemotherapy, a ≥ 50% decrease in the CA19-9 level had less effect on both PFS and OS based on hazard ratios and significance levels. ctDNA could be monitored in half of the patients whose baseline CA19-9 levels were within the reference range.

Conclusions

Residual ctDNA analysis post-chemotherapy is a promising approach for predicting the clinical outcomes of patients with metastatic PDAC.

Investigation of bioavailability and anti-pancreatic cancer efficacy of a self-nanoemulsifying erlotinib delivery system

AIMS

A new self-nanoemulsifying drug delivery system (SNEDDS) was developed for erlotinib (Ert) oral delivery.

MATERIALS AND METHODS

A pseudo-ternary phase diagram for olive oil, Tween 80 and polyethylene glycol (PEG) 600 mixtures, was firstly constructed. Based on the data about Ert solubility and cytotoxicity of these components, a SNEDDS composed of 10% olive oil, 20% Tween 80 and 70% (V/V) polyethylene glycol 600 was selected for Ert loading (Ert-SNEDDS).

RESULTS AND CONCLUSIONS

SNEDDS formed 31.2-nm droplets upon dilution in water, and Ert loading led to increment in the oil droplets to 83.9 ± 0.6 nm. Ert-SNEDDS represented a loading capacity and an entrapment efficiency of 22.7 ± 0.7 and 40.7 ± 0.5%, respectively. Ert release from Ert-SNEDDS was monitored in both a mixture of phosphate buffer saline and 0.5% Tween 80, and artificial gastric fluid. Ert-SNEDDS was orally administrated in rats, and the Ert plasma level was monitored over time to measure pharmacokinetic parameters. Ert-SNEDDS led to enhancement in the drug bioavailability and changed the release route of Ert. Ert-SNEDDS showed enhanced cytotoxicity toward ASPC-1 and PANC-1 cells, and half-maximal inhibitory concentration values were obtained and compared with free Ert. Ert-SNEDDS may be considered as an alternative route for oral Ert delivery.

Updates in the Surgical Management of Pancreatic Ductal Adenocarcinoma

Surgical management of pancreas cancer is complex, including the timing of surgery, surgical approach, intraoperative techniques, and postoperative management, which are reviewed in detail in this manuscript. Ultimately, referral to a high-volume pancreatic surgeon or pancreatic surgery center is critical to ensuring appropriate short-term and long-term outcomes.

The protective role of anti-parkinsonian drugs in pancreatic cancer risk: A comprehensive case-control study in Taiwan

Pancreatic cancer is among the deadliest cancers, with a grim prognosis despite advances in treatment. We conducted a population-based case-control study from Taiwan, linking Health and Welfare Data Science Center data to the Taiwan Cancer Registry, which offers a promising strategy for its treatment through drug repurposing. The study aims to identify the association of anti-parkinsonian drugs with pancreatic cancer risk across different age groups. The analysis encompassed 18,921 pancreatic cancer cases and 75,684 matched controls, employing conditional logistic regression to assess the impact of anti-parkinsonian drugs on the risk of pancreatic cancer. Key findings revealed a statistically significant association of the administration with specific anti-parkinsonian medications, including anticholinergic agents, tertiary amines, dopa derivatives, and dopamine receptor agonists, with a reduction in pancreatic cancer risk. These associations were represented as adjusted odds ratios (aORs), ranging from 0.620 (95% CI 0.470-0.810) to 0.764 (95% CI 0.655-0.891). Further, age-stratified analysis revealed variations in efficacy across different age groups. Anticholinergic agents and tertiary amines exhibited greater effectiveness in the 40-64-year age group (aOR, 0.653; 95% CI, 0.489-0.872), whereas dopa derivatives and dopamine receptor agonists were particularly efficacious in the cohort aged ≥65 years (aOR, 0.728; 95% CI, 0.624-0.850 and aOR, 0.665; 95% CI, 0.494-0.894, respectively). Notably, specific drugs such as trihexyphenidyl, levodopa/dopa decarboxylase inhibitor (DDCI), and pramipexole demonstrated a significant decrease in cancer risk, especially in the elderly population. These preliminary findings can contribute to the possible therapeutic role of anti-parkinsonian drugs in the treatment of pancreatic cancer.

Efficacy of liposomal irinotecan + 5-FU/LV vs. S-1 in gemcitabine-refractory metastatic pancreatic cancer: a real-world study using inverse probability of treatment weighting

BACKGROUND

S-1 monotherapy had previously been widely used as a second-line treatment for pancreatic cancer (PC) after gemcitabine-based chemotherapy mainly in Japan. Based on the results of the NAPOLI-1 trial, the recommended second-line therapy is now liposomal irinotecan plus fluorouracil/folinic acid (nal-IRI + 5-FU/LV). However, there have been no studies comparing nal-IRI + 5-FU/LV therapy with S-1 monotherapy.

METHODS

The main objective of this study was to compare overall survival (OS) in patients treated with nal-IRI + 5-FU/LV and those treated with S-1 monotherapy as second-line treatments, using the inverse probability of treatment weighting (IPTW) method. This study was conducted in 31 institutions participating in Japan Oncology Network in Hepatobiliary and Pancreas. To minimize potential biases due to the retrospective design, IPTW analysis was performed with multiple imputation, and imputed IPTW-adjusted hazard ratios and corresponding 95% confidence intervals (CIs) were estimated using a Cox proportional hazards model and combined into pooled estimates.

RESULTS

A total of 463 metastatic PC patients were enrolled in this study (257 in the S-1 monotherapy group and 206 in the nal-IRI + 5-FU/LV group). The median OS was 7.50 months (95% CI 4.18-12.69 months) in the nal-IRI + 5-FU/LV group and 5.72 months (95% CI 2.76-10.79 months) in the S-1 monotherapy group. In the IPTW-adjusted Cox proportional hazards model, nal-IRI + 5-FU/LV was associated with a significant OS benefit (pooled IPTW-adjusted hazard ratio, 0.779; 95% CI 0.399-0.941; p = 0.025).

CONCLUSION

These findings support the use of nal-IRI + 5-FU/LV as standard second-line treatment for PC patients after gemcitabine-based chemotherapy.

Contrast agent dispersion visualized by CE-EUS may be a prediction tool for FOLFIRINOX chemotherapy effectiveness in patients with pancreatic adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) still has a dismal 5-year overall survival of 13 %. Chemotherapy is increasingly used as treatment in both (neo-) adjuvant and palliative conditions. However, the overall survival benefits of chemotherapy must be weighed against significant side effects leading to a reduction in quality of life. CE-EUS and elastography could provide additional information about the vascularization and elasticity of the pancreatic tumor. The aim of this study was to investigate if contrast-enhanced endoscopic ultrasound and/or elastography could be suitable to predict the effectiveness of FOLFIRINOX.

METHODS

Single center, prospective proof-of-concept study in which intravenous contrast agent was administered and strain ratio was calculated in patients undergoing EUS in their regular diagnostic work-up. Directly after contrast administration, a video of 120 s was recorded and afterwards tracked and fitted by a Modified Local Density Random Walk (mLDRW) model.

RESULTS

We included 17 patients. Based on cross-sectional imaging based RECIST criteria, chemotherapy treatment was effective in 11 patients and not effective in 6 patients. The contrast dispersion parameter (κ1) differed significantly between both groups in favor of the responders: 2.994 (IQR 1.670-5.170) vs 1.203 (IQR 0.953-1.756), p = 0.005. The elastography strain ratio was higher in the effectively treated group (20.9 vs 13.6, p = 0.138).

CONCLUSION

This proof-of-concept study showed that the dispersion parameter of the first wave of contrast was 2.5 times higher in patients in whom FOLFIRINOX was effective, suggesting that this parameter could possibly be a reliable prediction tool.

[Precancerous lesions of the pancreas, prophylactic surgery]

Pancreatic cancer is a serious pathology whose incidence is increasing. Advances in imaging have made it possible to fortuitously highlight more and more cystic pancreatic lesions, some of which have a malignant potential, leading to the consideration of prophylactic excision. The various known precancerous lesions of the pancreas as well as current management recommendations are here reviewed.

Moving From the Background Toward the Spotlight: A Critical Review of Radiation Therapy for Locally Advanced Pancreas Cancer

Radiation therapy (RT) for locally advanced pancreatic cancer (LAPC) continues to be controversial. Advances in both systemic therapy and RT techniques have changed the landscape of LAPC management in recent years. Clinical outcomes of ablative RT have been encouraging, and randomized clinical trials may clarify the role of RT for LAPC. We present a contemporary critical review of key aspects regarding optimal patient selection, radiation dose escalation techniques, novel radiosensitizers and radioprotectors, and treatment response assessment for LAPC.

MYH knockdown in pancreatic cancer cells creates an exploitable DNA repair vulnerability

Pancreatic ductal adenocarcinoma (PDAC) has a poor 5-year survival rate of just 13 %. Conventional therapies fail due to acquired chemoresistance. We previously identified MutY-Homolog (MYH), a protein that repairs oxidative DNA damage, as a therapeutic target that induces apoptosis in PDAC cells. However, we did not understand the mechanism driving these anti-PDAC effects, nor did we have a means to therapeutically inhibit MYH. In this study, we demonstrated that MYH inhibition induces DNA damage and checkpoint activation in PDAC cells. Using a clinically-relevant PDAC mouse model, we showed that therapeutic MYH-siRNA delivery using Star 3 nanoparticles increased intratumoural PDAC cell death, but did not inhibit tumour growth. Finally, we showed that MYH knockdown in PDAC cells sensitised them to the anti-proliferative and anti-clonogenic effects of oxaliplatin and olaparib. Our findings identify a potential novel therapeutic approach for PDAC that induces a therapeutically exploitable DNA repair vulnerability.

ATR inhibition promotes synergistic antitumor effect in platinum-resistant pancreatic cancer

BACKGROUND

Oxaliplatin is a commonly used platinum-based chemotherapy drug for patients with pancreatic cancer (PC). Drug resistance is a major challenge in PC treatment, underscoring the urgent need for new approaches. Targeting DNA damage repair, one of the factors responsible for platinum resistance, is an attractive strategy to overcome drug resistance. This study aimed to investigate the potential of the ATR inhibitor BAY 1895344 in improving the drug responsiveness of oxaliplatin-resistant PC.

METHODS

Oxaliplatin-resistant PC cells (CFPAC-1 and Capan-2) were selected and treated with oxaliplatin, BAY 1895344, or a combination of both in vivo and in vitro. Their combinatorial effects on the DNA damage response (DDR) signaling pathway, apoptosis, and extent of DNA damage were evaluated using appropriate methods. Patient response was predicted using organoid models.

RESULTS

Combination treatment with BAY 1895344 and oxaliplatin exhibited a synergistic effect on both PC cell lines, with the effect being more pronounced on Capan-2. Additionally, the combination treatment substantially suppressed phospho-Chk1, a coordinator of DDR and cell cycle checkpoints. Mechanistically, ATR inhibition augmented the DNA damage induced by oxaliplatin, leading to mitotic catastrophe and cell death. Furthermore, in an in vivo study using a tumor-bearing xenograft mouse model, the combination treatment markedly reduced tumor growth. This synergistic effect was confirmed in patient-derived organoids with poor response to oxaliplatin.

CONCLUSION

ATR inhibition enhanced the anticancer effect of oxaliplatin, suggesting that this combination treatment could be an effective therapeutic strategy for overcoming platinum resistance in PC.

The efficacy and safety profile of third-line treatment in patients with metastatic pancreatic adenocarcinoma

BACKGROUND

For metastatic pancreatic ductal adenocarcinoma (mPDAC), there are no established third-line chemotherapy options. We examined the efficacy and safety of third-line chemotherapy in patients with mPDAC in real-world practice.

METHODS

We retrospectively analyzed 257 patients with mPDAC and progressive disease after first-line treatment with gemcitabine-based regimens and second-line treatment with liposomal irinotecan plus 5-fluorouracil and leucovorin at five Taiwanese medical centers from 2018 to 2022. Treatment efficacy and toxicity were analyzed in 77 of 257 patients receiving third-line treatment subsequently. We performed univariate and multivariate analyses to identify prognostic factors for overall survival (OS) in patients receiving third-line treatment.

RESULTS

Patients receiving third-line treatment had a median OS of 4.5 months (95 % confidence interval [CI], 3.6-5.4), compared to 1.6 months (95 % CI, 1.3-1.9) for those who did not. Independent poor prognostic factors for OS included the absence of previous pancreatectomy (adjusted hazard ratio [aHR] 3.03, 95 % CI, 1.30-7.14, P = 0.001), an ECOG score of ≥2 ((aHR 9.81, 95 % CI 4.34-22.1, P < 0.001), and progressive disease response during second-line treatment (aHR 1.90, 95 % CI 1.21-8.91, P = 0.020, P = 0.020). Median OS for patients with none, one, two, and three poor prognostic factors were 15.9 (95 % CI, 12.3-19.6), 7.0 (2.6-13.3), 4.4 (3.5-5.2), and 2.0 (1.7-2.2) months, respectively. 43 of 77 patients (56 %) experienced at least one grade 3 or 4 toxicity.

CONCLUSION

In real-world settings, patients with mPDAC receiving third-line chemotherapy may have a moderate survival advantage, although clinicians should carefully select patients owing to high incidence of grade 3/4 toxicities.

Predictive factors of FOLFIRINOX chemotherapy toxicity in pancreatic adenocarcinoma patients

INTRODUCTION

FOLFIRINOX, a primary chemotherapy for metastatic pancreatic cancer, often causes severe toxicity, necessitating hospitalization and dose adjustments. This study aims to identify predictors of FOLFIRINOX toxicity, focusing on biological, clinical, and anthropometric factors.

MATERIAL & METHODS

This retrospective study analyzes pancreatic adenocarcinoma patients on FOLFIRINOX, assessing pre-treatment biological, clinical, and anthropometric traits. Hospitalizations and tolerance during the first chemotherapy month were evaluated using CTCAE v5.0 grading, with early toxicity assessed via anthropometric factors using Anthropometer3DNet software from pre-treatment scans.

RESULTS

In 152 pancreatic cancer patients (median age: 62), FOLFIRINOX was administered in metastatic (81%), locally advanced (14%), and adjuvant/neoadjuvant (5%) settings. Performance Status was zero (49%), one (41%) and ≥ 2 (10%). Median follow-up was 62.5 months, with median overall survival of 13.7 months and progression-free survival of 8.9 months. First-cycle dose reduction occurred in 14% of patients. Within the first month, 48% experienced toxicity leading to hospitalization and/or dose reduction, with 28% requiring a median 8-day hospitalization. Low muscle body mass (MBM) significantly correlated with dose reduction (AUC 0.63; p = 0.005). An NLR ratio less than 4 was significantly associated with longer OS (p = 0.001).

CONCLUSION

Low MBM is linked to FOLFIRINOX toxicity, suggesting MBM assessment could allow better selection of patients to avoid these toxicities, warranting further confirmation in larger cohorts.

Pancreatic ductal adenocarcinoma (PDAC): clinical progress in the last five years

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal malignancy with limited therapeutic options and poor overall survival. In recent years, advances in genomic profiling have revealed the complex molecular and cellular heterogeneity of PDAC, offering new avenues for therapeutic intervention.

AREAS COVERED

This review explores emerging therapeutic strategies targeting dysregulated molecular pathways, along with the tumor microenvironment, that have shown promise in overcoming drug resistance. Novel immunotherapy strategies, such as immune checkpoint inhibitors and CAR T-cell therapies, are currently being explored in an attempt to modulate PDAC immugnosuppressive microenvironment. Additionally, we highlight recent clinical trials over the last 5 years and innovative therapeutic strategies aiming to improve outcomes in PDAC.

EXPERT OPINION

Significant progress in genomic profiling, targeted therapies, and immunotherapy is shaping the treatment of PDAC. Despite challenges posed by its dense stroma and immune suppressive microenvironment, novel strategies such as IL 6 and CD137 inhibitors, CAR-T, and therapeutic cancer vaccines are promising. KRAS targeted therapies are expanding beyond G12C inhibitors, with novel drugs in development that will further improve treatment options. Additionally, tumor treating fields (TTF) are being investigated in locally advanced PDAC, with the PANOVA-3 trial potentially integrating this modality into future treatment strategies. Continued advancements in these areas will significantly enhance PDAC outcomes.

Dynamine 3 as a diagnostic and prognostic biomarker in pancreatic cancer: Implications for early detection and targeted therapy

BACKGROUND

Dynamins are defined as a group of molecules with GTPase activity. Among them, DNM3 has gained recognition in oncology for its tumor suppressor role. Based on this, the aim of this study is to investigate the effects of the DNM3 gene in patients diagnosed with pancreatic cancer using bioinformatics databases.

MATERIALS AND METHODS

For differential gene expression analysis, TCGA TARGET GTEx study on the UCSC Xena and GEO datasets were utilized; for the analysis of changes in gene expression according to clinical and pathological characteristics, UALCAN was employed; for Overall Survival (OS) analysis, Kaplan-Meier Plotter was used; for gene alteration analysis, cBioPortal was utilized; for immune cell infiltration analysis, Tumor Immune Estimation Resource (TIMER) and TIMER2.0 were employed; for enrichment analyses Enrichr was used; for Gene Set Correlation Enrichment Analysis Gscore was used on GSE15471; for essentiality of DNM3 gene in pancratic cancer cell lines DepMap was used; and for the detection of miRNAs, miRDB was utilized; ENCORI was used for gene-miRNA correlation and miRNA prognosis analyses.

RESULTS

In the pancreatic adenocarcinoma (PAAD) cohort, DNM3 gene expression was higher in tumor samples, and there was no significant difference in expression among cancer stages. High levels of DNM3 gene expression were associated with longer OS in PAAD. A weak positive correlation was observed between DNM3 gene expression and B-Cell and CD4+ T Cell infiltrations, while a moderate positive correlation was found with CD8+ T Cell, Macrophage, Neutrophil, and Dendritic Cell infiltrations in TIMER. NK cell by QUANTISEQ, CD 4+ T Cell by TIMER, T cell regulatory (Tregs) by CIBERSORT-ABS infiltrations were positively associated with DNM3 gene expression and decreased risk in prognosis. Common lymphoid progenitor by XCELL and MDSC by TIDE infiltrations were negatively associated with DNM3 gene expression and increased risk of prognosis. Macrophage M1 by QUANTISEQ was positively associated with DNM3 gene expression and increased risk in prognosis. DNM3 gene appears to be associated with various pathways related to inflammation and the immune system. Amplification of the DNM3 gene was detected in 5 out of 175 patients. Enrichment was observed in pathways such as bacterial invasion of epithelial cells, endocytosis, endocrine and other factor-regulated calcium reabsorption, synaptic vesicle cycle, and phospholipase D signaling pathway. According to Gscore, DNM3 gene was associated with Fc epsilon RI signaling pathway, HALLMARK MTORC1 SIGNALING, HALLMARK EPITHELIAL MESENCHYMAL TRANSITION gene sets. According to ENCORI, DNM3 gene was negatively correlated with hsa-miR-203a-3p and increased expression of this miRNA was associated with adverse prognosis in PAAD.

CONCLUSIONS

The DNM3 gene may play a tumor suppressor role in pancreatic cancer, similar to its role in other malignancies. The contribution of immune cells may also be significant in this effect. However, in vitro studies are needed to elucidate the mechanisms triggered in pancreatic cancer.

Administration of FOLFIRINOX for Advanced Pancreatic Cancer: Physician Practice Patterns During Early Use

Advanced pancreatic cancer results in high morbidity and mortality. The standard of care treatment in the advanced setting changed in 2011 with the introduction of FOLFIRINOX (FFX) chemotherapy. However, it was highly toxic with significant risk of complications. We assessed the practice patterns of medical oncologists across Canada.

METHODS

We performed a retrospective study of consecutive patients with advanced pancreatic cancer treated with FFX at eight Canadian cancer centers. Demographic, treatment, and outcome data were collected and analyzed.

RESULTS

The median age of the patients was 61 (range 24-80), 43% were female, 96% had an ECOG PS of 0 or 1, and 50% had three or more metastatic sites. The median follow-up time was 20.8 months (95%CI 18.6-24.9). Physicians started FFX at the standard dose 31% of the time. Physicians prescribed GCSF for primary prophylaxis most when giving standard-dose FFX (30% of the time) in comparison to reduced dose with or without the 5-FU bolus. Dose reductions occurred in 78.1% of patients, while dose delay occurred in 65.2% of patients.

CONCLUSIONS

Medical oncologists in Canada historically prescribed FFX to patients with advanced pancreatic cancer in a fashion that was not uniform, prior to the emergence of evidence for upfront dose reductions.

NFE2-driven neutrophil polarization promotes pancreatic cancer liver metastasis progression

Pancreatic cancer liver metastasis is an important factor leading to dismal prognoses. The details of adaptive immune remodeling in liver metastasis, especially the role of neutrophils, remain elusive. Here, combined single-cell sequencing with spatial transcriptomics results revealed that liver metastases exhibit more aggressive transcriptional characteristics and higher levels of immunosuppression compared with the primary tumor. We identified neutrophils_S100A12 (S100 calcium binding protein A12) cells as the pivotal pro-metastatic cluster, specifically distributed at the invasive front of the metastatic lesions. Mechanistically, our findings indicated that nuclear factor erythroid 2 (NFE2) is a key transcription factor regulating neutrophil phenotypic polarization. Metastatic tumors produce transforming growth factor β to activate the SMAD3 pathway within neutrophils, inducing NFE2-driven polarization. NFE2 promotes the transcription of peptidylarginine deiminase 4 by binding to its promoter, leading to the generation of neutrophil extracellular traps at the invasive front. Collectively, our data demonstrate that NFE2-driven neutrophil polarization is a potential target for anti-metastatic therapy.

Reciprocal regulation of MMP-28 and EGFR is required for sustaining proliferative signaling in PDAC

BACKGROUD

Sustaining proliferation signaling is the top hallmarks of cancer, driving continuous tumor growth and resistance to drug treatments. Blocking proliferation signaling has shown limited benefit in clinical treatment of pancreatic ductal adenocarcinoma, highlighting the urgent need to deeply understand proliferation signaling and develop new therapeutic strategies.

METHODS

By leveraging clinical data and data from the TCGA and GDSC datasets, we investigated the association between MMP-28 expression and the sensitivity to EGFR inhibitors as well as the prognosis of PDAC. Transcriptomic and biological experiments explore the regulatory role of MMP-28 on the EGFR signaling pathway. Additionally, in vitro and in vivo studies are employed to evaluate MMP-28 as a biomarker for sensitivity to EGFR inhibitors.

RESULTS

We found that MMP-28, a metalloproteinase, was significantly associated with the sensitivity to EGFR inhibitors. Furthermore, MMP-28 could promote PDAC growth and metastasis. Mechanistically, MMP-28 facilitated the maturation and release of the TGF-α precursor, thus promoting EGFR activation. In return, EGFR upregulated MMP-28 through AP-1-mediated transcription, forming a positive feedback loop that provided sustaining proliferation signaling for PDAC. Subsequently, MMP-28 was identified to predict the response to EGFR inhibitors and recognize responsive patients.

CONCLUSIONS

Our findings revealed the role of MMP-28 and EGFR in generation of sustaining proliferation signaling and provided a new therapy strategy for PDAC.

Perioperative Radiation for Patients with Resectable Pancreatic Cancer: an Updated Review After the Initial RTOG 0848 Results

PURPOSE

Pancreatic cancer remains one of the most lethal malignancies, with limited long-term survival despite advances in treatment strategies. While surgical resection offers the best chance for cure in localized disease, high rates of recurrence underscore the need for effective adjuvant therapies. Over four decades, the role of adjuvant chemoradiation (CRT) has been the subject of significant debate, with numerous trials yielding mixed outcomes regarding its impact on survival. Improvements in chemotherapy regimens and radiotherapy techniques have prompted renewed efforts to define the value of CRT, particularly in comparison to chemotherapy alone. The recent initial results of RTOG 0848 mark a critical milestone in this ongoing discussion, providing contemporary evidence that challenges established assumptions and refines patient selection criteria. By identifying specific subgroups-such as lymph node-negative patients-which may benefit from CRT, the trial offers clarity while highlighting the limitations of CRT in other populations.

METHODS

Herein, we review prior prospective and retrospective trials that investigated the role of perioperative CRT, in particular radiation therapy, for resectable pancreatic cancer.

RESULTS

This review examines the trajectory of research on CRT in pancreatic cancer, assesses the implications of RTOG 0848 for current clinical practice, and underscores the importance of further studies to optimize the integration of multimodal therapy in the management of this aggressive disease.

CONCLUSION

The combination of results from RTOG 0848 in conjunction with the results of prior prospective and retrospective trials lend support for the use of adjuvant RT for patients with both lymph node-negative and lymph node-positive disease. However, several open questions remain about the role of this therapy in select patient cohorts, and whether neoadjuvant versus advent radiation is optimal.

Comparison of inflammatory markers before and after nanoliposomal irinotecan and fluorouracil with folic acid in patients with pancreatic cancer: results from the NAPOLEON-2 study (NN-2302)

Background

Relationships between cancer onset, progression, and inflammation have been reported; yet, the significance of inflammatory markers before and after treatment with nanoliposomal irinotecan and fluorouracil with folic acid (NFF) is unclear.

Objectives

We aimed to (1) investigate whether worsening inflammation is associated with disease progression and whether it can be used as a biomarker by comparing inflammatory markers before and after treatment with NFF and (2) verify which is a superior biomarker.

Design

This was a preplanned analysis of a retrospective cohort of the NAPOLEON-2 study, a multicenter observational study. Patients from 20 institutions were enrolled. Those with unresectable pancreatic cancer who received NFF as a second-line or later-line treatment between June 1, 2020, and May 31, 2021, were included.

Methods

The primary endpoint was overall survival, and the main secondary endpoint was progression-free survival. The following inflammatory markers were assessed: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, Prognostic Nutrition Index (PNI), C-reactive protein/albumin ratio (CAR), Glasgow prognostic score (GPS), Prognostic Index (PI), and Komori score.

Results

A total of 161 patients were enrolled. The CAR, NLR, GPS (1 vs 2), PI (1 vs 2), PNI, and Komori score were useful pre-NFF biomarkers (hazard ratios (HRs): 2.59, 2.28, 2.76/3.35, 2.16/18.89, 2.13, and 3.39, respectively). The CAR, NLR, GPS (compared with a score of 1/2), and PI (compared with a score of 1/2) were useful post-NFF biomarkers (HRs: 2.63, 1.88, 2.54/3.09, 2.30/5.39, respectively). In terms of the receiver operating characteristic curve and Akaike information criterion, the CAR, GPS, and PI showed favorable trends, and overall, CAR was a useful biomarker.

Conclusion

Inflammatory markers can be used as biomarkers both before and after NFF treatment, and CAR may be useful. We hope these findings will contribute to the selection of appropriate treatment options.

Advancing Targeted Therapies in Pancreatic Cancer: Leveraging Molecular Aberrations for Therapeutic Success

Pancreatic cancer is one of the most deadly with poor prognosis and overall survival rate due to the dense stroma in the tumors which often is challenging for the delivery of drug to penetrate deep inside the tumor bed and usually results in the progression of cancer. The conventional treatment such as chemotherapy, radiotherapy or surgery shows a minimal benefit in the survival due to the drug resistance, poor penetration, less radiosensitivity or recurrence of tumor. There is an urgent demand to develop molecular- level targeted therapies to achieve therapeutic efficacy in the pancreatic ductal adenocarcinoma (PDAC) patients. The precision oncology focuses on the unique attributes of the patient such as epigenome, proteome, genome, microbiome, lifestyle and diet habits which contributes to promote oncogenesis. The targeted therapy helps to target the mutated proteins responsible for controlling growth, division and metastasis of tumor in the cancer cells. It is very important to consider all the attributes of the patient to provide the suitable personalized treatment to avoid any severe side effects. In this review, we have laid emphasis on the precision medicine; the utmost priority is to improve the survival of cancer patients by targeting molecular mutations through transmembrane proteins, inhibitors, signaling pathways, immunotherapy, gene therapy or the use of nanocarriers for the delivery at the tumor site. It will become beneficial therapeutic window to be considered for the advanced stage pancreatic cancer patients to prolong their survival rate.

Nationwide implementation of the international multidisciplinary best-practice for locally advanced pancreatic cancer (PREOPANC-4): study protocol

BACKGROUND

The introduction of (m)FOLFIRINOX and gemcitabine-nab-paclitaxel has changed the perspective for patients with locally advanced pancreatic cancer (LAPC). Consequently, in experienced centres 23% of patients with LAPC undergo a resection with 5-year overall survival (OS) rates of up to 25%. In the Netherlands, the nationwide resection rate for LAPC remains low at 8%. The PREOPANC-4 program aims for a nationwide implementation of the international multidisciplinary best-practice to improve patient outcome.

METHODS

Nationwide program implementing the international multidisciplinary best-practice for LAPC. In the training phase, multidisciplinary and surgical webinars are given by 4 international experts, leading to a clinical protocol, followed by surgical off-site and on-site proctoring sessions. In the implementation phase, the clinical protocol will be implemented in all centres, including a nationwide expert panel (2022-2024). Healthcare professionals will be trained in shared decision-making. Consecutive patients diagnosed with pathology-proven LAPC (i.e., arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion [DPCG criteria]) are eligible. Primary outcomes are median and 5-year OS from diagnosis, resection rate, in-hospital/30-day mortality and major morbidity (i.e., Clavien-Dindo grade ≥ IIIa), and radical resection (R0) rate. Secondary outcomes include quality of life, functioning, side effects, and patients' healthcare satisfaction in all included patients. Outcomes will be compared with patients with borderline resectable pancreatic cancer (BRPC) treated with neoadjuvant FOLFIRINOX in the PREOPANC-2 trial (EudraCT: 2017-002036-17) and a historical cohort of patients with LAPC from the PACAP registry (NCT03513705). The existing prospective LAPC Registry and PACAP PROMs (NCT03513705) will be used for data collection. In qualitative interviews, treatment preferences, values, and experiences of LAPC patients, their relatives, and healthcare professionals will be assessed for the development of shared decision-making supportive tools. It is hypothesized that the program will double the nationwide LAPC resection rate to 16% with major morbidity < 50% and mortality ≤ 5%, and OS following resection similar to that observed in patients with BRPC.

DISCUSSION

The PREOPANC-4 program aims to safely implement the international multidisciplinary best-practice for LAPC leading to benchmark outcomes for both short-term morbidity, mortality, and OS.

TRIAL REGISTRATION

PREOPANC-4 program was registered at ClinicalTrials.gov (NCT05524090) on September 1, 2022.

HMGA2 Expression Predicts Subtype, Survival, and Treatment Outcome in Pancreatic Ductal Adenocarcinoma

PURPOSE

The purpose of this study was to establish HMGA2 as a marker of basal-like disease in pancreatic ductal adenocarcinoma (PDAC) and explore its use as a biomarker for prognosis and treatment resistance.

EXPERIMENTAL DESIGN

We identified high-mobility group A2 (HMGA2) protein expression in basal PDAC cells in a single-cell RNA sequencing (RNA-seq) atlas of 172 patient samples. We then analyzed HMGA2 expression, along with expression of the classic marker GATA-binding factor 6 (GATA6), in a cohort of 580 PDAC samples with multiplex IHC. We further supplemented these data with an additional 30 diverse patient samples and multiple independent single-cell RNA-seq databases.

RESULTS

We found that expression of HMGA2, but not previously described basal markers cytokeratins 5 or 17, predicted overall survival in our cohort. Combining HMGA2 and GATA6 statuses allowed for the identification of two key study groups: an HMGA2+/GATA6- cohort with worse survival, low tumor-infiltrating CD8+ T cells, increased FAP+ fibroblasts, and poorer response to gemcitabine-based chemotherapies (n = 94, median survival = 11.2 months after surgery) and an HMGA2-/GATA6+ cohort with improved survival, increased CD8+ T-cell infiltrate, decreased FAP+ fibroblasts, and improved survival with gemcitabine-based chemotherapy (n = 198, median survival = 21.7 months after surgery). HMGA2 was also prognostic for overall survival in RNA-seq from an independent cohort.

CONCLUSIONS

IHC stratification of primary tumors by HMGA2 and GATA6 statuses in pancreatic cancer is associated with differential outcomes, survival following chemotherapy, and tumor microenvironments. As a nuclear marker for basal disease, HMGA2 complements GATA6 to identify disease subtypes in PDAC.

Proteomic meta-analysis unveils new frontiers for biomarkers research in pancreatic carcinoma

Pancreatic carcinoma (PC) is the sixth leading cause of cancer death in both sexes in 2022, responsible for almost 5% of all cancer deaths worldwide; it is characterized by a poor prognosis since most patients present with an unresectable and metastatic tumor. To date, the decreasing trend in mortality rates related to the most common cancers has contributed to making pancreatic cancer a serious public health problem. In the last few years, scientific research has led to many advances in diagnostic approaches, perioperative management, radiotherapy techniques, and systemic therapies for advanced disease, but only with modest incremental progress in PC patient outcomes. Most of the causes of this high mortality are, unfortunately, late diagnosis and an important therapeutic resistance; for this reason, the most recent high-throughput proteomics technologies focus on the identification of novel biomarkers and molecular profiling to generate new insights in the study of PC, to improve diagnosis and prognosis and to monitor the therapies progress. In this work, we present and discuss the integration of results from different revised studies on protein biomarkers in a global proteomic meta-analysis to understand which path to pursue scientific research. In particular, cancer signaling, inflammatory response, and cell migration and signaling have emerged as the main pathways described in PC, as well as scavenging of free radicals and metabolic alteration concurrently highlighted new research insights on this disease. Interestingly, from the study of upstream regulators, some were found to be shared by collecting data relating to both biological fluid and tissue biomarkers, side by side: specifically, TNF, LPS, p38-MAPK, AGT, miR-323-5p, and miR-34a-5p. By integrating many biological components with their interactions and environmental relationships, it's possible to achieve an in-depth description of the pathological condition in PC and define correlations between concomitant symptoms and tumor genesis and progression. In conclusion, our work may represent a strategy to combine the results from different studies on various biological samples in a more comprehensive way.

Identification of patients with advanced pancreatic cancer who might benefit from third-line chemotherapy

BACKGROUND

Survival rates of patients with advanced pancreatic cancer (APC) have been improved with palliative chemotherapy series. The current preferred first-line regimen consists of combination therapy of 5-fluorouracil (5-FU)/leucovorin (LV), irinotecan, and oxaliplatin (FOLFIRINOX) or gemcitabine plus albumin-bound paclitaxel (GNP). After failure of first-line chemotherapy, there are a few options for subsequent therapy including switch to the unused first-line regimen or nano-liposomal irinotecan and 5-FU/LV. However, there are limited studies on the efficacy of third-line chemotherapy after failure of second-line chemotherapy.

AIM

To identify patients with APC who might benefit from third-line chemotherapy.

METHODS

Medical records from a single tertiary hospital were retrospectively reviewed between 2012 and 2021. The study included patients with histologically or cytologically confirmed metastatic or locally APC who underwent first-line FOLFIRINOX or GNP and subsequently received third-line chemotherapy. Overall survival (OS) after diagnosis and OS after third-line chemotherapy (OS3) were defined as the interval from the diagnosis to all-cause death and the time between the initiation of the third-line chemotherapy to all-cause death, respectively.

RESULTS

A total of 141 patients were enrolled. The median patient age at diagnosis was 61.8 years (36.0-86.0), and 54.9% were male. The first-line regimen was FOLFIRINOX (67.4%) or GNP (32.6%). The second-line regimen was FOLFIRINOX (27.0%), GNP (52.5%), or other (20.6%). The median OS was 19.0 months, and the median OS3 and progression-free survival after third-line treatment were 15.3 and 7.3 weeks, respectively. With regard to the best tumor response during third-line chemotherapy, 1.4% had partial response, 24.8% had stable disease, and 59.6% had progressive disease. The following clinical factors before third-line chemotherapy affected OS3: Good performance status (PS), serum carbohydrate antigen 19-9 (CA19-9) level < 1000 U/mL, duration of second-line chemotherapy ≥ 19 weeks, and no peritoneal seeding.

CONCLUSION

This study identified that patients with good PS, CA19-9 < 1000 U/mL, second-line chemotherapy ≥ 19 weeks, and no peritoneal seeding before starting third-line treatment may benefit more from third-line chemotherapy.

Advanced pancreatic cancer treated with camrelizumab combined with apatinib: A case report

BACKGROUND

The 5-year survival rate for patients with pancreatic cancer (PC) is 4%-12%. Surgery is the only treatment that offers curative potential, but only 15%-20% of patients are eligible for surgery. PC is prone to recurrence and metastasis, and the antitumor effect of chemotherapy is notably limited.

CASE SUMMARY

Histopathological analysis of a 53-year-old female PC patient who underwent Whipple surgery revealed poorly differentiated tumor cells infiltrating nerves, lymphatics, and blood vessels. The patient received two different first-line chemotherapy regimens consecutively; however, both regimens struggled to control disease progression. During this period, the patient underwent liver metastasis ablation surgery, Candida albicans liver abscess, and stereotactic body radiotherapy. With the addition of camrelizumab to the modified FOLFIRINOX regimen, tumor control was achieved. The patient subsequently refused to continue chemotherapy, and the antitumor regimen was changed to a combination of camrelizumab and apatinib. After patients received a combination of immunotherapy and targeted therapy, the length of hospital stay was significantly reduced. Furthermore, all side effects were within acceptable limits, leading to an improved quality of life and prolonged progression-free survival. Unfortunately, the pain associated with cancer, coupled with the side effects of opioid analgesics, has led the patient to reject all available anticancer treatment options. Approximately one month after camrelizumab and apatinib were discontinued without medical authorization, the PC recurred and rapidly progressed to widespread metastasis, ultimately leading to the patient's death approximately one month later. The overall survival was 2 years.

CONCLUSION

Immunotherapy and targeted therapy have the potential to increase both the quality of life and survival time of PC patients, particularly those whose tumor progression is not effectively controlled by chemotherapy alone. Nevertheless, further clinical trials are necessary to validate these findings.

Exercise Guidelines in Pancreatic Cancer Based on the Dietz Model

Pancreatic and gastrointestinal cancers are associated with debility, frailty, and chemotherapy regiments with significant toxicity. Practical exercise guidelines to combat these ailments and optimize functional status are lacking. We present a model for exercise for these cancers based on the Dietz framework for rehabilitation in cancer. The Dietz framework for rehabilitation describes four phases of rehabilitation including preventative (prehabilitation), restorative, supportive, and palliative. We present practical guidelines for exercise at each phase. Prehabilitation seeks to optimize functional performance typically prior to surgical resection and may occur concurrently with neoadjuvant therapy. Restorative rehabilitation occurs following the development of a physical deficit such as after surgery and may utilize skilled therapies in the inpatient, subacute, outpatient, and home settings to address functional impairments. Supportive rehabilitation occurs during stable disease or remission and depends on the frequent monitoring of functional status and particularly the development of chemotherapy-induced neuropathy to ensure timely exercise interventions. Palliative rehabilitation occurs at the end stage of life and shifts to a focus on patient comfort and safety. Exercise is a critical component of treatment in cancer demonstrating numerous quality-of-life benefits. The customization of exercise recommendations to individual patients based on their functional status and phase in treatment is essential for safety and adherence.

Multidisciplinary Therapeutic Approaches to Pancreatic Cancer According to the Resectability Status

Pancreatic ductal adenocarcinoma (PDAC) is among the most lethal cancers, characterized by late diagnosis, rapid progression, and limited therapeutic options. Despite advancements, only 20% of patients are eligible for surgical resection at diagnosis, the sole curative treatment. Multidisciplinary evaluation is critical to optimize care, stratifying patients based on resectability into resectable, borderline resectable, locally advanced, and metastatic stages. Preoperative imaging, such as computed tomography (CT) and endoscopic ultrasound (EUS), remains central for staging, for vascular assessment, and tissue acquisition. Endoscopic and systemic approaches are pivotal for addressing complications like biliary obstruction and improving outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) has been considered for years the gold standard for biliary drainage, although EUS-guided drainage is increasingly utilized due to its efficacy in both resectable and unresectable disease. Systemic therapies play a key role in neoadjuvant, adjuvant, and palliative settings, with ongoing trials exploring their impact on survival and resectability chance. This review highlights the evolving multidisciplinary approaches tailored to the disease stage, focusing on biliary drainage techniques, systemic therapies, and their integration into comprehensive care pathways for PDAC. The continuous refinement of these strategies offers incremental survival benefits and underscores the importance of personalized, multidisciplinary management.

Current and Emerging Treatment Options for Pancreatic Cancer: A Comprehensive Review

Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of death worldwide, and its global burden has increased significantly over the past few years. The incidence of pancreatic cancer has also increased in the United States, and most of this increase is attributed to the population's aging process in addition to the rise in the prevalence of risk factors such as obesity, diabetes, smoking, and alcohol intake. Most patients with pancreatic cancer present with advanced unresectable or metastatic disease. Only a few patients present at an early stage with localized disease, and a multidisciplinary approach is required to maximize survival and outcomes. The surgical approach is an option for localized disease, and surgery's safety and efficacy have also been improved in recent years due to the increasing use of minimally invasive surgical techniques. Moreover, systematic chemotherapy has also been used and has had a significant impact on survival. More recently, neoadjuvant therapy has been used for pancreatic cancer along with radiation therapy, optimizing survival among those patients. Targeted therapies have been introduced based on genetic testing in metastatic pancreatic cancer and have shown promising results. Moreover, immune checkpoint inhibitors and targeted agents such as PARP inhibitors and vaccines have emerged with optimal results in terms of survival. To conclude, pancreatic cancer is considered a disease with poor long-term survival; however, recent developments in pharmacotherapy have changed its treatment and have improved outcomes with improved survival. Our review summarizes ongoing therapeutic options for local and metastatic pancreatic cancer. It also summarizes new state-of-the-art therapies that have emerged or are in trials, which can change the pancreatic cancer treatment perspective.

SWOG S1815: A Phase III Randomized Trial of Gemcitabine, Cisplatin, and Nab-Paclitaxel Versus Gemcitabine and Cisplatin in Newly Diagnosed, Advanced Biliary Tract Cancers

PURPOSE

SWOG S1815 was a randomized, open label phase III trial, evaluating gemcitabine, nab-paclitaxel, and cisplatin (GAP) versus gemcitabine and cisplatin (GC) in patients with newly diagnosed advanced biliary tract cancers (BTCs).

METHODS

Patients with newly diagnosed locally advanced unresectable or metastatic BTC, including intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC) and gallbladder carcinoma (GBC), were randomly assigned 2:1 to either GAP (gemcitabine 800 mg/m2, cisplatin 25 mg/m2, and nab-paclitaxel 100 mg/m2 intravenously once per day on days 1 and 8 of a 21-day cycle) or GC (gemcitabine 1,000 mg/m2 and cisplatin 25 mg/m2 intravenously once per day on days 1 and 8 of a 21-day cycle).

RESULTS

Among 452 randomly assigned participants, 441 were eligible and analyzable, 67% with ICC, 16% with GBC, and 17% with ECC. There was no significant difference in overall survival (OS) between GAP versus GC. Median OS with GAP was 14.0 months (95% CI, 12.4 to 16.1) and 13.6 months with GC (95% CI, 9.7 to 16.6); hazard ratio (HR), 0.91 (95% CI, 0.72 to 1.14); P = .41. Median progression-free survival (PFS) was similar between groups with median PFS for GAP being 7.5 months (95% CI, 6.4 to 8.5) versus 6.3 months for GC (95% CI, 4.4 to 8.2); HR, 0.89 (95% CI, 0.71 to 1.12); P = .32. In exploratory subset analyses, the OS and PFS benefits of GAP versus GC treatment were greater in locally advanced disease compared with metastatic disease, although not statistically significant (interaction P = .14 for OS and P = .17 for PFS). Moreover, GAP versus GC showed greater improvement in PFS among participants with GBC than those with ICC or ECC (interaction P = .01), but not OS (interaction P = .28).

CONCLUSION

The addition of a taxane in the GAP regimen to the standard gemcitabine-cisplatin regimen did not improve OS in newly diagnosed BTC. More toxicity was encountered with GAP versus GC.

Advancing Immunotherapy in Pancreatic Cancer: A Brief Review of Emerging Adoptive Cell Therapies

Pancreatic cancer has the lowest 5-year survival rate (13%) among major cancers and is the third leading cause of cancer-related deaths in the United States. The high lethality of this cancer is attributed to its insidious onset, late-stage diagnosis, rapid progression, and limited treatment options. Addressing these challenges requires a deeper understanding of the complex tumor microenvironment to identify novel therapeutic targets. Newer approaches like adoptive cell therapy have shown remarkable success in treating hematological malignancies, but their application in solid tumors, particularly pancreatic cancer, is still in the early stages of development. ACT broadly involves isolating immune cells (T lymphocytes, Natural Killer cells, and macrophages) from the patient, followed by genetic engineering to enhance and mount a specific anti-tumor response. Various ACT modalities are under investigation for pancreatic cancer, including chimeric antigen receptor T cells (CAR-T), chimeric antigen receptor NK cells (CAR-NK), tumor-infiltrating lymphocytes (TIL), T-cell receptor (TCR)-engineered T cells, and cytokine-induced killer cells (CIK). Major hurdles have been identifying actionable tumor antigens and delivering focused cellular therapies to overcome the immunosuppressive and dense fibrotic stroma surrounding the pancreatic cancer. Further studies are needed to explore the limitations faced by cellular therapy in pancreatic cancer and identify novel combination treatment approaches in order to improve clinical outcomes.

Immunomodulation of Pancreatic Cancer via Inhibition of SUMOylation and CD155/TIGIT Pathway

Pancreatic ductal adenocarcinoma (PDAC) is the deadliest major cancer and has a profoundly immunosuppressive tumor microenvironment (TME). Previous studies have shown that inhibition of the E1 enzyme, which catalyzes the small ubiquitin-like modifiers (SUMO), with the small molecule TAK-981, can reprogram the TME to enhance immune activation and suppress tumor growth. We found that the CD-155/TIGIT pathway, a key regulator of immune evasion in PDAC, is influenced by SUMOylation. We hypothesized that the combination of SUMO E1 and TIGIT inhibition would synergistically induce anti-tumor immune effects. We used a clinically relevant orthotopic mouse model that consistently develops liver metastases to study this combination therapy alone and in the perioperative setting with surgical resection. The combination of SUMO E1 and TIGIT inhibition significantly prolonged survival. Complete responders exhibited protective immunity and enhanced T cell reactivity to model-specific alloantigens. Complementary immune analyses of resected tumors demonstrated that combination therapy more significantly reduces the abundance of regulatory FOXP3+CD4+ T cells than each monotherapy alone. The findings suggest that SUMO E1 inhibition enhances antibody-mediated elimination of Tregs through innate immune cells, potentially by activation of type I interferon responses. Our results highlight a mechanism to enhance the efficacy of anti-TIGIT therapy.

Brief Summary

SUMOylation is a post-translational modification process critical for cancer. Inhibition of SUMOylation can improve the sensitivity of pancreatic cancer to immune checkpoint inhibition.

Tumor-Intrinsic Kinome Landscape of Pancreatic Cancer Reveals New Therapeutic Approaches

SIGNIFICANCE

We provide a comprehensive tumor-intrinsic kinome landscape that provides a roadmap for the use of kinase inhibitors in PDAC treatment approaches.

TOPBP1 as a potential predictive biomarker for enhanced combinatorial efficacy of olaparib and AZD6738 in PDAC

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive and often lethal malignancy, requiring the development of enhanced therapeutic approaches. The DNA damage response (DDR) pathway is frequently altered during PDAC development, leading to an increased occurrence of DNA damage. DNA topoisomerase II-binding protein 1 (TOPBP1) plays a supportive role in regulating the DDR pathway, and its overexpression has been linked to the tumorigenesis of various cancers. This study investigated the biological role of TOPBP1 in PDAC pathogenesis and evaluated its clinical relevance in guiding treatment regimens. We examined the relationship between TOPBP1 expression, DDR pathway modulation, and therapeutic response in PDAC cell lines, primary cells, and subcutaneous mouse models. We found that elevated TOPBP1 expression was positively correlated with increased histologic grade and reduced patient survival in PDAC. TOPBP1 knockdown increased the sensitivity of PDAC cells to olaparib treatment and improved therapeutic efficacy in both PDAC cell lines and subcutaneous mouse models. Combination treatment with olaparib and AZD6738 effectively induced P53-dependent apoptosis via inhibiting the ATR pathway and enhancing signaling through the ATM pathway, which significantly reduced the viability of pancreatic cell lines. Notably, this combination therapy was more effective in PDAC cell lines exhibiting high TOPBP1 expression, indicating that TOPBP1 may serve as a useful predictive biomarker. In conclusion, TOPBP1 is a potential marker for optimizing the olaparib and AZD6738 combination therapy in PDAC. This study highlights the clinical significance of TOPBP1 in the treatment of PDAC and emphasizes the potential implications for a broader population of patients.

Study protocol of the METAPANC trial - intensified treatment in patients with local operable but oligometastatic pancreatic cancer - multimodal surgical treatment versus chemotherapy alone: a randomized controlled trial

BACKGROUND

Based on current guidelines, surgical treatment of hepatic oligometastases in patients with pancreatic ductal adenocarcinoma (PDAC) is not primarily recommended. Systematic chemotherapy is the therapy of choice for these patients. The relevance of subsequent surgical resection after chemotherapy remains unclear. This multicentre, randomized, controlled phase III trial is planned to evaluate whether resection of the primary tumor and liver metastases can improve overall survival in patients with PDAC with hepatic oligometastases in a multimodal treatment setting.

METHODS

After an induction therapy with eight cyles of mFOLFIRINOX and a response assessment after four and eight cycles, patients will be randomized to either Arm 1 (perioperative mFOFIRINOX plus resection of the primary tumor with resection or ablation of all hepatic metastases) or Arm 2 (continuation of 4 cycles of the standard-of-care mFOLFIRINOX chemotherapy). This clinical trial will focus on a well-defined patient group with metastatic disease limited to the liver as the target organ, with a maximum of three metastases.

DISCUSSION

METAPANC is the first international, randomized, controlled, open-label, multicentre, phase III clinical trial for curative intended surgical therapy of oligometastatic pancreatic cancer in Europe and America. The multimodal surgical treatment of patients with oligometastatic pancreatic cancer could significantly extend the overall survival of this patient group. A possible recommendation of this multimodal treatment regimen outside of clinical trials requires data from randomized controlled trials first. To identify patient subgroups that might benefit from multimodal surgical therapy, additional information on tumor genetics could supplement valid parameters.

TRIAL REGISTRATION

EU Clinical Trials No. 2023-503558-10-00.

Blood Sample Collection in Randomized Controlled Trials for Biomarker Discovery and Validation: Experience of the PREOPANC-2 Trial

BACKGROUND

This study aimed to investigate the feasibility and yield of blood sample collection in an investigator-initiated nationwide randomized controlled trial (RCT).

METHODS

In the PREOPANC-2 trial, 375 patients with (borderline) resectable pancreatic cancer were randomly assigned to two neoadjuvant regiments in 19 centers in the Netherlands (2018-2021). Blood sample collection was scheduled at seven time points before, during, and after treatment. The primary outcome was the proportion of successfully collected blood samples at each scheduled time point.

RESULTS

Of the 375 randomized patients, 12 were excluded from blood sample collection before any treatment. From the remaining 363 patients, 1513 (87 %) of 1748 blood samples were collected, processed, mailed, and centrally stored. The blood samples were collected before treatment from 347 (96 %) of the 363 patients, after the first neoadjuvant cycle from 322 (94 %) of 343 patients, after neoadjuvant treatment (i.e., before surgery) from 260 (83 %) of 313 patients, and after surgery from 210 (77 %) of 271 patients. During the follow-up visits, blood samples were collected from 147 (82 %) of 179 patients 12 months after randomization and from 83 (77 %) of 108 patients after 24 months. A total of 220 samples (13 %) were missing. The most common causes for missing blood samples were scheduling oversights, unsuccessful blood draw attempts, and mailing failures (151 times, 69 %). Blood sample collection was canceled 69 times (31 %) due to COVID-19.

CONCLUSION

Blood sample collection in the PREOPANC-2 trial had a yield of 96 % before treatment and an overall yield of 87 %. Collection of blood samples for biomarker studies is feasible in a nationwide RCT.

A logistic regression model to predict long-term survival for borderline resectable pancreatic cancer patients with upfront surgery

BACKGROUND

The machine learning model, which has been widely applied in prognosis assessment, can comprehensively evaluate patient status for accurate prognosis classification. There still has been a debate about which predictive strategy is better in patients with borderline resectable pancreatic cancer (BRPC). In the present study, we establish a logistic regression model, aiming to predict long-term survival and identify related prognostic factors in patients with BRPC who underwent upfront surgery.

METHODS

Medical records of patients with BRPC who underwent upfront surgery with portal vein resection and reconstruction from Jan. 2011 to Dec. 2020 were reviewed. Based on postoperative overall survival (OS), patients were divided into the short-term group (≤ 2 years) and the long-term group (> 2 years). Univariate and multivariate analyses were performed to compare perioperative variables and long-term prognoses between groups to identify related independent prognostic factors. All patients are randomly divided into the training set and the validation set at a 7:3 ratio. The logistic regression model was established and evaluated for accuracy through the above variables in the training set and the validation set, respectively, and was visualized by Nomograms. Meanwhile, the model was further verified and compared for accuracy, the area under the curve (AUC) of the receiver operating characteristic curves (ROC), and calibration analysis. Then, we plotted and sorted perioperative variables by SHAP value to identify the most important variables. The first 4 most important variables were compared with the above independent prognostic factors. Finally, other models including support vector machines (SVM), random forest, decision tree, and XGBoost were also constructed using the above 4 variables. 10-fold stratified cross-validation and the AUC of ROC were performed to compare accuracy between models.

RESULTS

104 patients were enrolled in the study, and the median OS was 15.5 months, the 0.5-, 1-, and 2- years OS were 81.7%, 57.7%, and 30.8%, respectively. In the long-term group (n = 32) and short-term group (n = 72), the overall median survival time and the 1-, 2-, 3- years overall survival were 38 months, 100%, 100%, 61.3% and 10 months, 38.9%, 0%, 0%, respectively. 4 variables, including age, vascular invasion length, vascular morphological malformation, and local lymphadenopathy were confirmed as independent risk factors between the two groups following univariate and multivariate analysis. The AUC between the training set (n = 72) and the validation set (n = 32) were 0.881 and 0.875. SHAP value showed that the above variables were the first 4 most important. The AUC following 10-fold stratified cross-validation in the logistic regression (0.864) is better than SVM (0.693), random forest (0.789), decision tree (0.790), and XGBoost (0.726).

CONCLUSION

Age, vascular invasion length, vascular morphological malformation, and local lymphadenopathy were independent risk factors for long-term survival of BRPC patients with upfront surgery. The logistic regression model plays a predictive role in long-term survival and may further assist surgeons in deciding the treatment option for BRPC patients.

Extensive molecular profiling of KRAS wild-type as compared to KRAS mutated pancreatic ductal adenocarcinoma on 318 patients

PURPOSE

Molecular profiling is increasingly implemented to guide treatment of advanced pancreatic ductal adenocarcinoma (PDAC), especially when for clinical trials enrollment. This study aimed to describe actionable alterations detected in KRAS mutated (KRASm) versus KRAS wild-type (KRASwt) PDAC, the latter group being considered enriched in molecular alterations.

METHODS

This prospective monocentric study included patients with locally advanced or metastatic PDAC who underwent next-generation sequencing (NGS) on liquid biopsy and/or tissue samples between 2015 and 2023, as part of the BIP academic study (NCT02534649). Actionable alterations were classified using the ESCAT (ESMO Scale for Clinical Actionability of molecular Targets).

RESULTS

A total of 378 patients with a PDAC underwent NGS: 73 on tissue samples, 162 on liquid biopsies, and 143 on both tissue and liquid. Liquid biopsies had a 59.3 % performance (181 informative samples out of 305). Among 318 informative NGS samples, 273 (86 %) were KRASm, and 45 (14 %) were KRASwt. Median overall survival (OS) was 19.35 in KRASwt patients and 16.89 months for KRASm patients (HR 0.67, 95 %CI (0.49-0.90), p = 0.02). ESCAT alterations were found in 15.7 % of total population, with 31.1 % in KRASwt tumors and 13.2 % in KRASm tumors. BRCA1/2 mutations were identified in 7.5 % of the population, and one NTRK fusion was found in a KRASwt PDAC. The molecular tumor board considered 71 patients (22.3 %) eligible for early-phase trials, with 14 treated with matched therapy.

CONCLUSION

Although actionable mutations were more frequent in KRASwt tumors, 13.2 % of KRASm PDAC harbored ESCAT alterations, emphasizing the importance of molecular profiling regardless of KRAS status.