Predictive global trends in the incidence and mortality of pancreatic cancer based on geographic location, socio-economic status, and demographic shift

Identification and analysis of pancreatic intraepithelial neoplasia: opportunities and challenges

Pancreatic intraepithelial neoplasia (PanIN) is the most common precursor lesion of pancreatic ductal adenocarcinoma (PDAC), which has poor prognosis with a short median overall survival of 6-12 months and a low 5-year survival rate of approximately 3%. It is crucial to remove PanIN lesions to prevent the development of invasive PDAC, as PDAC spreads rapidly outside the pancreas. This review aims to provide the latest knowledge on PanIN risk, pathology, cellular origin, genetic susceptibility, and diagnosis, while identifying research gaps that require further investigation in this understudied area of precancerous lesions. PanINs are classified into PanIN 1, PanIN 2, and PanIN 3, with PanIN 3 having the highest likelihood of developing into invasive PDAC. Differentiating between PanIN 2 and PanIN 3 is clinically significant. Genetic alterations found in PDAC are also present in PanIN and increase with the grade of PanIN. Imaging methods alone are insufficient for distinguishing PanIN, necessitating the use of genetic and molecular tests for identification. In addition, metabolomics technologies and miRNAs are playing an increasingly important role in the field of cancer diagnosis, offering more possibilities for efficient identification of PanIN. Although detecting and stratifying the risk of PanIN poses challenges, the combined utilization of imaging, genetics, and metabolomics holds promise for improving patient survival in this field.

The Initial Journey of Patients with Metastatic Pancreatic Cancer (PaCTO Project): A Nationwide Survey among Portuguese Specialist Physicians

Introduction

We aimed to characterize the initial healthcare journey of metastatic pancreatic ductal adenocarcinoma (mPDAC) patients in Portugal, including healthcare provision and factors affecting therapeutic decisions, namely BRCA mutations testing.

Methods

This is a descriptive cross-sectional, web-based survey using a convenience sampling approach. Portuguese oncologists and pathologists that routinely work with mPDAC patients from the different geographical regions and settings were invited to participate in the study via email (December 2020). Descriptive statistical analyses were performed, with categorical variables reported as absolute and relative frequencies, and continuous variables with non-normal distribution as median and interquartile range (IQR) (Stata v.15.0).

Results

Seventy physicians participated in the study (43 oncologists, 27 pathologists). According to the responses, a median of 28 patients per center (IQR 12-70) was diagnosed with PDAC in the previous year; 22 of them referring (IQR 8-70) to mPDAC. The pointed median time from patients' first hospital admission until disease diagnosis/staging is between 2 and 4 weeks. Endoscopic ultrasound with fine-needle biopsy is available in most hospitals (86%). Around 50% of physicians request BRCA testing; the assessment of additional biomarkers besides BRCA is requested by 40% of professionals. Half of them stated that BRCA testing should be requested earlier-upon histological diagnosis, especially because the median time for results is of 4.0 weeks (IQR 4-8). PARP inhibitors such as olaparib, when available, would be the therapy of choice for most oncologists (71%) if no disease' progression occurs after 4 months. Treatments' selection is usually grounded on clinical criteria (e.g., performance status, liver function). Around 45% of patients use FOLFIRINOX/mFOLFIRINOX as the first-line therapy. Gemcitabine + nab-paclitaxel is used by 35% of patients as the second-line therapy.

Conclusions

Physicians in Portugal support the increasing role of patient-tailored treatments in mPDAC, whose selection should be grounded on tumoral subtyping and molecular profiling. Further efforts to develop multidisciplinary teams, standardized clinical practice, and optimize the implementation of new target therapies are needed.

Nicotine promotes epithelial to mesenchymal transition and gemcitabine resistance via hENT1/RRM1 signalling in pancreatic cancer and chemosensitizing effects of Embelin-a naturally occurring benzoquinone

Pancreatic cancer is lethal due to poor prognosis with 5-year survival rate lesser than 5 %. Gemcitabine is currently used to treat pancreatic cancer and development of chemoresistance is a major obstacle to overcome pancreatic cancer. Nicotine is a known inducer of drug resistance in pancreatic tumor micro-environment. Present study evaluates chemoresistance triggered by nicotine while treating with gemcitabine and chemosensitization using Embelin. Embelin is a naturally occurring benzoquinone from Embelia ribes possessing therapeutic potency. To develop nicotine-induced chemo-resistance, pancreatic cancer cells PANC-1 and MIA PaCa-2 were continuously treated with nicotine followed by exposure to gemcitabine. Gemcitabine sensitivity assay and immunoblotting was performed to assess the chemo-resistance. Antiproliferative assays such as migration assay, clonogenic assay, Mitochondrial Membrane Potential (MMP) assay, dual staining assay, comet assay, Reactive Oxygen Species (ROS) assay, cell cycle analysis and immunoblotting assays were performed to witness the protein expression involved in chemoresistance and chemosensitization. Epithelial to mesenchymal transition was observed in nicotine induced chemoresistant cells. Gemcitabine sensitivity assay revealed that relative resistance was increased to 6.26 (p < 0.0001) and 6.45 (p < 0.0001) folds in resistant PANC-1 and MIA PaCa-2 compared to parental cells. Protein expression studies confirmed resistance markers like hENT1 and dCK were downregulated with subsequent increase in RRM1 expression in resistant cells. Embelin considerably decreased the cell viability with an IC50 value of 4.03 ± 0.08 μM in resistant PANC-1 and 2.11 ± 0.04 μM in resistant MIA PaCa-2. Cell cycle analysis showed Embelin treatment caused cell cycle arrest at S phase in resistant PANC-1 cells; in resistant MIA PaCa-2 cells there was an escalation in the Sub G1. Embelin upregulated Bax, γH2AX, p53, ERK1/2 and hENT1 expression with concomitant down regulation of Bcl-2 and RRM1. Bioactive molecule embelin, its combination with gemcitabine could provide new vistas to overcome chemo resistance in pancreatic cancer.

Reading Holy Quran Associated With Better Cognitive Function in Older Adults: A Systematic Review

Background: As the global population ages, understanding factors that contribute to better cognitive function in older adults becomes crucial. This systematic review delves into the potential relationship between reading the Holy Quran and cognitive function in older adults. Methods: A systematic search was conducted across five electronic databases (PubMed, ScienceDirect, Google Scholar, Tripdatabase, Cochrane) to identify relevant studies that were published between 2004 to December 2023. Inclusion criteria were centered on studies exploring the correlation between reading the Quran and cognitive function in older adults. Results: Five studies meeting the inclusion criteria were included in this systematic review. Notably, four of these studies reported a significant correlation between the intensity or duration of Quranic reading and improved cognitive function in older adults. Discussion: The findings imply a potential positive association between engaging with the Holy Quran and cognitive function among the elderly. This relationship holds promise for potential applications in cognitive health interventions for older adults especially for Muslim patients. Conclusion: This review provides evidence supporting the relationship between reading the Holy Quran and normal cognitive function in older adults. The consistent findings underscore the importance of further research to elucidate underlying mechanisms and consider potential implications for cognitive health interventions.

Global trends in the incidence and mortality of pancreatic cancer based on geographic location, socioeconomic status, and demographic shift

BACKGROUND

Pancreatic cancer (PC) is a lethal malignancy with a significantly rising rate of incidence and mortality. This study aims to describe the influence of geography, socioeconomic development (based on the Human Development Index [HDI]), gender, and demographic shift on the temporal trends in the global burden of PC.

METHODS

Data (2020-2040) relating to the incidence, mortality of PC, and demographic shifts based on continents and HDI areas were extracted from GLOBOCAN 2020.

RESULTS

PC was associated with a higher socioeconomic status. Asia contributed to the majority of the burden, led by China. Advanced age (≥65 years) contributed to the majority of the burden in all socioeconomic regions except in Medium HDI and Low HDI countries, where the younger population (<65 years) contributed more. Females contributed to a higher burden in certain countries. Future trends for 2040 showed a >60% increase in the incidence and mortality of PC with an associated demographic shift.

CONCLUSION

The global burden of PC is expected to rise significantly over the next few decades regardless of geography, socioeconomic development, age, and gender. Advance knowledge of this data can help to formulate strategies and public health policies to specifically target countries and populations at risk.

Global long-term trends and spatial cluster analysis of pancreatic cancer incidence and mortality over a 30-year period using the global burden of disease study 2019 data

INTRODUCTION

Pancreatic cancer (PC) is one of the most fatal malignancies, and its incidence and mortality rates are growing annually throughout the world. In this research, we aimed to investigate the time trends and identify the spatial clusters of incidence and mortality on a global scale over the last 30 years, using the Global Burden of Disease (GBD) study 2019 data.

METHODS

Age-standardized incidence and mortality data due to PC were extracted from the GBD study, which was carried out from 1990 to 2019. A Joinpoint regression analysis was utilized to examine trends in the incidence and mortality of PC over the past three decades. As such, spatial analyses were undertaken to detect the spatial distribution and clustering of the metrics globally.

RESULTS

It was observed that both the incidence and mortality rates were higher in males than in females worldwide. The global mortality and incidence rates significantly increased by 0.8% per year over the time of follow-up period (p<0.05). By spatial cluster analysis for mortality, European and North African countries, as well as Greenland were explored as hot spots; while South African and Southeast Asian countries were explored as cold spots. Regarding incidence, hot spots were found in European countries, Southern America, and Greenland; whilst cold spots were determined in Southern Africa and Madagascar.

CONCLUSIONS

Collectively, the temporal trends disclosed a gradual rise in PC incidence and mortality rates over the period 1990-2019, reflecting the global health concern. We further found geographical variations in the patterns and identified high- and low-risk areas for incidence and mortality. These findings facilitate the design and implementation of more resource-efficient and geographically targeted treatments. Given the results of the current study, a practical approach to minimizing the future PC burden involves planned population-wide interventions, as well as primary prevention through healthier lifestyles.

Molecular Research in Pancreatic Cancer: Small Molecule Inhibitors, Their Mechanistic Pathways and Beyond

Pancreatic enzymes assist metabolic digestion, and hormones like insulin and glucagon play a critical role in maintaining our blood sugar levels. A malignant pancreas is incapable of doing its regular functions, which results in a health catastrophe. To date, there is no effective biomarker to detect early-stage pancreatic cancer, which makes pancreatic cancer the cancer with the highest mortality rate of all cancer types. Primarily, mutations of the KRAS, CDKN2A, TP53, and SMAD4 genes are responsible for pancreatic cancer, of which mutations of the KRAS gene are present in more than 80% of pancreatic cancer cases. Accordingly, there is a desperate need to develop effective inhibitors of the proteins that are responsible for the proliferation, propagation, regulation, invasion, angiogenesis, and metastasis of pancreatic cancer. This article discusses the effectiveness and mode of action at the molecular level of a wide range of small molecule inhibitors that include pharmaceutically privileged molecules, compounds under clinical trials, and commercial drugs. Both natural and synthetic small molecule inhibitors have been counted. Anti-pancreatic cancer activity and related benefits of using single and combined therapy have been discussed separately. This article sheds light on the scenario, constraints, and future aspects of various small molecule inhibitors for treating pancreatic cancer-the most dreadful cancer so far.

Management of pain and cachexia in pancreatic cancer: Protocol for two systematic reviews, network meta-analysis, surveys and focus groups (Preprint)

BACKGROUND

 Approximately 75% of people with pancreatic cancer experience pain, and >50% of them have cachexia (weakness and wasting of the body). However, there is considerable uncertainty regarding the management of these distressing symptoms.

OBJECTIVE

 Our primary objectives are to compare the relative benefits and harms of different interventions for pain in people with unresectable pancreatic cancer and for prevention and treatment of cachexia due to pancreatic cancer, through systematic reviews and network meta-analysis. Our secondary objectives are to develop an evidence-based clinical care pathway to manage pain and prevent and treat cachexia in people with pancreatic cancer through surveys and focus groups involving patients, carers, and health care professionals.

METHODS

 We will perform 2 systematic reviews of the literature related to pain and cachexia in people with pancreatic cancer using searches from Cochrane Library, MEDLINE, Embase, Science Citation Index, and trial registries. Two researchers will independently screen for eligibility and identify randomized controlled trials (no language or publication status restriction), comparing interventions for pain or cachexia based on full-texts for articles shortlisted during screening. We will assess risk of bias in the trials using the Cochrane risk of bias tool (version 2.0) and obtain data related to baseline prognostic characteristics, potential effect modifiers and outcome data related to overall survival, health-related quality of life, treatment-related complications, and resource utilisation. We aim to conduct network meta-analysis on outcomes with multiple treatment comparisons where possible, otherwise, meta-analysis with direct comparisons, or narrative synthesis. We will perform various subgroup and sensitivity analyses. Using information obtained from both systematic reviews, we will conduct 2 surveys: one directed to patients or carers to assess acceptability of interventions, and the other to health care professionals to assess feasibility of delivery in the National Health Service. Four mixed focus groups will be conducted to evaluate findings and foster consensus in the development of the care pathway.

RESULTS

 Funding was awarded from April 2022 (NIHR202727). Both systematic review protocols were prospectively registered on PROSPERO in May 2022. Formal searches began thereafter. Approval by the University College London Research Ethics Committee (23563/001) was received in December 2022. Data collection began in January 2023; data analysis will begin in May 2023 (completion expected by October 2023).

CONCLUSIONS

 This study will comprehensively encompass major interventions for management of pain in people with unresectable pancreatic cancer, and prevention and treatment of cachexia in people with pancreatic cancer. Key stakeholders will facilitate the development of an evidence-based care pathway, ensuring both acceptability and feasibility. The project ends in April 2024 and published results are expected within 12 months of completion. We aim to present the findings through patient group websites, conferences, and publications, irrespective of the findings, in a peer-reviewed journal.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46335.

Dietary patterns associated with the risk of pancreatic cancer: Case-control study findings

Diet is an important modifiable lifestyle factor, but epidemiological studies evaluating the association between dietary patterns and pancreatic cancer (PC) have reported inconsistent findings. This study aimed to evaluate the impact of several dietary choices on the risk of PC among newly diagnosed Jordanian patients. A case-control study was conducted at major teaching and general hospitals, including a Jordanian oncology center. The study included 101 patients with incident pancreatic cancer and 314 controls. Data was collected using interview-based questionnaires. Dietary intake was estimated using a validated Arabic and reproducible food-frequency questionnaire. Dietary patterns were derived using Principal Component Analysis. Multinomial logistic regression was used to estimate the association between dietary patterns and PC. Four dietary patterns were identified. The "Traditional" dietary pattern, which presented a diet rich in fresh fruits, vegetables, milk, yogurt, and lentils, was associated with a significant decrease in the odds of PC (OR = 0.42, 95% CI = 0.21-0.84) for the third quartile compared to first one. The "High-fruit" dietary pattern, which was loaded with strawberry, melon, watermelon, and other fruits, significantly reduced the odds of PC (OR = 0.38, 95% CI = 0.19-0.75) for the second quartile compared to the first one. The "Soup" dietary pattern was mainly composed of vermicelli soup, vegetable soup, lentil soup, and mushroom soup, which decreased the odds of PC (OR = 0.18, 95% CI = 0.07-0.38). There was no relation between PC and the "Western" dietary pattern, loaded with beer, wine, roasted lamb, meat, chicken sandwich, beefsteak, and fried fish. The "Traditional," "High-fruit," and "Soup" dietary patterns were associated with reduced risk of PC among Jordanians.

Update on quantitative radiomics of pancreatic tumors

Radiomics is a newer approach for analyzing radiological images obtained from conventional imaging modalities such as computed tomography, magnetic resonance imaging, endoscopic ultrasonography, and positron emission tomography. Radiomics involves extracting quantitative data from the images and assessing them to identify diagnostic or prognostic features such as tumor grade, resectability, tumor response to neoadjuvant therapy, and survival. The purpose of this review is to discuss the basic principles of radiomics and provide an overview of the current clinical applications of radiomics in the field of pancreatic tumors.

Lifestyle, body mass index, diabetes, and the risk of pancreatic cancer in a nationwide population-based cohort study with 7.4 million Korean subjects

BACKGROUND

Large-scale epidemiological studies on pancreatic cancer in non-Western populations are insufficient. We investigated the risk factors for pancreatic cancer.

METHODS

Using the Korean National Health Insurance database, subjects who participated in the health examination program between 2005 and 2006 were identified and followed up until 2017. Adjusted hazard ratios (HRs) for pancreatic cancer risk were estimated using a Cox proportional hazards model.

RESULTS

During 11.5 years follow-up, 22,543 of 7,445,947 participants were newly diagnosed with pancreatic cancer. Compared with normal-weight subjects, pancreatic cancer risk was increased in those with severe obesity (BMI ≥ 28 kg/m2) (HR = 1.16; 95% CI, 1.11-1.23). Subjects with diabetes had an increased risk compared with those without diabetes (HR = 1.48; 95% CI, 1.43-1.53). Current smokers had a higher risk than never smokers (HR = 1.43; 95% CI, 1.38-1.48). Current smoking combined with diabetes increased the risk compared with never smokers without diabetes (HR = 2.13; 95% CI, 2.00-2.28). Current smoking combined with BMI ≥ 25 kg/m2 had an increased risk compared with never smokers with BMI < 23 kg/m2 (HR = 1.55; 95% CI, 1.46-1.65).

CONCLUSION

Smoking, obesity, and diabetes are significant risk factors for pancreatic cancer in Koreans. Lifestyle modifications for smoking and obesity would be beneficial for pancreatic cancer prevention.

Treatment of unresectable locally advanced pancreatic cancer with percutaneous irreversible electroporation (IRE) following initial systemic chemotherapy (LAP-PIE) trial: study protocol for a feasibility randomised controlled trial

BACKGROUND

Approximately 30% of patients with pancreas cancer have unresectable locally advanced disease, which is currently treated with systemic chemotherapy. A new treatment option of irreversible electroporation (IRE) has been investigated for these patients since 2005. Cohort studies suggest that IRE confers a survival advantage, but with associated, procedure-related complications. Selection bias may account for improved survival and there have been no prospective randomised trials evaluating the harms and benefits of therapy. The aim of this trial is to evaluate the feasibility of a randomised comparison of IRE therapy with chemotherapy versus chemotherapy alone in patients with locally advanced pancreatic cancer (LAPC).

METHODS AND ANALYSIS

Eligible patients with LAPC who have undergone first-line 5-FluoroUracil, Leucovorin, Irinotecan and Oxaliplatin chemotherapy will be randomised to receive either a single session of IRE followed by (if indicated) further chemotherapy or to chemotherapy alone (standard of care). Fifty patients from up to seven specialist pancreas centres in the UK will be recruited over a period of 15 months. Trial follow-up will be 12 months. The primary outcome measure is ability to recruit. Secondary objectives include practicality and technical success of treatment, acceptability of treatment to patients and clinicians and safety of treatment. A qualitative study has been incorporated to evaluate the patient and clinician perspective of the locally advanced pancreatic cancer with percutaneous irreversible electroporation trial. It is likely that the data obtained will guide the structure, the primary outcome measure, the power and the duration of a subsequent multicentre randomised controlled trial aimed at establishing the clinical efficiency of pancreas IRE therapy. Indicative procedure-related costings will be collected in this feasibility trial, which will inform the cost evaluation in the subsequent study on efficiency.

ETHICS AND DISSEMINATION

The protocol has received approval by London-Brent Research Ethics Committee reference number 21/LO/0077.Results will be analysed following completion of trial recruitment and follow-up. Results will be presented to international conferences with an interest in oncology, hepatopancreaticobiliary surgery and interventional radiology and be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN14986389.

Thyroid Cancer: Global Burden and Trends

The incidence of thyroid cancer continues to increase, representing the 5th most common cancer type in the USA today (Sherman, Lancet 361(9356):501-11, 2003). The current study sought to analyze the global burden of thyroid cancer utilizing the publicly accessible GLOBOCAN database. An estimated 586,202 cases of thyroid cancer were reported in 2020, making thyroid cancer the 10th most common cancer worldwide. The majority of thyroid cancer cases occurred in countries with a high or very high Human Development Index (HDI), accounting for 91% of new cases. With respect to the World Health Organization (WHO) regions, the Western Pacific had the highest incidence of thyroid cancer accounting for 47.6% of cases despite representing only 25.4% of the world's population. Thyroid cancer incidence and mortality are expected to increase by 29.9% and 67%, respectively, by the year 2040. The African region is projected to experience the highest increase in both incidence (84.3%) and mortality (100.3%) over this time period. The results of our study demonstrate that the incidence and mortality of thyroid cancer vary by the geographic location and socio-economic status. Although the incidence was noted to be the highest in very high HDI countries and the Western Pacific region, mortality was noted to be disproportionately higher in the low HDI countries and African region. This may be due to discrepancies in access to care and/or environmental exposures such as ionizing radiation and iodine deficiency. Further measures are required to improve the outcomes from thyroid cancer regardless of the geographic location or socio-economic status.

Global, regional, and national survey on the burden and quality of care of pancreatic cancer: a systematic analysis for the Global Burden of Disease study 1990-2017

BACKGROUND

Pancreatic cancer (PC) is among the most lethal cancers worldwide, and the quality of care provided to PC patients is a vital public health concern. We aimed to investigate the quality of care of PC globally and to report its current burden.

METHODS

The Quality of Care Index (QCI) was achieved by performing a Principal Component Analysis utilizing the results of the GBD study 2017. The QCI was defined as a range between 0 and 100, in which higher QCIs show higher quality of care. Possible gender- and age-related inequalities in terms of QCI were explored based on WHO world regions and the sociodemographic index (SDI).

RESULTS

In 2017, Japan had the highest QCI among all countries (QCI = 99/100), followed by Australia (QCI = 83/100) and the United States (QCI = 76/100). In Japan and Australia, males and females had almost the same QCIs in 2017, while in the United States, females had lower QCIs than males. In contrast to these high-QCI nations, African countries had the lowest QCIs in 2017. Besides, QCI increased by SDI, and high-SDI regions had the highest QCIs. Regarding patients' age, elderly cases had higher QCIs than younger patients globally and in high-SDI regions.

CONCLUSION

This study provides clinicians and health authorities with a wider vision around the quality of care of PC worldwide and highlights the existing disparities. This could help them investigate possible effective strategies to improve the quality of care in regions with lower QCIs and higher gender- and age-related inequities.

Liver-Metastasis-Related Genes are Potential Biomarkers for Predicting the Clinical Outcomes of Patients with Pancreatic Adenocarcinoma

It is widely acknowledged that metastasis determines the prognosis of pancreatic adenocarcinoma (PAAD), and the liver is the most primary distant metastatic location of PAAD. It is worth exploring the value of liver-metastasis-related genetic prognostic signature (LM-PS) in predicting the clinical outcomes of PAAD patients post R0 resection. We collected 65 tumors and 165 normal pancreatic data from The Cancer Genome Atlas (TCGA) and the Genotype-Tissue Expression project (GTEx), respectively. Differentially expressed genes (DEGs) between primary tumor and normal pancreatic samples were intersected with DEGs between primary tumor samples with liver metastasis and those without new tumor events. The intersected 45 genes were input into univariate Cox regression analysis to identify the prognostic genes. Thirty-three prognostic liver-metastasis-related genes were identified and included in least absolute shrinkage and selection operator (LASSO) analysis to develop a seven-gene LM-PS, which included six risk genes (ANO1, FAM83A, GPR87, ITGB6, KLK10, and SERPINE1) and one protective gene (SMIM32). The PAAD patients were grouped into low- and high-risk groups based on the median value of risk scores. The LM-PS harbored an independent predictive ability to distinguish patients with a high-risk of death and liver metastasis after R0 resection. Moreover, a robust prognostic nomogram based on LM-PS, the number of positive lymph nodes, and histologic grade were established to predict the overall survival of PAAD patients. Besides, a transcription factor-microRNA coregulatory network was constructed for the seven LM-PS genes, and the immune infiltration and genomic alterations were systematically explored in the TGCA-PAAD cohort.

Epidemiology of the Incidence and Mortality of Pancreas Cancer and its Relationship with the Human Development Index (HDI) in the World: An Ecological Study in 2018

OBJECTIVE

Pancreatic cancer is one of the leading causes of mortality in developed countries and a lethal malignant neoplasm worldwide. This study aims to evaluate the epidemiology of pancreatic cancer incidence and mortality and its relationship with HDI.

METHODS

This is a descriptive cross-sectional study that is based on cancer incidence data and cancer mortality rates derived from the GLOBOCAN in 2018. The incidence and mortality rates of Pancreas as well as Pancreas cancer distribution maps were derived for world countries. The data analysis was conducted using a correlation test, and regression tests were used to evaluate the correlation of the incidence and mortality of Pancreas with HDI. The statistical analysis was carried out by Stata-14, and a significance level of 0.05 was considered.

RESULTS

The highest incidence of pancreatic cancer was reported in Asia with 214499 (46.7%) cases and the lowest incidence was related to Oceania with 4529 cases (0.99%). The results showed a positive and significant correlation between incidence (r = 0.764, P <0.0001) and mortality (r = 0.771, P <0.0001) of pancreatic cancer and the HDI index. The results of ANOVA revealed that the highest mean incidence was related to the very high HDI (P <0.0001) and the highest mortality was connected to the very high human development (P <0.0001). The results exhibited that incidence was positively and significantly correlated with GNI (r = 0.497, P <0.0001), MYS (r = 0.746, P <0.0001), LEB (r = 0.676, <0.0001) and EYS (r = 0.738, P <0.0001). Also, a significant positive correlation was found between mortality and GNI (r = 0.507, P <0.0001), MYS (r = 0.745, P <0.0001), LEB (r = 0.679, <0.0001), and EYS (r = 0.748, P <0.0001).

CONCLUSION

Given the higher incidence and mortality of pancreatic cancer in countries with HDI, it is necessary to pay a greater attention to risk factors and appropriate planning to reduce these factors and minimize the impact and mortality rate of this disease.

Irreversible Electroporation (IRE) in Locally Advanced Pancreatic Cancer: A Review of Current Clinical Outcomes, Mechanism of Action and Opportunities for Synergistic Therapy

Locally advanced pancreatic cancer (LAPC) accounts for 30% of patients with pancreatic cancer. Irreversible electroporation (IRE) is a novel cancer treatment that may improve survival and quality of life in LAPC. This narrative review will provide a perspective on the clinical experience of pancreas IRE therapy, explore the evidence for the mode of action, assess treatment complications, and propose strategies for augmenting IRE response. A systematic search was performed using PubMed regarding the clinical use and safety profile of IRE on pancreatic cancer, post-IRE sequential histological changes, associated immune response, and synergistic therapies. Animal data demonstrate that IRE induces both apoptosis and necrosis followed by fibrosis. Major complications may result from IRE; procedure related mortality is up to 2%, with an average morbidity as high as 36%. Nevertheless, prospective and retrospective studies suggest that IRE treatment may increase median overall survival of LAPC to as much as 30 months and provide preliminary data justifying the well-designed trials currently underway, comparing IRE to the standard of care treatment. The mechanism of action of IRE remains unknown, and there is a lack of data on treatment variables and efficiency in humans. There is emerging data suggesting that IRE can be augmented with synergistic therapies such as immunotherapy.

Municipality and Adjusted Gross Income Influence Outcome of Patients Diagnosed with Pancreatic Cancer in a Newly Developed Cancer Center in Mercer County New Jersey, USA, a Single Center Study

Socioeconomic status (SES) correlates directly to ZIP code. Mercer County is not atypical as a collection of a dozen municipalities with a suburban/metropolitan population of 370,430 in the immediate vicinity of a major medical center. The purpose of this study for Mercer County, New Jersey, USA is to determine whether a patient's ZIP code is related to the outlook of pancreatic cancer defined as staging at diagnosis, prevalence, overall survival, type of insurance, and recurrence. Our hypothesis was that specific variables such as socio-economic status or race could be linked to the outcome of patients with pancreatic cancer. We interrogated a convenience sample from our cancer center registry and obtained 479 subjects diagnosed with pancreatic cancer in 1998-2018. We selected 339 subjects by ZIP code, representing the plurality of the cases in our catchment area. The outcome variable was overall survival; predictor variables were socio-economic status (SES), recurrence, insurance, type of treatment, gender, cancer stage, age, and race. We converted ZIP code to municipality and culled data using adjusted gross income (AGI, FY 2017). Comparative statistical analysis was performed using chi-square tests for nominal and ordinal variables, and a two-way ANOVA test was used for continuous variables; the p-value was set at 0.05. Our analysis confirmed that overall survival was significantly higher for Whites and for individuals who live in a municipality with a high SES. Tumor stage at the time of diagnosis was not different among race and SES; however, statistically significant differences for race or SES existed in the type of treatment received, with disparities found in those who received radiation therapy and surgery but not chemotherapy. The data may point to a lack of access to specific care modalities that subsequently may lead to lower survival in an underserved population. Access to care, optimal nutritional status, overall fitness, and co-morbidities could play a major role and confound the results. Our study suggests that low SES has a negative impact on overall pancreatic cancer survival. Surgery for pancreatic cancer should be appropriately decentralized to those community cancer centers that possess the expertise and the infrastructure to carry out specialized treatments regardless of race, ethnicity, SES, and insurance.

Same Chance of Accessing Resection? Impact of Socioeconomic Status on Resection Rates Among Patients with Pancreatic Adenocarcinoma-A Systematic Review

Background: The incidence of pancreatic cancer is growing and the survival rate remains one of the worst in oncology. Surgical resection is currently a crucial curative option for pancreatic adenocarcinoma (PA). Socioeconomic factors could influence access to surgery. This article reviews the literature on the impact of socioeconomic status (SES) on access to curative surgery among patients with PA.

Methods: The EMBASE, MEDLINE, Web of Science, and Scopus databases were searched by three investigators to generate 16 studies for review.

Results: Patients with the lowest SES are less likely to undergo surgery than high SES. Low income, low levels of education, not being insured, and living in deprived and rural areas have all been associated with decreased rates of surgical resection. Given the type of health care system and geographic disparities, results in North American populations are difficult to transpose to European countries. However, a similar trend is observed in difficulty for the poorest patients in accessing resection. Low SES seems to be less likely to be offered surgery and more likely to refuse it.

Conclusions: Inequalities in insurance coverage and living in poor/lower educational level areas are all demonstrated factors of a lower likelihood of resection populations. It is important to assess the causal effect of socioeconomic deprivation to improve understanding of this disease and improve access to care.

Assessing the Relationship between Chronic Lymphoid Leukemia Mortality Rates and Human Development Index: A 26-Year Trend Analysis Using Location-Scale Mixed Effects Model

BACKGROUND

Chronic lymphoid leukemia (CLL) is one of the most prevalent types of leukemia, which is responsible for a remarkable mortality rate in the world. This study aimed to investigate the global trend of this cancer from 1990 to 2015 and to determine the relationship between trend of CLL mortality rate and Human Development Index (HDI) throughout the world.

METHODS

The age-standardized mortality rate data of all countries of the world (per 100,000) were extracted from the GBD database. In addition, the HDI values for the studied countries in different years were obtained from the UNDP database. The statistical analysis was performed using the mixed-effects location-scale model in the SAS software, version 9.4.

RESULTS

The findings of the statistical modeling showed a downward slope for CLL Age Standardized Mortality Rate (ASMR) for total world countries (β̂ = -0.002). We also find a significant association between CLL ASMR and HDI. Countries with higher HDI had higher level of CLL ASMR in years 1990 to 2015 with a negative slope. Furthermore, countries with lower HDI had Lower level of CLL ASMR with rather fixed rates in this period.

CONCLUSION

These findings showed a decreasing trend of global CLL ASMR in the previous decades, although, the fixed trend of CLL ASMR in countries with low HDI is worrisome. The health policymakers should make more efforts to decrease the mortality due to this cancer in these countries.

DNA damage induced by KP372-1 hyperactivates PARP1 and enhances lethality of pancreatic cancer cells with PARP inhibition

The overall prognosis for pancreatic cancer remains dismal and potent chemotherapeutic agents that selectively target this cancer are critically needed. Elevated expression of NAD(P)H:quinone oxidoreductase 1 (NQO1) is frequent in pancreatic cancer, and it offers promising tumor-selective targeting. Recently, KP372-1 was identified as a novel NQO1 redox cycling agent that induces cytotoxicity in cancer cells by creating redox imbalance; however, the mechanistic basis of KP372-1-induced cytotoxicity remains elusive. Here, we show that KP372-1 sensitizes NQO1-expressing pancreatic cancer cells and spares immortalized normal pancreatic duct cells, hTERT-HPNE. Notably, we found that KP372-1 is ~ 10- to 20-fold more potent than β-lapachone, another NQO1 substrate, against pancreatic cancer cells. Mechanistically, our data strongly suggest that reactive oxygen species produced by NQO1-dependent redox cycling of KP372-1 cause robust DNA damage, including DNA breaks. Furthermore, we found that KP372-1-induced DNA damage hyperactivates the central DNA damage sensor protein poly(ADP-ribose) polymerase 1 (PARP1) and activates caspase-3 to initiate cell death. Our data also show that the combination of KP372-1 with PARP inhibition creates enhanced cytotoxicity in pancreatic cancer cells. Collectively, our study provides mechanistic insights into the cytotoxicity instigated by KP372-1 and lays an essential foundation to establish it as a promising chemotherapeutic agent against cancer.

Fibroblast growth factor 8 overexpression is predictive of poor prognosis in pancreatic ductal adenocarcinoma

Background

Despite distinctive advances in the field of pancreatic cancer therapy over the past few years, patient survival remains poor. Fibroblast growth factors 8 (FGF8) and 18 (FGF18) both play a role in modulating the activity of malignant cells and have been identified as promising biomarkers in a number of cancers. However, no data exist on the expression of FGF8 and FGF18 in pancreatic ductal adenocarcinoma (PDAC).

Methods

Protein expression levels of FGF8 and FGF18 in postoperative specimens of neoadjuvantly treated and primarily resected patients were investigated using immunohistochemistry. Immunostaining scores were calculated as the products of the staining intensity and the staining rate. Scores exceeding the median score were considered as high expression.

Results

Specimens from 78 patients with PDAC were available and met the eligibility criteria for analysis of protein expression using immunohistochemistry. 15 (19.2%) patients had received neoadjuvant chemotherapy. High protein levels of FGF8 and FGF18 were detected in 40 (51.8%) and 33 (42.3%) patients, respectively. Kaplan–Meier analysis demonstrated significantly shorter overall survival in patients with high expression of FGF8 (p = 0.04). Multivariable Cox proportional hazard regression models revealed that high expression of FGF8 (Hazard ratio [HR] 0.53, 95% Confidence interval [CI] 0.32–0.89, p = 0.016) was an independent prognostic factor for diminished overall survival in patients with PDAC. By contrast, no statistical significance was found for FGF18 overexpression. In addition, the FGF8 protein level correlated with the factor resection margin (p = 0.042).

Conclusion

FGF8 is a promising target for new anticancer therapies using FGF inhibitors in pancreatic ductal adenocarcinomas.

Schwann Cell Stimulation of Pancreatic Cancer Cells: A Proteomic Analysis

Schwann cells (SCs), the glial component of peripheral nerves, have been identified as promoters of pancreatic cancer (PC) progression, but the molecular mechanisms are unclear. In the present study, we aimed to identify proteins released by SCs that could stimulate PC growth and invasion. Proteomic analysis of human primary SC secretome was performed using liquid chromatography–tandem mass spectrometry, and a total of 13,796 unique peptides corresponding to 1,470 individual proteins were identified. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment were conducted using the Database for Annotation, Visualization, and Integrated Discovery. Metabolic and cell–cell adhesion pathways showed the highest levels of enrichment, a finding in line with the supportive role of SCs in peripheral nerves. We identified seven SC-secreted proteins that were validated by western blot. The involvement of these SC-secreted proteins was further demonstrated by using blocking antibodies. PC cell proliferation and invasion induced by SC-conditioned media were decreased using blocking antibodies against the matrix metalloproteinase-2, cathepsin D, plasminogen activator inhibitor-1, and galectin-1. Blocking antibodies against the proteoglycan biglycan, galectin-3 binding protein, and tissue inhibitor of metalloproteinases-2 decreased only the proliferation but not the invasion of PC cells. Together, this study delineates the secretome of human SCs and identifies proteins that can stimulate PC cell growth and invasion and therefore constitute potential therapeutic targets.

Inflammatory bowel disease and pancreatic cancer: a Scandinavian register-based cohort study 1969-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have an increased risk of cancer.

AIM

To assess the risk of pancreatic cancer in IBD compared to the general population.

METHODS

Patients with incident IBD 1969-2017 were identified in Danish and Swedish National Patient Registers and through biopsy data, and were matched to IBD-free reference individuals by sex, age, place of residence and year of IBD diagnosis. We linked data to Cancer and Causes of Death Registers and examined the absolute and relative risks of pancreatic cancer and pancreatic cancer death.

RESULTS

Among 161 926 patients followed for 2 000 951 person years, 442 (0.27%) were diagnosed with pancreatic cancer compared to 3386 (0.21%) of the 1 599 024 reference individuals. The 20-year cumulative incidence was 0.34% (95% confidence interval 0.30-0.38) vs 0.29% (0.28-0.30). The incidence rate was 22.1 (20.1-24.2)/100 000 person years in the patients (excluding the first year of follow-up: 20.8 [18.8-23.0]), and 16.6 (16.0-17.2) in the reference individuals. The hazard ratio (HR) for pancreatic cancer was increased overall: 1.43 (1.30-1.58), in subtypes (Crohn's disease: 1.44 [1.18-1.74]; ulcerative colitis: 1.35 [1.19-1.53]; IBD unclassified: 1.99 [1.50-2.64]) and especially in IBD patients with primary sclerosing cholangitis: 7.55 (4.94-11.5). Patients and reference individuals with pancreatic cancer did not differ in cancer stage (P = 0.17) or pancreatic cancer mortality (HR 1.07 [0.95-1.21]).

CONCLUSIONS

Patients with IBD had an excess risk of pancreatic cancer, in particular patients with primary sclerosing cholangitis. However, the cumulative incidence difference after 20 years was small: 0.05%, that is, one extra pancreatic cancer per 2000 IBD patients.

Microscopic size measurements in post-neoadjuvant therapy resections of pancreatic ductal adenocarcinoma (PDAC) predict patient outcomes

AIMS

Pancreatic ductal adenocarcinomas (PDACs) are increasingly being treated with neoadjuvant therapy. However, the American Joint Committee on Cancer (AJCC) 8th edition T staging based on tumour size does not reflect treatment effect, which often results in multiple, small foci of residual tumour in a background of mass-forming fibrosis. Thus, we evaluated the performance of AJCC 8th edition T staging in predicting patient outcomes by the use of a microscopic tumour size measurement method.

METHODS AND RESULTS

One hundred and six post-neoadjuvant therapy pancreatectomies were reviewed, and all individual tumour foci were measured. T stages based on gross size with microscopic adjustment (GS) and the largest single microscopic focus size (MFS) were examined in association with clinicopathological variables and patient outcomes. Sixty-three of 106 (59%) were locally advanced; 78% received FOLFIRINOX treatment. The average GS and MFS were 25 mm and 11 mm, respectively; nine cases each were classified as T0, 35 and 85 cases as T1, 42 and 12 cases as T2, and 20 and 0 cases as T3, based on the GS and the MFS, respectively. Higher GS-based and MFS-based T stages were significantly associated with higher tumour regression grade, lymphovascular and perineural invasion, and higher N stage. Furthermore, higher MFS-based T stage was significantly associated with shorter disease-free survival (DFS) (P < 0.001) and shorter overall survival (OS) (P = 0.002). GS was significantly associated with OS (P = 0.046), but not with DFS.

CONCLUSIONS

In post-neoadjuvant therapy PDAC resections, MFS-based T staging is superior to GS-based T staging for predicting patient outcomes, suggesting that microscopic measurements have clinical utility beyond the conventional use of GS measurements alone.

Hereditary and Sporadic Pancreatic Ductal Adenocarcinoma: Current Update on Genetics and Imaging

Pancreatic ductal adenocarcinoma (PDAC) is a genetically heterogeneous, biologically aggressive malignancy with a uniformly poor prognosis. While most pancreatic cancers arise sporadically, a small subset of PDACs develop in patients with hereditary and familial predisposition. Detailed studies of the rare hereditary syndromes have led to identification of specific genetic abnormalities that contribute to malignancy. For example, germline mutations involving BRCA1, BRCA2, PRSS1, and mismatch repair genes predispose patients to PDAC. While patients with Lynch syndrome develop a rare "medullary" variant of adenocarcinoma, intraductal papillary mucinous tumors are observed in patients with McCune-Albright syndrome. It is now well established that PDACs originate via a multistep progression from microscopic and macroscopic precursors due to cumulative genetic abnormalities. Improved knowledge of tumor genetics and oncologic pathways has contributed to a better understanding of tumor biology with attendant implications on diagnosis, management, and prognosis. In this article, the genetic landscape of PDAC and its precursors will be described, the hereditary syndromes that predispose to PDAC will be reviewed, and the current role of imaging in screening and staging assessment, as well as the potential role of molecular tumor-targeted imaging for evaluation of patients with PDAC and its precursors, will be discussed. Keywords: Abdomen/GI, Genetic Defects, Oncology, Pancreas Supplemental material is available for this article. © RSNA, 2020.

Role of oncogenic KRAS in the diagnosis, prognosis and treatment of pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is predicted to be the second most common cause of death within the next 10 years. The prognosis for this disease is poor despite diagnostic progress and new chemotherapeutic regimens. The oncogenic KRAS mutation is the major event in pancreatic cancer; it confers permanent activation of the KRAS protein, which acts as a molecular switch to activate various intracellular signalling pathways and transcription factors inducing cell proliferation, migration, transformation and survival. Several laboratory methods have been developed to detect KRAS mutations in biological samples, including digital droplet PCR (which displays high sensitivity). Clinical studies have revealed that a KRAS mutation assay in fine-needle aspiration material combined with cytopathology increases the sensitivity, accuracy and negative predictive value of cytopathology for a positive diagnosis of pancreatic cancer. In addition, the presence of KRAS mutations in serum and plasma (liquid biopsies) correlates with a worse prognosis. The presence of mutated KRAS can also have therapeutic implications, whether at the gene level per se, during its post-translational maturation, interaction with nucleotides and after activation of the various oncogenic signals. Further pharmacokinetic and toxicological studies on new molecules are required, especially small synthetic molecules, before they can be used in the therapeutic arsenal for pancreatic ductal adenocarcinoma.

Current epidemiology of pancreatic cancer: Challenges and opportunities

Pancreatic cancer (PC) is an increasingly common disease worldwide. Having a better understanding of worldwide and regional epidemiologic features and risk factors of PC is essential to identify new approaches for prevention, early diagnosis, surveillance, and treatment. In this article, we review the epidemiologic features and risk factors for PC and discuss opportunities and challenges of PC future treatment.

Everolimus for the treatment of advanced pancreatic ductal adenocarcinoma (PDAC)

Introduction: PDAC is a lethal malignancy with a clear unmet need; almost all patients fail 1st, 2nd, and 3rd line multi-agent cytotoxic chemotherapy. The mammalian target of rapamycin (mTOR) has been identified as a key signaling node enhancing tumor survival and drug resistance in PDAC; hence, it is considered a promising therapeutic target. Areas covered: We comprehensively reviewed the evidence from preclinical and phase I and II clinical trials, based on the authors'clinical experience and a PubMed, Cochrane library, Embase, and Google Scholar search everolimus + pancreatic cancer. Expert opinion: Everolimus has not demonstrated efficacy in PDAC; however, an mTOR inhibitor in combination with stroma-targeted therapies may be a promising area to explore in clinical trials.

Improving preoperative detection of synchronous liver metastases in pancreatic cancer with combined contrast-enhanced and diffusion-weighted MRI

PURPOSE

To explore the value of gadolinium-enhanced MRI combined with diffusion-weighted MRI (Gd-enhanced MRI with DWI) in addition to contrast-enhanced CT (CECT) for detection of synchronous liver metastases for potentially resectable pancreatic cancer.

METHODS

By means of a retrospective cohort study we included patients with potentially resectable pancreatic cancer on CECT, who underwent Gd-enhanced MRI with DWI between January 2012 and December 2016. A single observer evaluated MRI and CT and was blinded to imaging, pathology, and surgery reports. Liver lesions were scored in both modalities, using a 3-point scale: 1-benign, 2-indeterminate, 3- malignant (i.e., metastasis). The primary outcome parameters were the presence of liver metastases on Gd-enhanced MRI with DWI and the sensitivity of Gd-enhanced MRI with DWI for synchronous liver metastases.

RESULTS

We included 66 patients (42 men, 24 women; median age 65 years, range 36-82 years). In 19 patients, liver metastases were present, which were confirmed by histopathology (n = 12), ¹⁸FDG-PET (n = 6), or surgical inspection (n = 1). Gd-enhanced MRI with DWI showed metastases in 16/19 patients (24%), which resulted in a sensitivity of 84% (95% CI 60-97%). Contrast-enhanced MRI showed 156 and DWI 397 metastases (p = 0.051), and 339 were particularly small (< 5 mm).

CONCLUSIONS

In this study, Gd-enhanced MRI with DWI detected synchronous liver metastases in 24% of patients with potentially resectable pancreatic cancer on CECT with a sensitivity of 84%. Diffusion-weighted MRI showed a greater number of metastases than any other sequence, particularly small metastases (< 5 mm).

Occupational class differences in pancreatic cancer survival: A population-based cancer registry-based study in Japan

Background

Little is known about occupational class differences in pancreatic cancer survival.

Methods

Using a population‐based cancer registry in Japan, 3 578 patients with incident pancreatic cancer (1970‐2011) were followed up for 5 years (median follow‐up time 0.42 years). We classified patients into four occupational classes based on their longest‐held jobs: white‐collar (professional and managers), service, blue‐collar, and those not actively employed. Using white‐collar class as the reference group, hazard ratios (HRs) and 95% confidence intervals (CIs) for overall death were estimated by Cox proportional hazard model. Covariates included age, sex, and year of diagnosis. Prognostic variables (pathology, stage, and treatment) and smoking behaviors were additionally adjusted as possible mediating factors.

Results

Overall survival was poor in this population (median, 0.50 and 0.33 years in white‐collar and service classes, respectively). Compared with white‐collar patients, survival was significantly poorer across all occupational classes, most pronounced in the service worker group: mortality HRs ranged from 1.11 (95% CI 1.00‐1.24) in blue‐collar workers to 1.24 (95% CI 1.12‐1.37) in service workers. Even after controlling for potential mediating factors, service workers showed worse survival.

Conclusion

We documented occupational class disparities in pancreatic cancer survival in Japan. Even in the setting of lethal prognostic cancer with universal health coverage, high‐occupational class groups may enjoy a health advantage.

Lifetime alcohol intake and pancreatic cancer incidence and survival: findings from the Melbourne Collaborative Cohort Study

PURPOSE

Pancreatic cancer has one of the worst prognoses with 5-year survival below 10%. There is some evidence that alcohol consumption might increase the risk of pancreatic cancer. We examined associations of pre-diagnostic alcohol intake with (i) incidence of pancreatic cancer, and (ii) overall survival following pancreatic cancer.

METHODS

Usual alcohol intake was estimated at recruitment in 1990-1994 for 38,472 participants in the Melbourne Collaborative Cohort Study using recalled frequency and quantity of beverage-specific intake for 10-year periods from age 20. Pancreatic cancer incidence (C25 according to International Classification of Diseases for Oncology) and vital status were ascertained through to 30 September 2015. Cox regression was performed to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for associations with lifetime, age 20-29, and baseline alcohol intakes.

RESULTS

By the end of follow-up (average 20.2 years), 239 incident cases of pancreatic cancer were diagnosed, of which 228 had died. No evidence of an association was observed between alcohol intake and risk of pancreatic cancer. Higher lifetime alcohol intake was associated with lower overall survival following a diagnosis of pancreatic cancer (mortality HR 1.09 per 10 g/day increment, 95% CI 1.00-1.19; p value = 0.04). A similar finding was observed for age 20-29 intake (HR 1.09 per 10 g/day increment, 95% CI 1.02-1.18; p value = 0.01) but not with baseline intake.

CONCLUSIONS

We observed an association between lower alcohol use from an early age and improved survival following pancreatic cancer, but this finding needs to be confirmed by other studies.

Expression and Clinical Significance of Protein Kinase RNA-Like Endoplasmic Reticulum Kinase and Phosphorylated Eukaryotic Initiation Factor 2α in Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Endoplasmic reticulum stress and subsequent phosphorylation of eukaryotic initiation factor 2α (eIF2α) by protein kinase R-like endoplasmic reticulum kinase (PERK) plays an important role in the development and chemoresistance of pancreatic ductal adenocarcinoma (PDAC). However, the expression and significance of phosphorylated eIF2α (p-eIF2α) and PERK in PDAC have not been examined.

METHODS

We examined p-eIF2α and PERK expression in 84 PDAC and paired normal pancreas samples by immunohistochemistry and Western blotting and correlated the results with clinicopathologic parameters and survival.

RESULTS

Mean PERK H score was 140.8 in PDAC compared with 82.1 in normal pancreas (P < 0.001). High p-eIF2α expression was present in 56% of PDACs versus 7.6% of normal pancreases (P < 0.001). High PERK and p-eIF2α expression correlated with shorter overall survival (P = 0.048 and P = 0.03, respectively). By multivariate analysis, high p-eIF2α (P = 0.01), positive margin (P = 0.002), and lymph node metastasis (P = 0.01) were independent prognosticators for survival.

CONCLUSIONS

The expression levels of PERK and p-eIF2α are higher in PDAC than those in normal pancreas. High levels of PERK and p-eIF2α are predictors of shorter survival in PDAC patients, suggesting that PERK and eIF2α could be promising targets in PDAC.

Comparative Accuracy of Tumor Size Assessment and Stage Analysis by Imaging Modalities Versus Gross Examination for Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Tumor size has been shown to be a strong predictor of patient survival in pancreatic ductal adenocarcinoma (PDAC). The aims of this study were to assess the consistency of preoperative imaging and gross examination for PDAC tumor size measurement and to evaluate the impact on T and overall tumor staging when size measurements by imaging and gross examination were different.

METHODS

Patients diagnosed with PDAC who underwent pancreaticoduodenectomy or distal pancreatectomy from 2007 to 2017 were retrospectively reviewed. A total of 268 cases were included.

RESULTS

Imaging studies underestimated tumor size in comparison with gross examination. Staging the tumors based on imaging size using the eighth edition American Joint Committee on Cancer resulted in an altered T stage in 106 cases (39.6%). There was no T-stage change in the remaining 162 cases (60.4%) despite the presence of variable size discrepancies (0.1-1.7 cm). When nodal metastases were also considered, there was no change in the overall tumor stage in most cases.

CONCLUSIONS

Although discrepancies exist between tumor size measurements by imaging modalities and gross examination, which may result in an altered T stage in a substantial number of cases, the overall tumor stage is only rarely altered.

Socioeconomic status impacts survival and access to resection in pancreatic adenocarcinoma: A high-resolution population-based cancer registry study

BACKGROUND

Survival of patients with pancreatic adenocarcinoma (PA) is very poor. Resection status is highly associated with prognosis but only 15%-20% are resectable. The aim of this study was to analyse the impact of socioeconomic deprivation on PA survival and to define which management steps are affected.

METHODS

Between 01/01/2000 and 31/12/2014, 1451 incident cases of PA recorded in the digestive cancer registry of the French department of Calvados were included. The population was divided between less deprived areas (quintile 1) and more deprived areas (quintile 2,3,4,5 aggregated).

RESULTS

Patients from less deprived areas were younger at diagnosis than those from more deprived areas (69.9 vs 72.3 years, p = 0.01). There was no difference in stage or comorbidities. Three- and 5-year survival rates were significantly higher for less deprived areas than more deprived areas: 10.5% vs 5.15% and 4.7% vs 1.7% respectively (p = 0.01). In univariate analysis, those living in less deprived areas had a better survival than those in more deprived areas (HR = 0.81 [0.69-0.95], p = 0.009) but not in multivariable analysis (HRa = 0.93 [0.79-1.11], p = 0.383) or analysis stratified on resection. In multivariable regression, less deprived areas had more access to surgery than more deprived areas (ORa = 1.73 [1.08-2.47], p = 0.013). No difference was observed on access to adjuvant chemotherapy (ORa = 0.95 [0.38-2.34], p = 0.681).

CONCLUSION

The key to reducing survival inequalities in PA is access to resection, so future studies should investigate the factors impacting this issue.

Increased Levels of Branched-Chain Amino Acid Associated With Increased Risk of Pancreatic Cancer in a Prospective Case-Control Study of a Large Cohort

BACKGROUND & AIMS

A marker is needed to identify individuals at risk for pancreatic cancer. Increases in branched-chain amino acids (BCAAs) have been associated with pancreatic cancer. We performed a prospective case-control study to study the association between plasma BCAA levels and risk of pancreatic cancer in a large cohort.

METHODS

We conducted a nested case-control study selected from 30,239 eligible participants 40-69 years old within the Japan Public Health Center-based prospective study. Over 16.4 years, 170 newly diagnosed pancreatic cancer cases were identified. Each case was matched to 2 controls by age, gender, geographic area, and fasting time at blood collection. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for pancreatic cancer were calculated using conditional logistic regression models with adjustment for potential confounding factors.

RESULTS

Increased plasma BCAA levels at baseline were associated with an increased risk of pancreatic cancer. Compared with the lowest quartile of BCAA levels, the OR in the highest quartile was 2.43 (95% CI 1.21-4.90), and the OR per 1 SD increase in BCAA levels was 1.32 (95% CI 1.05-1.67). The association was especially strong for cases with blood samples collected at least 10 years before cancer diagnosis (OR per SD 1.60, 95% CI 1.10-2.32) compared with those detected less than 10 years before diagnosis (OR per SD 1.16, 95% CI 0.86-1.57).

CONCLUSIONS

In an analysis of data from the Japan Public Health Center-based prospective study, we found an association between increased plasma BCAA level and increased risk of pancreatic cancer-particularly when the increase in BCAAs was observed at least 10 years before diagnosis. These findings add to the growing body of evidence for the association between BCAA levels and pancreatic cancer risk.

Urban versus rural residency and pancreatic cancer survival: A Danish nationwide population-based cohort study

It is unknown whether urban versus rural residency affects pancreatic cancer survival in a universal tax-financed healthcare system. We conducted a nationwide, population-based cohort study of all patients diagnosed with pancreatic cancer in Denmark from 2004–2015. We used nationwide registries to collect information on characteristics, comorbidity, cancer-directed treatment, and vital status. We followed the patients from pancreatic cancer diagnosis until death, emigration, or 1 October 2017, whichever occurred first. We truncated at five years of follow up. We stratified patients into calendar periods according to year of diagnosis (2004–2007, 2008–2011, and 2012–2015). We used Cox proportional hazards model to compute hazard ratios (HRs) with associated 95% confidence intervals (CIs) of death, comparing patients in urban and rural areas. HRs were adjusted for age, sex, comorbidity, tumor stage, and localization. In a sub-analysis, we also adjusted for cancer-directed treatment. We included 10,594 patients diagnosed with pancreatic cancer. Median age was 71 years (inter-quartile range: 63–78 years), and half were men. The majority (61.7%) lived in an urban area at the time of diagnosis. When adjusting for potential confounders, we observed a better survival rate among pancreatic cancer patients residing in urban areas compared with rural areas (adjusted HR: 0.92; 95% CI: 0.87–0.98). When taking treatment into account, the association was unclear (adjusted HR: 0.96; 95% CI: 0.88–1.04). Pancreatic cancer patients residing in urban areas had a slightly better survival rate compared with patients in rural areas.

The Significant Value of Preoperative Prognostic Nutritional Index for Survival in Pancreatic Cancers: A Meta-analysis

Nutritional status plays a significant value in the incidence of postoperative complications and survival rate after resection of cancers. The preoperative prognostic nutritional index (PNI) has recently been reported to be a simple, sensitive, and effective prognostic parameter in various cancers. We conducted a meta-analysis to explore the significant value of PNI in pancreatic cancers. We systematically searched electronic databases of PubMed, Embase, Cochrane Library, Web of Science, Wanfang Data, and Chinese National Knowledge Infrastructure. Then, relevant studies were selected to perform this meta-analysis. Eleven studies with a total of 2123 patients met the inclusion criteria of this meta-analysis. The pooled results revealed that a lower PNI was significantly correlated with poorer overall survival (hazard ratio, 1.57; 95% confidence interval, 1.40-1.77; P < 0.001). Preoperative PNI might be an efficient predictor of survival with pancreatic cancers.

The interaction of long non-coding RNA MIAT and miR-133 play a role in the proliferation and metastasis of pancreatic carcinoma

Pancreatic cancer (PC) is one of the most aggressive malignancies in humans. Despite advances in early detection and treatment of PC, the prognosis is still limited. LncRNA myocardial infarction-associated transcript (MIAT) is found abnormally expressed in a variety of cancers. However, the role of MIAT in PC is still unknown. This study aimed to explore whether MIAT was related to the progression of PC and the underlying mechanism. Bioinformatics analysis and luciferase reporter assay validated that miR-133 may target MIAT 3'-UTR. MIAT expression was found remarkably increased and miR-133 expression was significantly decreased in PC tissues and PC cell lines (PATU-8988, BxPC-3, PANC-1, SW1990 and AsPC-1 cells). PC patients with high MIAT level had poor prognosis than that with low MITA level. Besides that, PATU-8988 cells transfected with siMIAT and/or miR-133 inhibitor. The results exhibited that the inhibition of miR-133 expression reversed the inhibition effect of MIAT down-regulation in the growth, migration and invasion of PC cells. Moreover, tumor growth was tremendously suppressed in nude rats received injection of PATU-8988 cells transfected with siMIAT. Taken together, our results suggest that the interaction of MIAT and miR-133 play a role in the proliferation and metastasis of pancreatic carcinoma.

Identification of potential target genes in pancreatic ductal adenocarcinoma by bioinformatics analysis

Pancreatic ductal adenocarcinoma (PDAC) is one of the most complicated and fatally pathogenic human malignancies. Therefore, there is an urgent need to improve our understanding of the underlying molecular mechanism that drives the initiation, progression, and metastasis of PDAC. The aim of the present study was to identify the key genes and signaling pathways associated with PDAC using bioinformatics analysis. Four transcriptome microarray datasets (GSE15471, GSE55643, GSE62165 and GSE91035) were acquired from Gene Expression Omnibus datasets, which included 226 PDAC samples and 65 normal pancreatic tissue samples. We screened differentially expressed genes (DEGs) with GEO2R and investigated their biological function by Gene Ontology (GO) and Kyoto Encyclopedia of Genes (KEGG) analysis. The overall survival data was obtained from UALCAN, which calculated the data shared with The Cancer Genome Atlas. In addition, a protein-protein interaction (PPI) network of the DEGs was constructed by STRING and Cytoscape software. The four sets of DEGs exhibited an intersection consisting of 205 genes (142 up-regulated and 63 down-regulated), which may be associated with PDAC. GO analysis showed that the 205 DEGs were significantly enriched in the plasma membrane, cell adhesion molecule activity and the Energy pathways, and glycine, serine, threonine metabolism were the most enriched pathways according to KEGG pathway analysis. Kaplan-Meier survival analysis revealed that 22 of 205 common genes were significantly associated with the overall survival of pancreatic cancer patients. In the PPI network and sub-network, DKK1 and HMGA2 were considered as hub genes with high connectivity degrees. DKK1 and HMGA2 are strongly associated with WNT3A and TP53 separately, which indicates that they may play an important role in the Wnt and P53 signaling pathways. Using integrated bioinformatics analysis, we identified DKK1 and HMGA2 as candidate genes in PDAC, which may improve our understanding of the mechanisms of the pathogenesis and integration; the two genes may be therapeutic targets and prognostic markers for PDAC.

Focus on an unusual rise in pancreatic cancer incidence in France

Background

Pancreatic cancer is one of the most lethal. Most countries have exhibited a stable or decreasing incidence over time. The aim of this study was to provide updated French temporal trends in pancreatic cancer incidence and mortality over the past three decades.

Methods

Incidence was estimated using the French National Network of Cancer Registries (FRANCIM) and mortality using the French Mortality Statistics Office. World age-standardized incidence and mortality were modelled by age-period-cohort models. The net cumulative risk of developing pancreatic cancer by birth cohort was calculated, as were annual percentage changes (APCs) in incidence and mortality.

Results

Between 1982 and 2012, age-standardized incidence increased from 4.8 in 1980 to 9.6 per 100 000 in men and from 2.3 to 6.8 in women. The mean APC was 2.3% (2.1-2.6) and 3.6% (3.3-3.9), respectively. The cumulative risk of developing pancreatic cancer before age 75 rose from 0.62% for males born around 1920 to 1.17% for those born around 1950. It was respectively 0.31% and 0.86% for women. Mortality did not vary in men (8.1 per 100 000). It slightly increased in women from 4.0 in 1982 to 5.4 in 2012.

Conclusion

Pancreatic cancer incidence and mortality exhibited diverging trends. Incidence increased over the last 30 years in France whereas mortality did not vary in men and moderately increased in women. Incidence remained lower than mortality up to 2002. One cannot exclude the possibility that a similar trend may appear in other countries. Etiological studies are required to further explain this increase.

Long non-coding RNA GAS5 antagonizes the chemoresistance of pancreatic cancer cells through down-regulation of miR-181c-5p

OBJECTIVE

To explore the core mechanism of long non-coding RNA (lncRNA) growth arrest-specific transcript 5 (GAS5) in the regulation of multidrug resistance of pancreatic cancer cells.

METHODS

mRNA levels of GAS5, miR-181c-5p and Hippo pathway related genes were detected by quantitative real-time PCR (qRT-PCR). Protein levels of MDR-1, MST1, YAP and TAZ were measured by western blot. Cell viability was detected by MTT assay. The combination between GAS5 and miR-181c-5p was confirmed by RNA pull-down and RNA immunoprecipitation (RIP) assay. We also established pancreatic cancer-bearing mice model and analyzed tumor volumes.

RESULTS

Our data showed GAS5 expression was significantly down-regulated, miR-181c-5p expression was significantly up-regulated in pancreatic cancer cells. Besides, Overexpresson of GAS5 obviously inhibited cell viability, while GAS5 knockdown showed the opposite outcome. Additionally, we also found that GAS5 negatively regulated miR-181c-5p, and miR-181c-5p dramatically promoted pancreatic cancer cell chemoresistance through inactivating the Hippo signaling. GAS5 regulated chemoresistance and Hippo pathway of pancreatic cancer cells via miR-181c-5p/Hippo. Finally, we confirmed that overexpression of GAS5 inhibited tumor growth in pancreatic cancer-bearing mice model.

CONCLUSION

GAS5 regualtes Hippo signaling pathway via miR-181c-5p to antagonize the development of multidrug resistance in pancreatic cancer cells.

Prognostic Significance of New AJCC Tumor Stage in Patients With Pancreatic Ductal Adenocarcinoma Treated With Neoadjuvant Therapy

The American Joint Committee for Cancer has adopted a size-based T stage system (eighth edition) for pancreatic ductal adenocarcinoma (PDAC), defined as follows: pT1≤2 cm (pT1a≤0.5 cm, pT1b>0.5 and<1 cm, and pT1c 1-2 cm); pT2>2 and ≤4 cm; and pT3> 4 cm. However, the prognostic value of this new T staging system has not been validated in patients who underwent pancreaticoduodenectomy (PD) after neoadjuvant therapy. In this study, we analyzed 398 PDAC patients who underwent neoadjuvant therapy and PD at our institution from 1999 to 2012. The results were correlated with clinicopathologic parameters and survival. The new T stage correlated with lymph nodes metastasis (P<0.001), tumor response grade (P<0.001), disease-free survival (DFS, P<0.001) and overall survival (OS, P<0.001). None of the patients with ypT0 had recurrence or died of disease. Among the patients with ypT1 disease, patients with ypT1a and ypT1b had better DFS (P=0.046) and OS (P=0.03) than those with ypT1c. However, there was no significant difference in either DFS or OS between ypT1c and ypT2 or between ypT2 and ypT3 groups (P>0.05). In multivariate analysis, new ypT3 stage was associated with shorter OS (P=0.04), but not DFS (P=0.16). Our results show that the new ypT stage better stratify survival than the ypT stage in American Joint Committee for Cancer seventh edition for PDAC patients who received PD after neoadjuvant therapy, and that tumor size cutoff of 1.0 cm work better for ypT2 than the proposed tumor size cutoff of 2.0 cm in this group of patients.

Molecular Drivers of Pancreatic Cancer Pathogenesis: Looking Inward to Move Forward

Pancreatic cancer (PC) continues to rank among the most lethal cancers. The consistent increase in incidence and mortality has made it the seventh leading cause of cancer-associated deaths globally and the third in the United States. The biggest challenge in combating PC is our insufficient understanding of the molecular mechanism(s) underlying its complex biology. Studies during the last several years have helped identify several putative factors and events, both genetic and epigenetic, as well as some deregulated signaling pathways, with implications in PC onset and progression. In this review article, we make an effort to summarize our current understanding of molecular and cellular events involved in the pathogenesis of pancreatic malignancy. Specifically, we provide up-to-date information on the genetic and epigenetic changes that occur during the initiation and progression of PC and their functional involvement in the pathogenic processes. We also discuss the impact of the tumor microenvironment on the molecular landscape of PC and its role in aggressive disease progression. It is envisioned that a better understanding of these molecular factors and the mechanisms of their actions can help unravel novel diagnostic and prognostic biomarkers and can also be exploited for future targeted therapies.

Colorectal cancer-global burden, trends, and geographical variations

BACKGROUND

The aim of this study is to describe the trends and variations in the global burden of colorectal cancer (CRC).

METHODS

Data (2012-2030) relating to CRC was extracted from GLOBOCAN 2012 database and analyzed.

RESULTS

The results of our study demonstrate a rising global burden of colorectal cancer which persists until the year 2035 and likely beyond. The rise in the global burden is not uniform with significant variations influenced by geographic location, socio-economic status, age, and gender. Although the EURO region has the highest burden, Asia as a continent continues to bear the heaviest brunt of the disease. Although the burden of disease is higher in more developed regions, mortality is considerably higher in less developed regions and this gap widens over the next two decades. The disease predominantly affects the male gender across all regions of the world. Age has a complex relation with the burden of CRC and is affected by the cross-influences relating to socio-economic status.

CONCLUSIONS

The results of our study demonstrate a rising global burden of CRC with some unique variations. Knowledge of this data can increase awareness and help strategic targeting of efforts and resources.