Pancreatic Adenocarcinoma, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

Recurrent pancreatic cancer treated with N-803 and PD-L1 t-haNK followed by an EGFR-targeted nanocell drug conjugate

Multimodal temporal therapy orchestrated to leverage immunotherapy, tumor-targeted chemotherapy, and natural killer (NK) cell therapy may provide an opportunity to induce immunogenic cell death for tumor response and increased survival in patients with recurrent cancer. The interleukin-15 (IL-15) superagonist N-803, an enhancer of NK cells, CD4 + T cells, cytotoxic CD8 + T cells, and memory T-cell activity, combined with off-the-shelf PD-L1-targeted high-affinity NK (PD-L1 t-haNK) cells represent novel immunotherapies designed to overcome an immunosuppressive tumor microenvironment (TME). The epidermal growth factor receptor-targeted antibody-nanocell conjugate E-EDV-D682 provides tumor-targeted chemotherapy in the form of its anthracycline metabolite PNU159682 (nemorubicin) cargo and is currently being studied in combination with immunomodulatory EDVs delivering the adjuvant α-galactosyl ceramide (GC). Here, we report the compassionate use treatment of this combination in a patient with recurrent, metastatic pancreatic cancer (mPC) after 3 lines of therapy. Under the initial single-patient Investigational New Drug (spIND) protocol, the patient received N-803, PD-L1 t-haNK cells, and the albumin doxorubicin conjugate aldoxorubicin for ~27 months. The patient's disease became stable on this regimen, and a transient complete response was observed by ~14 months of therapy. Due to progression, a second spIND protocol was designed whereby the patient received E-EDV-D682 plus EDV-GC for more than 24 months, which resulted in stable disease and the patient's continued survival at the time this report was written. The patient's extended survival despite the dire prognosis associated with recurrent mPC points to the merits of this temporal combination regimen in overcoming immuno-chemo resistance with enhanced immune activity required for tumor response and extended survival.

Clinical role of intraperitoneal chemotherapy in patients with pancreatic ductal adenocarcinoma concomitant with occult peritoneal dissemination: A multicenter retrospective study

Background

The effectiveness of intraperitoneal chemotherapy using paclitaxel (i.p.‐PTX) in pancreatic ductal adenocarcinoma (PDAC) patients with peritoneal dissemination remains elusive. The aim of this study is to investigate the clinical outcome of patients treated with i.p.‐PTX combined with systemic chemotherapy compared with current standard chemotherapy including gemcitabine plus nab‐paclitaxel and FOLFIRINOX.

Methods

Data of patients with peritoneal dissemination was retrospectively collected and analyzed (i.p.‐PTX, n = 83; control, n = 86). Inverse probability of treatment‐weighted analyses (IPTW) was used to balance baseline characteristics between two groups. Survival curves were estimated using Kaplan–Meier method, and the differences were compared using the log‐rank test.

Results

No significant differences were noted in overall survival (14.9 vs. 15.5 months, p = 0.481) and progression free survival (9.5 vs. 9.1 months, p = 0.267) between i.p.‐PTX and the control groups. Nevertheless, i.p.‐PTX (9.9 months) significantly prolonged the median progression‐free survival (PFS) time compared with the control (8.6 months), among the matched patients using IPTW (hazard ratio 0.666, p = 0.041). Moreover, subgroup analysis among the patients whose primary tumor were evaluated either as resectable or borderline resectable disease revealed significantly better overall survival in the i.p.‐PTX group compared with the control group (21.3 vs. 14.7 months, hazard ratio; 0.532, p = 0.033). Conversion surgery was more frequently performed in the i.p.‐PTX group than the control group (24% vs. 4%, p = 0.006).

Conclusion

The i.p. PTX regimen prolonged PFS but not overall survival, and subgroup analysis suggested the possibility of survival benefit in patients with occult peritoneal dissemination whose primary tumor was classified as resectable/borderline resectable disease.

Role of neoadjuvant peptide receptor radionuclide therapy in unresectable and metastatic gastro-entero-pancreatic neuroendocrine neoplasms: A scoping review

Peptide receptor radionuclide therapy (PRRT) is an established therapy for metastatic neuroendocrine neoplasms (NEN). The role of PRRT as a neoadjuvant treatment prior to surgery or other local therapies is uncertain. This scoping review aimed to define the landscape of evidence available detailing the utility of PRRT in the neo-adjuvant setting, including the clinical contexts, efficacy, and levels of evidence. A comprehensive literature search of PUBMED, SCOPUS, and EMBASE through to December 2022 was performed to identify reports of PRRT use as neoadjuvant therapy prior to local therapies. Observational studies and clinical trials were included. A total of 369 records were identified by the initial search, and 17 were included in the final analysis, comprising 179 patients treated with neoadjuvant PRRT. Publications included case reports, retrospective cohort series and a phase 2 trial. Definitions of unresectable disease were variable. Radioisotopes used included 177Lu (n = 142) and 90Y (n = 36), used separately (n = 178) or in combination (n = 1). A combination of PRRT with chemotherapy was also explored (n = 2). Toxicity data was reported in 11/17 studies. Survival analysis was reported in 3/17 studies. Surgical resection following PRRT was reported for both the primary tumor (n = 71) and metastases (n = 12). Resection rates could not be calculated as not all publications reported whether resection was completed. Published literature exploring the use of PRRT in the neoadjuvant setting is mostly limited to case reports and retrospective cohort studies. From these limited data there is reported to be a role of PRRT in neoadjuvant setting in the literature. However, the low quality of evidence precludes any definite conclusion on the grade of disease, site of primary, isotope used or use of concomitant chemotherapy that can benefit from this application. Further prospective studies will require collaboration between multiple centers to gain sufficient high-quality evidence.

Hepatobiliary and Pancreatic Neoplasms: Essential Predictive Imaging Features for Personalized Therapy

Tumor biologic characteristics encompassing histopathologic, immune microenvironmental, genetic, and molecular aspects are becoming indispensable factors to be considered in treatment strategies for patients with cancer. Innovations in oncologic treatment have broadened the range of therapeutic approaches and now hold promise for treatments personalized according to tumor biologic characteristics. Particularly for hepatobiliary and pancreatic neoplasms, the advent of cytostatic agents such as molecularly targeted agents and immune checkpoint inhibitors, which differ markedly from conventional cytotoxic agents, has contributed to advances in clinical practice. These cytostatic agents increase the potential for curative-intent treatment of unresectable cancers by reducing tumor volume. Radiologic examinations are of more interest than ever to noninvasively obtain information about tumor biologic features. Radiomics represents an invaluable research method for elucidating associations between tumor biologic characteristics and radiologic imaging findings, but their applicability in daily clinical practice remains challenging. Various radiologic predictive findings for tumor biologic characteristics have already been proposed for hepatobiliary and pancreatic neoplasms. Radiologists must gain familiarity with these findings and the roles they have in predicting the clinical prognosis and treatment efficacy. In addition, radiologists should explore the potential applications of these imaging findings to current treatment strategies for the coming era of personalized medicine. The authors describe predictive findings using CT and MRI for diagnosis of hepatocellular carcinoma, colorectal liver metastases, intrahepatic cholangiocarcinoma, and pancreatic adenocarcinoma, with correlations to pathologic, immunologic, molecular, and genetic background factors. ©RSNA, 2025 Supplemental material is available for this article. See the invited commentary by Ronot in this issue.

Mortensen M, Lesurtel M, Bonds M, Chatzizacharias N, Strobel O, Turrini O, Griffin O, Franklin O, Pfeiffer P, Schulick RD, Salvia R, de Wilde RF, Dokmak S, Rodriguez Franco S, Augustinus S, Burgdorf SK, Crippa S, Hackert T, Tarvainen T, Burns WR, Messersmith W, Wilmink JW, Burkhart RA, Del Chiaro M, Besselink MG. Adjuvant Chemotherapy After Resection of Localized Pancreatic Adenocarcinoma Following Preoperative FOLFIRINOX

Importance

The effect of adjuvant chemotherapy following resection of pancreatic adenocarcinoma after preoperative (m)FOLFIRINOX (combination leucovorin calcium [folinic acid], fluorouracil, irinotecan hydrochloride, and oxaliplatin in full or modified dosing) chemotherapy on overall survival (OS) is unclear because current studies do not account for the number of cycles of preoperative chemotherapy and adjuvant chemotherapy regimen.

Objective

To investigate the association of adjuvant chemotherapy following resection of pancreatic adenocarcinoma after preoperative (m)FOLFIRINOX with OS, taking into account the number of cycles of preoperative chemotherapy and adjuvant chemotherapy regimen.

Design, Setting, and Participants

This retrospective cohort study included patients with localized pancreatic adenocarcinoma treated with 2 to 11 cycles of preoperative (m)FOLFIRINOX followed by resection across 48 centers in 20 countries from 2010 to 2018. Patients who died within 3 months after surgery were excluded (landmark). Data were analyzed from February 1 to December 31, 2023.

Exposures

Preoperative (m)FOLFIRINOX chemotherapy followed by resection and eventually followed by adjuvant chemotherapy.

Main Outcomes and Measures

The primary outcome was OS, calculated from the 3-month landmark. Cox regression analysis, including interaction analyses, was performed to investigate the association of adjuvant chemotherapy with OS.

Results

Overall, 767 patients were included after resection of pancreatic adenocarcinoma (median [IQR] age, 62 [55-67] years; 404 [52.7%] male). Adjuvant chemotherapy was independently associated with prolonged OS (hazard ratio [HR], 0.66; 95% CI, 0.49-0.87), confirmed by adjusted OS curves. The interaction analysis to assess estimated treatment effect across subgroups was not statistically significant. The forest plot and interaction test suggest that the association of adjuvant chemotherapy was lower among patients receiving 8 or more cycles of preoperative (m)FOLFIRINOX, those who had radiological response, and those with ypN0 disease. Compared to no adjuvant chemotherapy, both adjuvant (m)FOLFIRINOX (HR, 0.57; 95% CI, 0.40-0.80) and other multiagent adjuvant regimens (HR, 0.61; 95% CI, 0.41-0.92) were associated with prolonged OS, whereas single-agent adjuvant chemotherapy was not (HR, 0.75; 95% CI, 0.55-1.03).

Conclusions and Relevance

In this cohort study, adjuvant (m)FOLFIRINOX and other multiagent chemotherapy regimens were associated with improved OS following resection of localized pancreatic adenocarcinoma after preoperative (m)FOLFIRINOX, whereas single-agent adjuvant chemotherapy was not. The impact of adjuvant chemotherapy on OS may be lower in subgroups such as patients with 8 or more preoperative cycles of (m)FOLFIRINOX, those having radiological response, and those with ypN0.

Preoperative Biopsy Is Not Associated With Adverse Outcomes in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Upfront Resection

INTRODUCTION

Obtaining a preoperative histological diagnosis in patients with resectable pancreatic disease has traditionally not been routinely sought, citing concerns in biopsy-associated complications, and risk of tumor seeding. We sought to determine if preoperative biopsy was associated with worse outcomes, including overall survival (OS).

METHODS

This was a retrospective analysis of the National Cancer Database including adult patients with clinical stage I-III pancreatic ductal adenocarcinoma who underwent upfront surgical resection. Univariate and multivariable analyses were conducted to determine if undergoing a preoperative biopsy was associated with impaired OS, increased 30-d readmissions, or delayed return to intended oncologic therapy (RIOT), defined by receipt of adjuvant therapy.

RESULTS

A total of 19,361 patients underwent upfront resection, of whom 11,038 (57%) underwent preoperative biopsy. Patients were more likely to undergo a preoperative biopsy if they were Black (11% versus 9%, P = 0.003), privately insured (34% versus 32%, P < 0.001), treated at academic facilities (58% versus 56%, P < 0.001), had tail tumors (14% versus 13%, P = 0.006), and were clinical stage II (44% versus 40%, P < 0.001). There was no difference in median OS between groups (23.0 mos versus 23.5 mos, P = 0.21). In multivariable analysis, preoperative biopsy did not predict OS, 30-d readmissions, or RIOT.

CONCLUSIONS

Preoperative biopsy was conducted in 57% of patients undergoing upfront resection and was not associated with impaired OS. Although surgical complications could not be evaluated, there were no differences in 30-d readmissions or RIOT. Preoperative biopsy appears oncologically safe and may help ensure an accurate diagnosis before pancreatectomy.

Copper complexes induce haem oxygenase-1 (HMOX1) and cause apoptotic cell death in pancreatic cancer cells

Pancreatic ductal adenocarcinoma (PDAC), the most common pancreatic malignancy, has a dismal 5-year survival rate, making palliative chemotherapy the only treatment option. Targeted therapy has limited efficacy in PDAC, underscoring the need for novel therapeutic approaches. The inducible stress-response protein, haem oxygenase-1 (HMOX1), has been implicated in treatment failure in PDAC. Copper coordination complexes have shown promise as anticancer agents against various cancers, and are associated with apoptotic cell death. The different ligands to which copper is complexed, determine the specificity and efficacy of each complex. Three different classes of copper complexes were evaluated for anti-cancer activity against AsPC-1 and MIA PaCa-2 pancreatic cancer cell lines. A copper-phenanthroline-theophylline complex (CuPhTh2), a copper-8-aminoquinoline-naphthyl complex (Cu8AqN), and two copper-aromatic-isoindoline complexes (CuAIsI) were effective inhibitors of cell proliferation with clinically relevant IC50 values below 5 μM. The copper complexes caused reactive oxygen species (ROS) formation, promoted annexin-V binding, disrupted the mitochondrial membrane potential (MMP) and activated caspase-9 and caspase-3/7, confirming apoptotic cell death. Expression of nuclear HMOX1 was increased in both cell lines, with the CuPhTh2 complex being the most active. Inhibition of HMOX1 activity significantly decreased the IC50 values of these copper complexes suggesting that HMOX1 inhibition may alter treatment outcomes in PDAC.

The Significant Impact of Fibrinogen-C-Reactive Protein-Albumin Ratio on the Long-Term Outcomes After Pancreatic Resection for Pancreatic Cancer

OBJECTIVES

This study aimed to assess the prognostic significance of a novel biomarker, the fibrinogen-C-reactive protein-albumin ratio (F-CAR), in pancreatic cancer patients undergoing pancreatectomy.

METHOD

We retrospectively analyzed 163 patients undergoing pancreatectomy for pancreatic cancer. The relationship between F-CAR, calculated from preoperative serum fibrinogen, albumin, and C-reactive protein levels, and long-term outcomes following pancreatectomy was examined.

RESULTS

Multivariate analysis revealed that several factors, including age (P < 0.01), high serum carbohydrate antigen 19-9 (CA19-9) level (P < 0.01), high serum carcinoembryonic antigen level (P = 0.049), pT3 or pT4 (UICC) (P < 0.01), pN1 or pN2 (P < 0.01), and high F-CAR (hazards ratio, 1.51; 95% confidence interval, 1.03-2.22; P = 0.04), were independent and significant predictors of disease-free survival. Moreover, factors such as age (P = 0.02), high serum carcinoembryonic antigen level (P < 0.01), preoperative biliary drainage (P = 0.02), preoperative chemotherapy (P = 0.04), lymph node metastasis (P < 0.01), adjuvant chemotherapy (P = 0.046), and high F-CAR (hazards ratio, 1.55; 95% confidence interval, 1.03-2.35; P = 0.04) were found to be independent and significant predictors of overall survival.

CONCLUSIONS

F-CAR is a useful prognostic factor for disease-free survival and overall survival after pancreatectomy in pancreatic cancer patients.

Time between pancreatic cancer diagnosis and treatment initiation and survival in the U.S. Military Health System

BACKGROUND

Pancreatic cancer has a high case fatality and treatment is known to improve survival. It is unknown whether the time between diagnosis and treatment initiation (time-to-treatment) is related to survival. Access to medical care may influence both treatment receipt and timing. We examined the relationship between time-to-treatment and survival among patients with pancreatic adenocarcinoma treated in the equal access Military Health System.

METHODS

We used the MilCanEpi database to study a cohort of 806 men and women who were diagnosed with stage I-IV pancreatic adenocarcinoma between 1998 and 2014 and received either surgery or chemotherapy as primary treatment. Time-to-treatment in relation to overall survival was examined in multivariable time-dependent Cox regression models.

RESULTS

Overall, median time-to-treatment was 3 weeks and 95 % of patients received treatment within 12 weeks. Time-to-treatment >6 weeks was associated with a statistically significant lower risk of death (AHR = 0.77, 95 % CI = 0.61-0.98) compared to time-to-treatment <3 weeks. Analysis by the first treatment type showed that time-to-surgery was not associated with survival among those receiving upfront surgery. Time-to-chemotherapy of >6 weeks was associated with reduced risks of death compared to <3 weeks (AHR = 0.62, 95 % CI = 0.48-0.80) for patients receiving primary chemotherapy.

CONCLUSIONS

Our data suggests that longer time-to-treatment, especially among patients with chemotherapy, was associated with lower risk of death among patients with pancreatic adenocarcinoma who received treatment. Further research is needed to understand the association of intervals along the whole cancer spectrum (e.g., presentation, diagnosis, treatment) and longer treatment intervals (i.e., >12 weeks) with survival.

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.

Dual-energy CT extracellular volume fraction predicts tumor collagen ratio and possibly survival for inoperable pancreatic cancer patients

OBJECTIVES

Tumor collagen is vital in chemotherapy resistance of pancreatic cancer (PC), but its non-invasive evaluation remains challenging. This study aims to investigate the association of variables derived from dual-energy CT with the collagen ratio (CR) of PC and to determine the prognostic value of CR in unresectable diseases.

MATERIALS AND METHODS

A total of 83 patients with resected PC and 71 patients with unresectable PC were enrolled. In the resected group, the correlation between the tumor CR and variables of dual-energy CT was analyzed. In the unresectable group, Cox regression analyses were conducted to investigate the prognostic value of dual-energy CT-predicted CR and other clinicoradiological indicators.

RESULTS

The patients with resected PC were divided into low and high-CR sets with a threshold of 55%. In the resected group, the extracellular volume fraction calculated by the iodine concentration (ECV_IC) was the only predictor of tumor CR according to univariate and multivariate analysis (hazard ratio [HR] (95% confidence interval [CI]):1.19 [1.03-1.37]). The correlation coefficient r was 0.26 (p = 0.02) between ECV_IC and specific CR values. In the training set of unresectable PC group, ECV_IC (HR (95% CI): 0.94 (0.89-0.99), p = 0.03) and contrast-enhanced pattern (CEP) (HR (95% CI): 3.20 (1.41-7.27), p = 0.01) were independent prognostic factors for overall survival. The nomogram model was constructed and showed a good performance.

CONCLUSION

The ECV_IC is a non-invasive indicator of tumor CR in PC. The ECV_IC and CEP have the potential to predict the prognosis of unresectable PC.

KEY POINTS

Question Non-invasive evaluation of tumor collagen, a vital determinant of chemotherapy resistance of pancreatic cancer, remains challenging. Findings Tumor collagen ratio can be noninvasively predicted by extracellular volume fraction based on iodine concentration. Clinical relevance The nomogram model composed of extracellular volume fraction and contrast-enhanced pattern can serve as an effective and convenient tool for stratifying the prognosis of patients with unresectable pancreatic cancer.

Concealed pancreatic cancer in acute pancreatitis: Early MRCP and EUS surveillance improves prognosis and identifies high-risk patients

BACKGROUND/OBJECTIVES

Acute pancreatitis (AP) may obscure small pancreatic cancers (PCs) on computed tomography during the acute phase. Surveillance with magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) may enhance early detection and improve patient outcomes. This study evaluated the impact of early MRCP/EUS surveillance on PC outcomes in AP patients and identified high-risk subgroups for early screening.

METHODS

We retrospectively analyzed 1562 AP patients treated between 2010 and 2021, categorizing them into early surveillance (MRCP/EUS within three months of AP onset; n = 760) and nonearly surveillance groups (n = 802). Key outcomes included time to PC diagnosis, surgical resection rate, tumor stage, and overall survival. Multivariate analysis was performed to identify risk factors for concealed PC in AP patients.

RESULTS

Among 27 PC cases analyzed, the early surveillance group achieved significantly earlier diagnosis, higher surgical resection rates, increased detection of early-stage PC, and improved overall survival compared with the nonearly surveillance group. Multivariate analysis revealed that subthreshold main pancreatic duct (MPD) dilation (≥2.5 mm) and moderately severe AP were significant predictors of PC.

CONCLUSIONS

Early MRCP/EUS surveillance in AP patients facilitates timely detection of occult PC and enhances patient prognosis. These findings support prioritizing early surveillance for AP patients with subthreshold MPD dilation and moderately severe disease. Further large-scale studies are warranted to validate these strategies in clinical practice.

Computer-Aided Decision Support and 3D Models in Pancreatic Cancer Surgery: A Pilot Study

Background: Preoperative planning of patients diagnosed with pancreatic head cancer is difficult and requires specific expertise. This pilot study assesses the added value of three-dimensional (3D) patient models and computer-aided detection (CAD) algorithms in determining the resectability of pancreatic head tumors. Methods: This study included 14 hepatopancreatobiliary experts from eight hospitals. The participants assessed three radiologically resectable and three radiologically borderline resectable cases in a simulated setting via crossover design. Groups were divided in controls (using a CT scan), a 3D group (using a CT scan and 3D models), and a CAD group (using a CT scan, 3D and CAD). For the perceived fulfillment of preoperative needs, the quality and confidence of clinical decision-making were evaluated. Results: A higher perceived ability to determine degrees and the length of tumor-vessel contact was reported in the CAD group compared to controls (p = 0.022 and p = 0.003, respectively). Lower degrees of tumor-vessel contact were predicted for radiologically borderline resectable tumors in the CAD group compared to controls (p = 0.037). Higher confidence levels were observed in predicting the need for vascular resection in the 3D group compared to controls (p = 0.033) for all cases combined. Conclusions: "CAD (including 3D) improved experts' perceived ability to accurately assess vessel involvement and supports the development of evolving techniques that may enhance the diagnosis and treatment of pancreatic cancer".

Impact of Preoperative Biliary Stenting on Intestinal Dysfunction and Perioperative Complications After Pylorus-Preserving Pancreaticoduodenectomy

Background and Objectives: Preoperative biliary stenting (PBS) is commonly used to manage obstructive jaundice in patients undergoing pylorus-preserving pancreaticoduodenectomy (PPPD). However, the impact of PBS on intestinal barrier function and perioperative complications remains controversial. This study aims to evaluate the effect of PBS on intestinal dysfunction and surgical outcomes, focusing on the influence of the stent duration. Materials and Methods: In this prospective cohort study, 235 patients undergoing PPPD for resectable pancreatic neoplasms at Timișoara Municipal Emergency Clinical Hospital (2016-2024) were analyzed. Patients were divided into two groups: those with PBS (n = 98) and without PBS (n = 137). Intestinal barrier function was assessed pre- and postoperatively using biomarkers such as zonulin, fecal calprotectin, and serum lipopolysaccharides (LPS). Perioperative outcomes, including pancreatic fistula, delayed gastric emptying (DGE), infections, and hospital stay, were compared. Additionally, outcomes were stratified based on stent duration (2-3 weeks vs. 3-4 weeks). Results: PBS was associated with significantly higher levels of zonulin, fecal calprotectin, and serum LPS postoperatively, indicating compromised intestinal barrier function. The stented group had a higher incidence of pancreatic fistulas (Grade B/C: 27.5% vs. 13.1%, p < 0.01), DGE (25.5% vs. 13.1%, p = 0.008), postoperative infections (34.7% vs. 17.5%, p = 0.002), and prolonged hospital stay (16.9 ± 4.2 days vs. 14.5 ± 3.7 days, p = 0.019). Prolonged stenting (3-4 weeks) was associated with worse outcomes compared to shorter stenting durations (2-3 weeks), including increased rates of infections, sepsis, and ICU stay (p < 0.05 for all comparisons). Conclusions: Preoperative biliary stenting is associated with increased intestinal barrier dysfunction, systemic inflammation, and higher rates of perioperative complications following PPPD. Prolonged stenting durations (>3 weeks) further exacerbate these risks. Limiting the PBS duration to 2-3 weeks, alongside optimized perioperative management, may help reduce postoperative morbidity and improve surgical outcomes.

Pharmacogenomics-based subtype decoded implications for risk stratification and immunotherapy in pancreatic adenocarcinoma

BACKGROUND

With fatal malignant peculiarities and poor survival rate, outcomes of pancreatic adenocarcinoma (PAAD) were frustrated by non-response and even resistance to therapy due to heterogeneity across clinical patients. Nevertheless, pharmacogenomics has been developed for individualized-treatment and still maintains obscure in PAAD.

METHODS

A total of 964 samples from 10 independent multi-center cohorts were enrolled in our study. With drug response data from the profiling of relative inhibition simultaneously in mixtures (PRISM) and genomics of drug sensitivity in cancer (GDSC) databases, we established and validated multidimensionally three pharmacogenomics-classified subtypes using non-negative matrix factorization (NMF) and nearest template prediction (NTP) algorithms, separately. The heterogenous biological characteristics and precision medicine strategies among subtypes were further investigated.

RESULTS

Three pharmacogenomics-classified subtypes after stable and reproducible validation, distinguished in six aspects of prognosis, biological peculiarities, immune landscapes, genomic variations, immunotherapy and individualized management strategies. Subtype 2 was close to immunocompetent phenotype and projected to immunotherapy; Subtype 3 held most favorable outcomes and metabolic pathways distinctively, promising to be treated with first-line agents. Subtype 1 with worst prognosis, was anticipated to chromosome instability (CIN) phenotype and resistant to chemotherapeutic agents. In addition, ITGB6 contributed to subtype 1 resistance to 5-fluorouracil, and knockdown of ITGB6 enhanced sensitivity to 5-fluorouracil in in vitro experiments. Ultimately, appropriate clinical stratified treatments were assigned to corresponding subtypes according to pharmacogenomic transcripts. Some limitations were not taken into account, thus needs to be supported by more research.

CONCLUSION

A span-new molecular subtype exploited for PAAD uncovered an insight into precise medication on ground of pharmacogenomics, and highly refined multiple clinical management strategies for specific patients.

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.

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.

An exploratory study of serum creatine kinase as a prognostic marker for patients with resectable pancreatic cancer: looking into the relationship with body composition

BACKGROUND

Among cancer patients, pancreatic cancer patients have the highest rate of sarcopenia, which is a critical prognostic factor. Serum creatine kinase (CK) is closely related to skeletal muscle mass and has been reported to decline with the progression of cancer. This study investigated whether preoperative serum CK is associated with the survival of patients with pancreatic cancer.

METHODS

Data were obtained from patients with pathologically confirmed pancreatic cancer between June 2016 and March 2022. The prognostic significance of CK was analyzed based on sex-stratified groups. The Kaplan-Meier method was used to compare overall survival (OS) and disease-free survival (DFS). Multivariate Cox proportional hazards models were used to determine prognostic factors. Body composition was analyzed based on preoperative abdominal CT images to explore the sex-specific associations between skeletal muscle area (SMA) and serum CK levels.

RESULTS

A total of 166 patients were included in this study. Sarcopenia was presented in 70 patients (42.2%). A low serum CK level showed a significant correlation with the diagnosis of sarcopenia in male patients (P = 0.026). The levels of CK did not predict the outcome in female patients, while a low preoperative CK was notably linked to shorter OS in male patients (median OS: 15 months vs. 33 months, P = 0.011; median DFS: 5 months vs. 14 months, P = 0.007). Multivariate analyses further confirmed the effect of CK in predicting OS (CK>44 IU/L, HR:0.226, 95% CI:0.107-0.478, P < 0.001) and DFS (CK>44 IU/L, HR:0.272, 95% CI:0.139-0.529, P < 0.001) of male patients. Correlation analysis revealed a significant association between SMA and CK levels in male patients (r = 0.225, P = 0.025), and such a correlation was not observed in female patients (r = 0.088, P = 0.478).

CONCLUSION

The pretherapeutic CK may represent a simple marker for predicting poor survival in male patients with resectable pancreatic cancer, thereby aiding in the selection of therapeutic strategies.

Artificial Intelligence in Pancreatic Imaging: A Systematic Review

The rising incidence of pancreatic diseases, including acute and chronic pancreatitis and various pancreatic neoplasms, poses a significant global health challenge. Pancreatic ductal adenocarcinoma (PDAC) for example, has a high mortality rate due to late-stage diagnosis and its inaccessible location. Advances in imaging technologies, though improving diagnostic capabilities, still necessitate biopsy confirmation. Artificial intelligence, particularly machine learning and deep learning, has emerged as a revolutionary force in healthcare, enhancing diagnostic precision and personalizing treatment. This narrative review explores Artificial intelligence's role in pancreatic imaging, its technological advancements, clinical applications, and associated challenges. Following the PRISMA-DTA guidelines, a comprehensive search of databases including PubMed, Scopus, and Cochrane Library was conducted, focusing on Artificial intelligence, machine learning, deep learning, and radiomics in pancreatic imaging. Articles involving human subjects, written in English, and published up to March 31, 2024, were included. The review process involved title and abstract screening, followed by full-text review and refinement based on relevance and novelty. Recent Artificial intelligence advancements have shown promise in detecting and diagnosing pancreatic diseases. Deep learning techniques, particularly convolutional neural networks (CNNs), have been effective in detecting and segmenting pancreatic tissues as well as differentiating between benign and malignant lesions. Deep learning algorithms have also been used to predict survival time, recurrence risk, and therapy response in pancreatic cancer patients. Radiomics approaches, extracting quantitative features from imaging modalities such as CT, MRI, and endoscopic ultrasound, have enhanced the accuracy of these deep learning models. Despite the potential of Artificial intelligence in pancreatic imaging, challenges such as legal and ethical considerations, algorithm transparency, and data security remain. This review underscores the transformative potential of Artificial intelligence in enhancing the diagnosis and treatment of pancreatic diseases, ultimately aiming to improve patient outcomes and survival rates.

Incidence and Management of Splanchnic Vein Thrombosis in Pancreatic Diseases

Splanchnic vein thrombosis (SVT) in pancreatic disease has a 20%-30% incidence rate, leading to increased mortality and complication rates. Therefore, the aim of this review is to summarize recent evidence about the incidence, risk factors, and management of pancreatic cancer, pancreatic cystic neoplasm-, and pancreatitis-related SVT. Doppler ultrasound should be the first imaging choice, followed by contrast-enhanced computed tomography or magnetic resonance imaging. Data regarding SVT treatment in acute pancreatitis and pancreatic cancer are scarce; however, for venous thromboembolism treatment, direct oral anticoagulants and low molecular weight heparin have been effective. Further trials must investigate the length of anticoagulant treatment and the need for interventional radiological procedures.

Preoperative assessment of pancreatic cancer with [68Ga]Ga-DOTA-FAPI-04 PET/MR versus [18F]-FDG PET/CT plus contrast-enhanced CT: a prospective preliminary study

PURPOSE

To assess the diagnostic performance of [68Ga]Ga-DOTA-FAPI-04 PET/MR imaging in the preoperative evaluation of pancreatic cancer and compare it with that of [18F]-FDG PET/CT plus contrast-enhanced CT (CECT).

METHODS

Thirty-one patients with pancreatic cancer underwent preoperative [68Ga]Ga-DOTA-FAPI-04 PET/MR, [18F]-FDG PET/CT, and CECT imaging. Two nuclear medicine physicians independently reviewed two sets of images (set 1, [68Ga]Ga-DOTA-FAPI-04 PET/MR; set 2, [18F]-FDG PET/CT plus CECT) and reached a consensus on tumour resectability, N staging (N0 or N positive) and M staging (M0 or M1). Based on the above indices, the resectability of the tumour was determined according to a five-point scale. Clinical, operative, and pathological findings were used as a reference standard to compare the diagnostic performance of the two imaging sets via the McNemar test.

RESULTS

The diagnostic performance of [68Ga]Ga-DOTA-FAPI-04 PET/MR imaging was not significantly different from that of [18F]-FDG PET/CT plus CECT imaging in the assessment of tumour resectability (area under the receiver operating characteristic curve: 0.854 vs. 0.775, p = 0.192), N staging [accuracy: 82.4% (14 of 17 patients) vs. 58.8% (10 of 17 patients), p = 0.125] and M staging [accuracy: 100% (31 of 31 patients) vs. 90.3% (28 of 31 patients), p = 0.250]. However, compared with [18F]-FDG PET/CT plus CECT imaging, [68Ga]Ga-DOTA-FAPI-04 PET/MR imaging changed the M stage in three patients by upstaging from M0 to M1 in 2 patients and downstaging from M1 to M0 in 2 patients. In 13 patients with liver metastases, the number of liver metastases detected via [68Ga]Ga-DOTA-FAPI-04 PET/MR imaging was greater than that detected via [18F]-FDG PET/CT plus CECT imaging (324 vs. 240). In 3 patients with peritoneal metastases, [68Ga]Ga-DOTA-FAPI-04 PET/MR imaging detected more peritoneal metastases than did [18F]-FDG PET/CT plus CECT imaging.

CONCLUSIONS

[68Ga]Ga-DOTA-FAPI-04 PET/MR imaging has diagnostic accuracy comparable to [18F]-FDG PET/CT plus CECT in terms of preoperative staging and assessment of resectability in pancreatic cancer; additionally, it exhibits superior capability in detecting liver and peritoneal metastases. Consequently, [68Ga]Ga-DOTA-FAPI-04 PET/MR has the potential to become a one-stop imaging tool for the preoperative evaluation of pancreatic cancer.

Recommendations, evidence and sustainability of screening for pancreatic cancer in high-risk individuals

Pancreatic cancer is a highly lethal malignancy and is predicted to become the second leading cause of cancer-related deaths by 2030. Early detection significantly improves outcomes, but general population screening remains infeasible due to the low prevalence of the disease and lack of specific biomarkers. This review evaluates current recommendations for pancreatic cancer surveillance in high-risk individuals, synthesises evidence from recent studies and explores the sustainability of current imaging-based surveillance programmes. Challenges such as overdiagnosis, economic feasibility and disparities in access highlight the need for targeted, cost-effective strategies. Collaborative initiatives and consortia are needed to advance biomarker research and refine risk stratification. By integrating evidence-based recommendations with sustainable approaches, this review outlines pathways to improve early detection and reduce mortality from pancreatic cancer.

DUPAN-2 in pancreatic cancer: Systematic review and meta-analysis

OBJECTIVE

Pancreatic cancer (PC) is a highly aggressive malignancy with poor prognosis and high mortality rate. Identifying reliable biomarkers for the early diagnosis and treatment is urgently needed. This study aims to comprehensively evaluate the diagnostic and prognostic value of DUPAN-2 in PC through a meta-analysis.

METHODS

We systematically searched PubMed, Embase, and other databases for studies related to DUPAN-2 and its prognostic and diagnostic relevance in PC, covering publications up to August 2024. We used pooled hazard ratios (HRs) to evaluate the prognostic value of DUPAN-2 in PC, the summary receiver operating characteristic (SROC) curve and the area under the curve (AUC) to assess diagnostic performance, while pooled odds ratios (ORs) analyzed associations with clinicopathological features.

RESULTS

A total of 22 studies involving 4765 patients were included in this meta-analysis, with 11 studies focusing on diagnostic analysis, 10 on prognostic analysis, and 3 on clinicopathological features. The diagnostic meta-analysis revealed a pooled sensitivity of 0.63 (95 % CI: 0.56-0.69), a pooled specificity of 0.98 (95 % CI: 0.95-0.99), and an AUC of 0.83 (95 % CI: 0.79-0.86). Subgroup analysis indicated that a DUPAN-2 threshold at 150 U/mL achieved the highest diagnostic performance. The prognostic meta-analysis demonstrated that elevated DUPAN-2 levels were associated with poorer OS (HR = 1.70, 95 % CI: 1.36-2.14) and PFS (HR = 1.33, 95 % CI: 1.14-1.56). Additionally, the clinicopathological features meta-analysis showed that elevated DUPAN-2 levels were associated with vascular invasion (OR = 3.48, 95 % CI: 1.26-9.59), while normalized DUPAN-2 levels were associated with higher resectability (OR = 0.57, 95 % CI: 0.36-0.90) and lower N-stage (OR = 0.39, 95 % CI: 0.24-0.63) CONCLUSION: Serum DUPAN-2 demonstrates significant potential as a biomarker for diagnosis and prognosis in patients with PC.

Best Practices for Delivering Neoadjuvant Therapy in Pancreatic Ductal Adenocarcinoma

Importance

Neoadjuvant therapy (NT) is an increasingly used treatment strategy for patients with localized pancreatic ductal adenocarcinoma (PDAC). Little research has been conducted on cancer care delivery during NT, and the standards for optimal delivery of NT have not been defined.

Objective

To develop consensus best practices for delivering NT to patients with localized PDAC.

Design, Setting, and Participants

This study used a modified Delphi approach consisting of 2 rounds of voting, and a series of virtual conferences (from October to December 2023) to reach expert consensus on candidate best practice statements generated from a systematic review of the literature and expert opinion. An interdisciplinary panel was formed including 47 North American experts from surgical, medical, and radiation oncology, radiology, pathology, gastroenterology, integrative oncology, anesthesia, pharmacy, nursing, cancer care delivery research, and nutrition as well as patient and caregiver stakeholders.

Main Outcome and Measures

Statements that reached 75% agreement or greater were included in final consensus statements.

Results

Of the 47 participating panel members, 27 (57.64%) were male, and the mean (SD) age was 47.6 (8.2) years. Physicians reported completing training a mean (SD) 14.6 (8.6) years prior and seeing a mean (SD) 110.6 (38.4) patients with PDAC annually; 35 (77.7%) were in academic practice. Final consensus was reached on 82 best practices for delivering NT. Of these, 38 statements focused on pre-NT practices, including diagnosis and staging (n = 15), evaluation and optimization (n = 20), and decision-making (n = 3); 29 statements defined best practices during NT, including initiation (n = 3), delivery of therapy (n = 8), restaging practices (n = 12), and management of complications during NT (n = 6); and 15 best practices were identified to guide treatment post-NT, focusing on surgery (n = 7), pathology (n = 4), and follow-up (n = 3).

Conclusions

Using a modified Delphi consensus technique, best practice guidelines were developed focusing on the optimal standards for delivering NT to patients with localized PDAC. Given the prognostic importance of completing multimodality therapy, efforts to standardize and optimize the delivery of NT represent an immediate opportunity to decrease care variation and improve outcomes for patients with PDAC. Future research should focus on validating and implementing best practice standards into clinical practice.

G3BP2 promotes tumor progression and gemcitabine resistance in PDAC via regulating PDIA3-DKC1-hENT in a stress granules-dependent manner

Pancreatic ductal adenocarcinoma (PDAC) is distinguished by its aggressive malignancy, limited treatment avenues and a tendency towards chemotherapy resistance, underscoring the critical need for advanced research to uncover new therapeutic approaches. Stress granules (SGs) that is implicated in cellular self-protection mechanism, along with its associated family molecules have shown pro-cancer effects and are closely related to tumor chemotherapy resistance. In this study we investigated the relationship between Ras GTPase-activating protein-binding proteins 2 (G3BP2), a core component of SGs, and the malignancy of PDAC as well as its resistance to the chemotherapy drug gemcitabine. Analyzing TCGA dataset revealed that the expression of G3BP1 and G3BP2 was significantly upregulated in PDAC compared with adjacent normal pancreatic tissues, and the high expression of G3BP2 rather than G3BP1 was significantly associated with poorer overall survival (OS) in PDAC patients. We demonstrated that knockdown of G3BP2 inhibited the proliferation and invasion of PANC-1 and CFPAC-1 cells in vitro and in vivo. By analyzing the differentially expressed genes in G3BP2 knockdown and overexpressed PANC-1 cells, we identified DKC1 that was associated with RNA stability and regulation as the target of G3BP2. We demonstrated that G3BP2 bound to PDIA3 mRNA and recruited them into SGs, increasing the stability of PDIA3 mRNA and attenuating its translation efficiency, thereby promoting DKC1 expression. Furthermore, DKC1 could bind to hENT mRNA and inhibited its expression, which enhanced gemcitabine resistance of PDAC. Therefore, we propose a novel mechanism wherein G3BP2 facilitates PDAC's resistance to chemotherapy by modulating PDIA3-DKC1-hENT in a SGs-dependent way, suggesting G3BP2 SGs a protentional therapeutic target for the treatment in PDAC.

Value of radiomics features extracted from baseline computed tomography images in predicting overall survival in patients with nonsurgical pancreatic ductal adenocarcinoma: incorporation of a radiomics score to a multiparametric nomogram to predict 1-year overall survival

PURPOSE

This study aimed to determine the value of radiomics features derived from baseline computed tomography (CT) scans and volumetric measurements to predict overall survival (OS) in patients with nonsurgical pancreatic ductal adenocarcinoma (PDAC) treated with a chemotherapy combination regimen of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX).

METHODS

In this retrospective single-institution study, 131 patients with nonsurgical PDAC who received FOLFIRINOX neoadjuvant chemotherapy between December 2012 and November 2021 were included. Pretreatment contrast-enhanced CT images were obtained for all patients before inclusion. The primary tumor was contoured by an expert radiologist with 25 years of experience. A total of 845 radiomics features, including first-, second-, and higher-order features, were extracted from the total tumor volume. A feature reduction pipeline was used to reduce the dimensionality of the data. The selected features were used to generate a radiomics score based on the Least Absolute Shrinkage and Selection Operator coefficients. A high-dimensional Cox model was generated on the basis of the radiomics score and other quantitative and semantic imaging findings.

RESULTS

From the 845 radiomics features extracted, 45 were significantly different between the tertiles. The following equation was used to generate a radiomics score: radiomics score = SmallAreaEmphasis (-66.87801 + LargeDependenceEmphasis) - 0.2345916. The radiomics score was significantly different among the 3 groups of the radiomics features (P = .034). The overall difference in survival was significant among the 3 groups (P = .02). The nomogram showed good calibration and showed significant differences among the patients when they were classified as tertiles (P < .00).

CONCLUSION

Radiomics approaches have the potential to predict OS in nonsurgical patients with PDAC, and the inclusion of semantic imaging findings and pathologic data could further enhance prognostication in patients with PDAC.

Reprint of: Avoiding "Needless" nephrectomy: What is the role of small renal mass biopsy in 2024?

Current guidelines do not mandate routine preoperative renal mass biopsy (RMB) for small renal masses (SRMs), which results in a considerable rate (18%-26%) of needless nephrectomy/partial nephrectomy for benign renal tumors. In light of this ongoing practice, a narrative review was conducted to examine the role of routine RMB for SRM. First, arguments justifying the current non-biopsy approach to SRM are critically reviewed and contested. Second, as a standalone procedure, RMB is critically assessed; RMB was found to have higher sensitivity, specificity, and an equal or lower complication rate when compared with other commonly preoperatively biopsied solid organ tumors (e.g., breast, prostate, lung, pancreas, thyroid, and liver). Based on the foregoing information, we propose a paradigm shift in SRM management, advocating for an updated policy in which partial nephrectomy or nephrectomy for SRM invariably occurs only after a preoperative biopsy confirms that a SRM is indeed malignant.

Cancer Susceptibility Gene Testing in Patients With Pancreatic Ductal Adenocarcinoma: Implementation in a Cancer Center Oncology Clinic

PURPOSE

Current guidelines recommend offering genetic susceptibility testing to individuals with pancreatic cancer regardless of family history, but previous studies have reported only moderate test uptake, highlighting the need for efficient and accessible clinical pathways for delivering pretest genetic education and testing. We evaluated gene testing uptake offered at the point-of-oncology care by a nongenetics provider in an outpatient setting.

METHODS

A retrospective chart review was performed of patients with pancreatic cancer treated at the Johns Hopkins Hospital between January 2021 and December 2023. During their initial clinic visit, patients were educated about germline testing by an oncology nurse and provided with educational and instructional handouts and video links, including how to arrange testing (with saliva) with a commercial testing provider. Patients with pathogenic variants and variants of uncertain significance were referred for genetic counseling.

RESULTS

Of the 992 patients seen in the oncology clinic (52.1% male, 75.4% White, 15.4% African American, 6% Asian; median age at diagnosis, 66.9 ± 10.6 years), 90% were offered testing, 77.6% of whom completed it. Factors significantly associated with not going forward with testing included being single, older age, African American, and having advanced-stage disease. Among the tested individuals, 78 (11.3%) had a pathogenic variant identified, including 55 (7.9%) with a pancreatic cancer susceptibility gene variant; of these, 72 (92.3%) were referred for genetic counseling and 50 (69.4%) completed their counseling visit. Testing led to a change in chemotherapy regimen in 28 patients.

CONCLUSION

The implementation of point-of-care encounters for cancer susceptibility gene testing by an oncology nurse in the outpatient setting yielded a high uptake of testing. Additional approaches are needed to increase testing rates and cancer genetics visits.

Elevated SAMD3 expression in T cells predicts improved survival in pancreatic ductal adenocarcinoma patients

OBJECTIVE

Pancreatic ductal adenocarcinoma (PDAC) has an immune-suppressive tumor microenvironment that contributes to resistance to immunotherapy. This study aimed to demonstrate that elevated sterile alpha motif domain-containing protein 3 (SAMD3) expression in effector CD8+ T cells was associated with improved survival in PDAC patients.

DESIGN

We investigated the heterogeneity and gene expression profiles of T cells using a single-cell RNA sequencing (sc-RNA-seq) dataset comprised of human PDAC samples. SAMD3 mRNA expression was further evaluated in a tumor-specific OT-I/ovalbumin (OVA) mouse model. SAMD3 levels and their clinical significance were evaluated via immunohistochemistry (IHC) analysis.

RESULTS

SAMD3 was highly expressed in cytotoxic CD8+ T cells, with expression significantly downregulated during T cell exhaustion. SAMD3 levels were positively correlated with CD8+ T cell function. In PDAC patients, high SAMD3 levels in T cells were associated with improved overall survival (OS), disease-free survival (DFS), and T cell infiltration. A patient exhibiting partial response to combination immunotherapy also showed high SAMD3 levels in T cells.

CONCLUSION

SAMD3 is a biomarker of T cell function, with elevated expression in T cells predicting improved survival. These findings highlight the potential of precision immunotherapy approaches for treating PDAC.

Sorafenib as Adjuvant Therapy Post-Liver Transplant: A Single-center Experience

Background

Hepatocellular carcinoma (HCC) has a rising incidence and mortality in North America. Liver transplantation (LT) with adjunctive therapies offers excellent outcomes. However, HCC recurrences are associated with high mortality. We investigate whether adjuvant systemic therapy can reduce recurrence, as shown with other malignancies.

Methods

Medical records of patients undergoing LT for HCC at a single center between January 2016 and December 2022 were retrospectively reviewed. Patients were stratified into 3 groups: (1) recipients of adjuvant sorafenib, (2) nonrecipients at high recurrence risk, and (3) nonrecipients at low risk by explant pathology features. The outcomes were overall survival (OS) and recurrence-free survival (RFS). Adjuvant sorafenib recipients were also propensity score matched 1:2 to nonadjuvant recipients based on recurrence risk features.

Results

During the study period, 273 patients with HCC underwent LT and 16 (5.9%) received adjuvant sorafenib therapy. Adjuvant sorafenib recipients were demographically similar to nonrecipients and, on explant pathology, had greater tumor burden, lymphovascular invasion, and poorer differentiation (all P < 0.001). Adverse events were observed in 12 adjuvant sorafenib recipients (75%). OS was similar among the 3 groups (P = 0.2), and adjuvant sorafenib was not associated with OS in multivariable analysis (hazard ratio, 1.31; 95% confidence interval, 0.45-3.78; P = 0.62). RFS was significantly lower in sorafenib patients (hazard ratio, 6.99; 95% confidence interval, 2.12-23.05; P = 0.001). Following propensity matching, adjuvant sorafenib use was not associated with either OS (P = 0.24) or RFS rates (P = 0.65).

Conclusions

In this single-center analysis, adjuvant sorafenib was not associated with OS. Recipients were observed to have shorter RFS, likely due to the increased prevalence of high-risk features, and sorafenib use was associated with high frequencies of adverse events.

Multiparametric quantitative diffusion weighted magnetic resonance imaging can effectively predict the response to neoadjuvant therapy in borderline resectable pancreatic ductal adenocarcinoma

PURPOSE

To investigate whether multiparametric quantitative diffusion weighted magnetic resonance imaging (DWI) can effectively predict the neoadjuvant therapy (NAT) response in borderline resectable pancreatic ductal adenocarcinoma (BRPC).

METHODS

The clinicopathological data, including tumor size, location, and CA19-9 values, as well as DWI parameters(ADC, D, and f values) from 72 patients with BRPC, were analyzed. The differences and changes in these factors before and after NAT were compared to identify those most accurately reflect the response to NAT. ROC analysis was used to evaluate the diagnostic efficacy, and Kaplan-Meier survival analysis explored the relationship between DWI parameters and prognosis. Subgroup survival analysis to further identify populations potentially benefiting from NAT based on multiparametric DWI.

RESULTS

After-NAT, the response group showed significantly higher ADC and D values and lower f values compared to the non-response group. The ΔADC (OR: 12.24, P = 0.013) emerged as the most important independent factor for tumor response, demonstrating the highest diagnostic accuracy for NAT response with an AUC of 0.936. Kaplan-Meier showed the high ADC value group, high D value group and low f value group were associated with better prognosis after NAT; and the ΔADC ≥ 0 group, ΔD ≥ 0 group, and Δf < 0 group was significantly associated with better prognosis. In addition, subgroup analysis suggested two groups of patients might potentially benefit from NAT.

CONCLUSIONS

Multiparametric quantitative DWI may offer valuable insights into the efficacy and prognosis of NAT in BRPC. These findings have the potential to support the evaluation and decision-making process for patients undergoing NAT.

Immune checkpoint inhibitors plus taxane-based chemotherapy for patients with advanced/metastatic NSCLC: a systematic review and meta-analysis across different PD-L1 expression levels

BACKGROUND

Immune checkpoint inhibitors (ICIs) are currently the primary approach for managing NSCLC. However, numerous combination therapies are currently under investigation. Our goal is to investigate the overall efficacy and safety of ICIs and taxane-based chemotherapy.

METHODS

We conducted a systematic review and meta-analysis, searching web databases for relevant literature. We limited our eligibility to phase II/III randomized clinical trials involving advanced/metastatic NSCLC patients.

RESULTS

We performed a meta-analysis encompassing nineteen studies derived from sixteen RCTs. For patients with sq-NSCLC PD-L1 ≥ 50%, using ICIs plus taxane significantly improve PFS and OS with HR of 0.58 (95% CI, 0.45-0.74, p < 0.0001) and 0.41 (95% CI, 0.33-0.50, p < 0.00001), respectively. For patients with non-sq NSCLC PD-L1 1-49%, the analysis revealed significant improvement of OS and PFS with HR of 0.64 (95% CI, 0.47-0.88, p = 0.005) and 0.62 (95% CI, 0.47-0.81, p = 0.0004), respectively. For TRAEs of all grades, ICIs plus taxane resulted with no significant difference compared to control group with risk ratio (RR) 1.00 (95% CI 0.99-1.02).

CONCLUSION

The analysis revealed significant improvement in efficacy of ICIs with taxane in advanced/metastatic NSCLC patients compared with ICI/taxane monotherapy.Registration: PROSPERO (CRD42023447532).

Translating knowledge into policy: Organizational model and minimum requirements for the implementation of a regional pancreas unit network

Pancreatic and periampullary cancers pose significant challenges in oncological care due to their complexity and diagnostic difficulties. Global experiences underscore the crucial role of multidisciplinary collaboration and centralized care in improving patient outcomes in this context. Recognizing these challenges, Lombardy, Italy's most populous region, embarked on establishing pancreas units across its territory to enhance clinical outcomes and organizational efficiency. This initiative, driven by a multistakeholder approach involving the Lombardy Welfare Directorate, clinicians, and a patient association, emphasizes the centralization of complex care in high-volume hospitals, adopting a hub-and-spoke model and a multidisciplinary approach. This article outlines the process and criteria set forth for pancreas unit implementation, aiming to provide a structured framework for enhancing pancreatic cancer care. Central to this initiative is the establishment of structured criteria and minimal requirements, not only for surgery but also for other essential components of care, ensuring a comprehensive approach to pancreatic cancer management. The Lombardy model offers a structured framework for enhancing pancreatic cancer care, with potential applicability to other regions and countries seeking to improve their cancer care infrastructure.

Multiomic quantification of the KRAS mutation dosage improves the preoperative prediction of survival and recurrence in patients with pancreatic ductal adenocarcinoma

Most cancer mutation profiling studies are laboratory-based and lack direct clinical application. For clinical use, it is necessary to focus on key genes and integrate them with relevant clinical variables. We aimed to evaluate the prognostic value of the dosage of the KRAS G12 mutation, a key pancreatic ductal adenocarcinoma (PDAC) variant and to investigate the biological mechanism of the prognosis associated with the dosage of the KRAS G12 mutation. In this retrospective cohort study, we analyzed 193 surgically treated patients with PDAC between 2009 and 2016. RNA, whole-exome, and KRAS-targeted sequencing data were used to estimate the dosage of the KRAS G12 mutant. Our prognostic scoring system included the mutation dosage from targeted sequencing ( > 0.195, 1 point), maximal tumor diameter at preoperative imaging ( > 20 mm, 1 point), and carbohydrate antigen 19-9 levels ( > 150 U/mL, 1 point). The KRAS mutation dosage exhibited comparable performance with clinical variables for survival prediction. High KRAS mutation dosages activated the cell cycle, leading to high mutation rates and poor prognosis. According to prognostic scoring systems that integrate mutation dosage with clinical factors, patients with 0 points had superior median overall survival of 97.0 months and 1-year, 3-year, and 5-year overall survival rates of 95.8%, 70.8%, and 66.4%, respectively. In contrast, patients with 3 points had worse median overall survival of only 16.0 months and 1-year, 3-year, and 5-year overall survival rates of 65.2%, 8.7%, and 8.7%, respectively. The incorporation of the KRAS G12 mutation dosage variable into prognostic scoring systems can improve clinical variable-based survival prediction, highlighting the feasibility of an integrated scoring system with clinical significance.

The combination of gemcitabine and albumin-bound paclitaxel effectively inhibits de novo lipogenesis in pancreatic cancer cells by targeting the AMPK/SREBP1 pathway

Abnormal de novo lipogenesis and reprogramming of lipid metabolism have been associated with the development and progression of various cancers, including pancreatic cancer. Gemcitabine (GEM) combined with albumin-bound paclitaxel (nab-PTX) is the first-line chemotherapeutic agent for pancreatic cancer. There have been many studies on the molecular mechanisms of gemcitabine and paclitaxel in cancer treatment. Still, the effects of the combination on lipid metabolism and the specific mechanisms have not been explored. This study found that GEM combined with nab-PTX inhibited pancreatic cancer cell proliferation and de novo lipogenesis. The exact mechanism is that GEM combined with nab-PTX induces adenosine triphosphate (ATP) depletion and activates AMP-activated protein kinase (AMPK) in pancreatic cancer cells, which in turn inhibits sterol regulatory element-binding protein 1 (SREBP1) expression and nuclear translocation, and ultimately inhibits de novo lipogenesis in pancreatic cancer cells. In addition, we found that the novel lipid-lowering drug bempedoic acid (ETC-1002) significantly enhanced the inhibitory effect of GEM combined with nab-PTX on de novo lipogenesis in pancreatic cancer cells. These findings establish a link between GEM combined with nab-PTX and lipid metabolism, and the discovery of the novel lipid-lowering drug ETC-1002 provides a potential therapeutic strategy for pancreatic cancer.

Skeletal Muscle Index Changes on Locoregional Treatment Application After FOLFIRINOX and Survival in Pancreatic Cancer

BACKGROUND

Patients with borderline resectable (BR) or locally advanced pancreatic cancer (LAPC) require complex management strategies. This study evaluated the prognostic significance of the perichemotherapy skeletal muscle index (SMI) and carbohydrate antigen 19-9 (CA 19-9) in patients with BRPC or LAPC treated with FOLFIRINOX.

METHODS

We retrospectively evaluated 227 patients with BR or LAPC who received at least four cycles of chemotherapy between 2015 and 2020. We analysed chemotherapy response, changes in SMI (ΔSMI, %) on computed tomography (CT) and CA19-9 to determine their impact on progression-free survival (PFS) and overall survival (OS). After the early application of loco-regional treatments (LRT) within 3 months after completing four cycles of chemotherapy, the outcomes were compared between ΔSMI and CA19-9 subgroups.

RESULTS

Among 227 patients (median age, 60 years; 124 [54.6%] male) with 97 BR and 130 LAPC, 50.7% showed partial response (PR) to chemotherapy, 44.5% showed stable disease and 4.8% showed progressive disease (PD). Post-chemotherapy CA19-9 levels were normalized in 41.0% of patients. The high and low ΔSMI groups (based on the gender-specific cut-off of -8.6% for males and -2.9% for females) comprised 114 (50.2%) and 113 (49.8%) patients, respectively. The high ΔSMI group had poorer survival rates than the low ΔSMI group in both PFS (HR = 1.32, p = 0.05) and OS (HR = 1.74, p = 0.001). Multivariable analysis showed that ΔSMI (high vs. low; PFS, HR = 1.39, p = 0.03; OS, HR = 1.82, p < 0.001) and post-chemotherapy response (PD vs. PR/SD; PFS, HR = 18.69, p < 0.001; OS, HR = 6.19, p < 0.001) were independently associated with both PFS and OS. Additionally, the post-chemotherapy CA19-9 (≥ 37 vs. < 37; HR = 1.48, p = 0.01) was an independent predictor for PFS. Early application of LRT after chemotherapy significantly improved PFS and OS in both ΔSMI groups (all p < 0.05). However, it was not beneficial in the group with high ΔSMI and post-chemotherapy CA19-9 ≥ 37 (PFS, p = 0.39 and OS, p = 0.33).

CONCLUSIONS

Progressive sarcopenic deterioration after four cycles of chemotherapy was associated with poor survival outcomes in patients with BR or LAPC after FOLFIRINOX. We also investigated the optimal clinical setting for the early application LRTs using the ΔSMI and post-chemotherapy CA 19-9.

Efficacy and safety of multi-target tyrosine kinase inhibitor AL2846 combined with gemcitabine in pancreatic cancer

Pancreatic cancer patients urgently need new treatments, and we explored the efficacy and safety of combination therapy with AL2846 and gemcitabine in pancreatic cancer patients. This was a single-arm, single-center, open-label phase I/IIa study (NCT06278493). The dose-escalation phase was designed to evaluate the maximum tolerated dose (MTD) of AL2846 combined with gemcitabine. One or two dose levels were chosen for the dose-expansion phase. Treatment continued until disease progression, intolerable toxicity, patient withdrawal, or at the investigators' discretion. The primary study endpoint is to evaluate the safety and MTD of AL2846 combined with gemcitabine. The secondary endpoints included objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and disease control rate (DCR). Between August 2018 and July 2021, 33 pancreatic cancer patients were enrolled in the study. A total of 15 patients were enrolled in the dose-escalation phase, and the MTD was not determined. Eventually 90 mg and 120 mg of AL2846 were chosen for the dose-expansion phase, in which 11 patients (90 mg) and 7 patients (120 mg) were administered. Treatment-related adverse events (TRAEs) of any grade were reported in 30 (90.91%) patients, and those of grade ≥ 3 were reported in 16 (48.48%) patients. The most frequently reported grade ≥ 3 TRAEs were thrombocytopenia (18.18%), neutropenia (12.12%), elevated γ-glutamyltransferase (6.06%), proteinuria (6.06%), and gastrointestinal hemorrhage (6.06%).The ORR was 6.06%, and the DCR was 72.73%. The median PFS was 3.71 months (95% CI: 3.38-4.11), and the median OS was 5.59 months (95% CI: 4.11-8.71). Gemcitabine and Al2846 combination therapy exhibited tolerable safety, but there was no improvement in efficacy over standard treatment. Further evaluation of this approach is still needed.

The global, regional burden of pancreatic cancer and its attributable risk factors from 1990 to 2021

BACKGROUND

Pancreatic cancer is the 12th most common type of cancer, and the sixth leading cause of cancer-related mortality, worldwide. Up-to-date statistics on pancreatic cancer would provide us with a better understanding of epidemiology and identify the causative risk factors for the prevention of this disease.

METHODS

The degree and change patterns of exposure as well as the attributable cancer burden, including incidence, mortality, disability-adjusted life years (DALYs), and prevalence in global and regional, by sex, age, year, for pancreatic cancer, with the data extracted from the Global Burden of Diseases Study (GBD) 2021. All data analyses were conducted using linear regression analysis and the Joinpoint software (version 5.0.1).

RESULTS

In 2021, 508,533 new cases of pancreatic cancer have been reported; the mortality and prevalence rate increased to 5.95, and 5.12 respectively; and the global DALYs rate increased to 130.33 this year. Besides, the pancreatic cancer-associated rates of incidence, mortality, DALYs, and prevalence were higher in males than in females. In addition, these indicators in the high SDI (Sociodemographic index) region were higher than the global mean. To date, the high fasting plasma glucose remained the major risk factor that influenced the incidence, mortality, DALYs, and prevalence of pancreatic cancer, followed by tobacco and high body mass index (BMI).

CONCLUSIONS

Results of this study suggest that the burden of pancreatic cancer is increasing generally, therefore, more attention and measures should be taken to cope with this situation.

Long non-coding RNAs in pancreatic cancer

This article reviews the recent advances in pathogenesis, diagnosis and treatment of pancreatic cancer, as well as the relationship between long non-coding RNA (lncRNA) in disease progression. Unfortunately, pancreatic cancer has no early symptoms and quickly invades surrounding tissue and organs, making it one of the deadliest. Accordingly, we urgently need to identify high-risk individuals with precancerous lesions through screening methods to identify early disease, provide better prevention strategies and improve overall survival. LncRNAs have a variety of biological functions in both physiologic and pathophysiologic states including tumor growth, differentiation and proliferation. Herein we review the biological functions, expression patterns, clinical significance and targeted therapy potential of lncRNAs to provide new approaches for diagnosis and treatment in pancreatic cancer.

CHMP4C promotes pancreatic cancer progression by inhibiting necroptosis via the RIPK1/RIPK3/MLKL pathway

INTRODUCTION

Pancreatic cancer (PC) cannot currently be completely cured and has a poor prognosis. Necroptosis is a distinct form of regulated cell death that differs from both necrosis and apoptosis. Understanding the role of necroptosis during PC progression would open new avenues for targeted therapy.

OBJECTIVES

The purpose of this study is to examine the impact of necroptosis on the progression of PC and related mechanisms.

METHODS

RNA sequencing was performed to identify necroptosis-related genes that are differentially expressed in PC tissues. The biological functions of CHMP4C and its necroptosis effects were determined in vitro and in vivo. RNA immunoprecipitation, MeRIP-qPCR, Co-immunoprecipitation assays were conducted to evaluate the interaction among CHMP4C, YBX1 and caspase-8 mRNA. Extracellular vesicles were isolated using the differential ultracentrifugation method. The expression of CHMP4C, p-MLKL and CD117 were detected on a PC tissue microarray using multiplex immunofluorescence staining.

RESULTS

CHMP4C was significantly overexpressed in PC cells and tissues. It promoted cell growth and suppressed necroptosis of PC cells in both in vivo and in vitro settings. Mechanistically, CHMP4C interacted with YBX1 to mediate m5C modification of caspase-8 mRNA, resulting in increased caspase-8 expression and inhibition of RIPK1/RIPK3/MLKL pathway phosphorylation. Furthermore, CHMP4C promoted extracellular exocytosis of p-MLKL to further suppress necroptosis. Additionally, PC cells used CHMP4C within extracellular vesicles to recruit and stimulate mast cells (MCs), which in turn promoted PC cell proliferation. In PC tissues, the expression of CHMP4C showed a negative correlation with p-MLKL and a positive association with CD117. High expression levels of CHMP4C in patients were associated with poorer overall survival outcomes.

CONCLUSIONS

CHMP4C promotes PC progression by inhibiting necroptosis, which has potential as a biomarker and therapeutic target in PC.

The choice of adjuvant radiotherapy in pancreatic cancer patients after up-front radical surgery

BACKGROUND

The role of adjuvant radiotherapy in pancreatic cancer following radical surgery remains a subject of of controversy. This study aimed to more accurately screen pancreatic patients who benefit from adjuvant radiotherapy.

METHODS

Clinicopathologic characteristics of patients with resectable pancreatic cancer were collected from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015). Univariate and multivariate analyses were applied to identify prognostic factors affecting patient survival. All the patients were divided into two groups, one receiving radiation and the other not. Selection bias were reduced by propensity-score matching (PSM). Kaplan-Meier analysis was used to estimate overall survival (OS) and cancer-specific survival (CSS) between the two groups.

RESULTS

Within 7097 patients, 2276 received adjuvant radiotherapy (external beam radiation), and 4821 did not. Multivariate analysis revealed that race, age, median income, sex, year of diagnosis, American Joint Committee on Cancer (AJCC) T stage, N stage, scope region lymph surgery, chemotherapy, and radiotherapy were independent predictors for overall survival of all the patients (all p < 0.05). After PSM, a total of 4304 patients were included. There was no OS and CSS benefit of radiotherapy compared with no-radiotherapy (all p > 0.05). Among patients with N1 stage, the radiotherapy group exhibited a median overall survival (mOS) of 21 months (95% CI, 19.82 to 22.18), while the non-radiotherapy group showed a slightly lower mOS of 18 months (95% CI, 16.88 to 19.12). Similarly, in terms of median cancer-specific survival (mCSS), the radiotherapy group demonstrated a mCSS of 22 months (95% CI, 20.79 to 23.21), whereas the non-radiotherapy group had a slightly shorter mCSS of 19 months (95% CI, 17.81 to 20.19). Radiotherapy reduced the all-cause mortality rate and cancer-specific mortality rate among patients with the N1 stage and T4 stage (all p < 0.05). In contrast, the patients in the radiotherapy group with the N0 stage (mOS, 28 months versus 34 months; mCSS, 30 months versus 41months), or primary focus on the body and tail of the pancreas (mOS, 23 months versus 29 months; mCSS, 25 months versus 32 months), or T1 stage (mOS, 36 months versus 113 months; mCSS, 36 months versus 104 months) exhibited a higher all-cause mortality rate and cancer-specific mortality rate compared to those without radiotherapy (all p < 0.05). Subgroup analysis indicated N1 stage pancreatic cancer patients with T2-4 stage, primary focus on the head of the pancreas, young age of onset, and combination chemotherapy were in favor of the adjuvant radiotherapy group (all p < 0.05).

CONCLUSIONS

Our analysis demonstrates that adjuvant radiotherapy may be beneficial for N1 stage (N+) pancreatic cancer patients who have undergone up-front radical surgery with T2-4 stage, primary focus on the head of the pancreas, young age of onset, and receiving combination chemotherapy. However, radiotherapy needs to be used with caution in patients with T1 stage, N0 stage (N-), or primary focus on the body and tail of the pancreas. These findings may contribute to the development of personalized selection criteria for adjuvant radiotherapy in post-surgical pancreatic cancer patients.

Expert Judgment Supporting a Bayesian Network to Model the Survival of Pancreatic Cancer Patients

Purpose: Pancreatic cancer is known for its poor prognosis. The most effective treatment combines surgery with peri-operative chemotherapy. Current prognostic tools are designed to predict patient outcomes and inform treatment decisions based on collected data. Bayesian networks (BNs) can integrate objective data with subjective clinical insights, such as expert opinions, or they can be independently based on either element. This pilot study is one of the first efforts to incorporate expert opinions into a prognostic model using a Bayesian framework. Methods: A clinical hybrid BN was selected to model the long-term overall survival of pancreatic cancer patients. The SHELF expert judgment method was employed to enhance the BN's effectiveness. This approach involved a two-phase protocol: an initial single-center pilot phase followed by a definitive international phase. Results: Experts generally agreed on the distribution shape among the 12 clinically relevant predictive variables identified for the BN. However, discrepancies were noted in the tumor size, age, and ASA score nodes. With regard to expert concordance for each node, tumor size, and ASA score exhibited absolute concordance, indicating a strong consensus among experts. Ca19.9 values and resectability status showed high concordance, reflecting a solid agreement among the experts. The remaining nodes showed acceptable concordance. Conclusions: This project introduces a novel clinical hybrid Bayesian network (BN) that incorporates expert elicitation and clinical variables present at diagnosis to model the survival of pancreatic cancer patients. This model aims to provide research-based evidence for more reliable prognosis predictions and improved decision-making, addressing the limitations of existing survival prediction models. A validation process will be essential to evaluate the model's performance and clinical applicability.

Digestive cancers: mechanisms, therapeutics and management

Cancers of the digestive system are major contributors to global cancer-associated morbidity and mortality, accounting for 35% of annual cases of cancer deaths. The etiologies, molecular features, and therapeutic management of these cancer entities are highly heterogeneous and complex. Over the last decade, genomic and functional studies have provided unprecedented insights into the biology of digestive cancers, identifying genetic drivers of tumor progression and key interaction points of tumor cells with the immune system. This knowledge is continuously translated into novel treatment concepts and targets, which are dynamically reshaping the therapeutic landscape of these tumors. In this review, we provide a concise overview of the etiology and molecular pathology of the six most common cancers of the digestive system, including esophageal, gastric, biliary tract, pancreatic, hepatocellular, and colorectal cancers. We comprehensively describe the current stage-dependent pharmacological management of these malignancies, including chemo-, targeted, and immunotherapy. For each cancer entity, we provide an overview of recent therapeutic advancements and research progress. Finally, we describe how novel insights into tumor heterogeneity and immune evasion deepen our understanding of therapy resistance and provide an outlook on innovative therapeutic strategies that will shape the future management of digestive cancers, including CAR-T cell therapy, novel antibody-drug conjugates and targeted therapies.

Sequence of Chemotherapy May Not Impact Survival After Resection of Pancreatic Tail Adenocarcinoma

Introduction

Pancreatic ductal adenocarcinoma (PDAC) of the body/tail is notably different than PDAC in the head of the pancreas. Surgery plus chemotherapy is known to improve outcomes for all PDAC. The sequence of this therapy is well studied in head cancers yet has never been evaluated systematically in relation to distal pancreatectomy (DP).

Methods

Patients receiving DP for PDAC and who received chemotherapy were included. Patients were compared receiving neoadjuvant systemic therapy (NAST) only, adjuvant (AST) only, both NAST + AST, and who received total neoadjuvant therapy (TNT), defined as > 24 weeks NAST before DP. PSM was performed 1:1 between AST and each other group creating quadruplets of patients for analysis. Matching factors were determined by multivariate cox‐regression analysis of factors independently affecting survival. Survival was considered from diagnosis and from surgery to account for potential biases.

Results

In total, 4677 patients were selected with 400 (8.6%) receiving TNT, 536 (11.5%) NAST, 3235 (69.2%) AST, and 506 (10.8%) NAST + AST. A total of 341 quadruplets were selected after PSM. There were no differences in comorbidities, T/N‐stage, retrieved or positive lymph nodes, and margin status after matching. Kaplan–Meier analysis showed no difference in median OS between the matched treatment groups (33.71 ± 2.07 vs. 35.22 ± 1.62 vs. 32.53 ± 3.31 vs. 37.88 ± 1.90, respectively; log‐rank p = 0.464). Five‐year OS was not different between the groups (21% vs. 18% vs. 20% vs. 25%, respectively; p = 0.501).

Conclusion

The sequence of chemotherapy and surgery did not impact survival in distal PDAC. Providers should tailor an individualized approach designed to maximize the chance of completing both treatments.

Multiparametric MRI for Assessment of the Biological Invasiveness and Prognosis of Pancreatic Ductal Adenocarcinoma in the Era of Artificial Intelligence

Pancreatic ductal adenocarcinoma (PDAC) is the deadliest malignant tumor, with a grim 5-year overall survival rate of about 12%. As its incidence and mortality rates rise, it is likely to become the second-leading cause of cancer-related death. The radiological assessment determined the stage and management of PDAC. However, it is a highly heterogeneous disease with the complexity of the tumor microenvironment, and it is challenging to adequately reflect the biological aggressiveness and prognosis accurately through morphological evaluation alone. With the dramatic development of artificial intelligence (AI), multiparametric magnetic resonance imaging (mpMRI) using specific contrast media and special techniques can provide morphological and functional information with high image quality and become a powerful tool in quantifying intratumor characteristics. Besides, AI has been widespread in the field of medical imaging analysis. Radiomics is the high-throughput mining of quantitative image features from medical imaging that enables data to be extracted and applied for better decision support. Deep learning is a subset of artificial neural network algorithms that can automatically learn feature representations from data. AI-enabled imaging biomarkers of mpMRI have enormous promise to bridge the gap between medical imaging and personalized medicine and demonstrate huge advantages in predicting biological characteristics and the prognosis of PDAC. However, current AI-based models of PDAC operate mainly in the realm of a single modality with a relatively small sample size, and the technical reproducibility and biological interpretation present a barrage of new potential challenges. In the future, the integration of multi-omics data, such as radiomics and genomics, alongside the establishment of standardized analytical frameworks will provide opportunities to increase the robustness and interpretability of AI-enabled image biomarkers and bring these biomarkers closer to clinical practice. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 4.

Ongoing Failure to Deliver Guideline-Concordant Care for Patients with Pancreatic Cancer

(1) Background: Comprehensive evaluation of guideline-concordant care (GCC) across all PDAC stages has yet to be thoroughly conducted. This study aimed to characterize treatment patterns and assess factors associated with receiving GCC among patients with pancreatic ductal adenocarcinoma (PDAC) in California. (2) Methods: Data on adult patients with PDAC were extracted from the California Cancer Registry (2004-2020). GCC is defined according to the recommendations provided by the National Comprehensive Cancer Network. We used multivariable logistic regression to identify factors associated with receiving GCC. A Cox model was used to examine the association of GCC with overall survival. (3) Results: A total of 50,346 PDAC patients were included (stage 1: 10%; stage 2: 25%; stage 3: 11%; stage 4: 54%). Only 46.7% of all patients received GCC (stage 1: 20%; stage 2: 40%; stage 3: 69%; stage 4: 50%). Only 31% of stage 1 patients underwent surgery. Factors inversely associated with receiving GCC were Hispanic ethnicity (OR 0.78; p < 0.001), Black race (OR 0.74; p < 0.001), having no insurance (OR 0.40; p < 0.001]), and a Charlson-Deyo score of ≥2 (OR 0.68; p < 0.001). Adherence to GCC was associated with improved survival (Hazard Ratio 0.39; p < 0.001). Notably, patients with stage 1 PDAC who received GCC had a median survival of 47 months vs. 8 months for those who did not. (4) Conclusions: Although stage 1 PDAC patients have the greatest potential for survival with GCC, only 20% of patients received such treatment. Thus, it is crucial to identify and address the modifiable factors contributing to these suboptimal care patterns.

Advances in Endoscopic Ultrasonography-Based Diagnosis of Pancreatic Lesions: Narrative Review

Pancreatic cancer is the fourth deadliest cancer in the U [...].

The up-regulation of SPTAN1 expression in Pancreatic adenocarcinoma is associated with tumor immune invasion and poor clinical prognosis

BACKGROUND

Pancreatic adenocarcinoma (PAAD) is a common malignancy with a very low survival rate. More and more studies have shown that SPTAN1 may be involved in the development and progression of a variety of tumors, including rectal cancer, Pancreatic adenocarcinoma, etc., and may affect their prognosis.

METHODS

Bioinformatics technology was used to analyze the relationship between SPTAN1 expression in PAAD and immune cell infiltration, immune regulatory factors and chemokines, and cell experiments were used to verify the relationship between SPTAN1 knock down and migration, invasion, apoptosis and cycle changes of PAAD cell lines. In addition, immunohistochemical staining of SPTAN1 was performed by tissue microarray (TMA) to study the relationship between high expression of SPTAN1 and clinicopathological features and overall survival rate.

RESULTS

The expression of SPTAN1 is significantly correlated with immune cell infiltration, immunomodulators, chemokines and their receptors. In addition, it was found that the knock-down of SPTAN1 inhibited the migration and invasion ability of PAAD cell lines, promoted the apoptosis of cell lines, and also affected the changes of cell cycle. Immunohistochemical staining using tissue microarray (TMA) showed that the high expression of SPTAN1 was associated with M stage (P = 0.004) and CA199 (P = 0.012), and the overall survival rate of the high expression group was significantly lower than that of the low expression group (P = 0.043).

CONCLUSION

Our results suggest that up-regulation of SPTAN1 is related to cell migration, invasion, apoptosis and cycle changes, and is associated with tumor immune invasion and poor prognosis of PAAD.

Role of volumetric tumor enhancement on CT in predicting overall survival in patients with unresectable pancreatic ductal adenocarcinoma

PURPOSE

To assess the utility of volumetric tumor enhancement on CT to predict tumor treatment response and the overall survival (OS) of patients with PDAC undergoing FOLFIRINOX-based systemic chemotherapy. Additionally, we aim to explore the performance of a novel model that incorporates relevant volumetric CT-derived parameters to the established RECIST 1.1 in predicting both treatment response and OS.

MATERIAL AND METHODS

In this retrospective single-institution study, 127 patients with PDAC who received FOLFIRINOX neoadjuvant chemotherapy between December 2012 and November 2021 were included. Manual volumetric segmentation of the single largest tumor was performed on portal venous phase images. Total and enhancing tumor volumes were calculated. Response by RECIST 1.1 was compared to response by tumor volume and enhancing tumor volume on follow-up CT.

RESULTS

There was no association between overall survival and RECIST 1.1 (p-value = 0.284), volumetric RECIST (p-value = 0.402), and other volumetric CT variables, except for a percentage reduction in enhancing tumor volume (p-value = 0.043). Using univariate survival analysis for categorical thresholds defined by CART, the percentage change in enhancing tumor volume was associated with OS (p-value = 0.018). There was also a significant association between baseline enhancing tumor volume and OS (p-value <0.0001). Using these two categories, we defined a multivariable model associated with OS (p-value <0.0001).

CONCLUSION

Percentage reduction in enhancing tumor volume was related to OS in non-surgical PDAC patients treated with FOLFIRINOX chemotherapy and could potentially be incorporated into patient survival prediction models.