High pre-operative fasting blood glucose levels predict a poor prognosis in patients with pancreatic neuroendocrine tumour

Incretins and SGLT-2 inhibitors in diabetic patients with neuroendocrine tumors: current updates and future directions

Neuroendocrine tumors (NET) are frequently associated with glycemic disorders, such as prediabetes or diabetes, which may result from either surgical or medical treatments or hormonal hypersecretion by the tumor itself. Moreover, pre-existing diabetes is a known risk factor for NET development, with metabolic control and antidiabetic therapies potentially influencing tumor progression. The complex interplay between diabetes and NET, which share several molecular pathways, has spurred interest in the anti-cancer effects of antidiabetic medications. This is particularly relevant as new antidiabetic drugs continue to emerge, including sodium-glucose cotransporter-2 (SGLT2) inhibitors and incretin-based therapies, such as dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor (GLP-1R) agonists and dual GIP/GLP- 1 R agonists. This review explores the impact of these novel pharmacological options on NET development and progression through a comprehensive analysis of pre-clinical and clinical studies, with the purpose to evaluate safety and feasibility of introducing these drugs in the treatment of NETs patients. We conducted a comprehensive search of online databases, including PubMed, ISI Web of Science, and Scopus, for studies assessing the therapeutic effects and potential mechanisms of action of incretins and SGLT2 inhibitors in patients with NET. These novel antidiabetic drugs exhibit promising anticancer properties, potentially inhibiting tumor cell proliferation and inducing apoptosis, though concerns about certain cancer risks remain. Based on current evidence, the benefits of incretin-based therapies outweigh any potential cancer risks, leading to the proposal of tailored management algorithms for diabetes in NET patients, factoring in the diabetes aetiology, comorbidities, and life expectancy.

Impact of preoperative blood glucose levels on prognosis and postoperative complications in patients with pancreatic cancer

The relationship between diabetes and pancreatic cancer is well documented; however, the effect of preoperative blood glucose levels on prognosis and postoperative complications is currently unclear. The present study aimed to investigate the effect of preoperative blood glucose levels on overall survival (OS) and postoperative complications in patients with pancreatic cancer. This retrospective study included 225 patients with pancreatic cancer treated at The Fourth Hospital of Hebei Medical University from January 2015 to December 2020. Patients were grouped based on preoperative blood glucose levels (normal, ≤6.11 mmol/l; high, >6.11 mmol/l). Data on demographics, clinical history, tumor characteristics, treatment and laboratory results were collected. High preoperative blood glucose levels were associated with reduced OS time [hazard ratio (HR), 1.68; 95% confidence interval (CI), 1.15-2.45; P=0.007] and increased postoperative complications (29.2 vs. 9.8%; χ2=13.658; P<0.001). Median OS time was significantly shorter in the high glucose group (14.2 vs. 20.5 months; HR, 1.96; 95% CI, 1.38-2.77; P<0.001). Elevated CA19-9 levels were also a predictor of poor OS (HR, 1.70; 95% CI, 1.06-2.74; P=0.029). High preoperative blood glucose and elevated CA19-9 levels were independent predictors of poor prognosis in patients with pancreatic cancer. This finding suggests that preoperative blood glucose levels have a greater impact on prognosis compared with a history of diabetes. Elevated preoperative blood glucose levels have poorer OS and a higher incidence of postoperative complications compared to those with lower preoperative glucose levels, underscoring the importance of preoperative glucose management. Effective preoperative blood glucose control may improve outcomes in patients with pancreatic cancer.

Recurrence-Free Survival and Disease-Specific Survival in Patients with Pancreatic Neuroendocrine Neoplasms: A Single-Center Retrospective Study of 413 Patients

INTRODUCTION

The prognosis and impact of different prognostic factors in pancreatic neuroendocrine neoplasms (pNEN) remain controversial.

AIM

To investigate prognostic factors for recurrence-free survival and disease-specific survival in patients with pNEN, divided into three groups: patients undergoing surveillance (tumor size < 2 cm, group 1), patients followed after curative-intended surgery (group 2), and patients with unresectable disease or residual tumors after resection (group 3).

METHOD

A single-center retrospective study including consecutive patients over a 20-year period. Multivariate Cox regression analyses were performed to identify risk factors.

RESULTS

413 patients were included, with a mean (SD) age of 62 ± 14 years. In group 1 (n = 51), median (IQR) follow-up was 29 (21-34) months, and tumor size was 1.0 (0.8-1.4) cm. One progressed and had a tumor resection. In group 2 (n = 165), follow-up 59 (31-102) months, median tumor size 2 (1.2-3.4) cm, median Ki-67 index 5 (3-10)%, the 5-year recurrence rate was 21%. Tumor size (p < 0.001), Ki-67 index (p = 0.02), and location in the pancreatic head (p < 0.001) were independent risk factors. In group 3 (n = 197), follow-up 19 (6-46) months, median tumor size 4.2 (2.6-7.0) cm, Ki-67 index 17 (9-64)%, the median disease-specific survival was 22 (6-75) months-99 in NET G1; 54 in NET G2; 14 in NET G3; and 6 months in neuroendocrine carcinomas (NEC). Age (p = 0.029), plasma chromogranin A (p = 0.014), and proliferation, expressed by grade (p = 0.001) and Ki-67 index (p < 0.001), were risk factors.

CONCLUSION

Growth in pNET < 2 cm requiring surgery was observed in 1/51. Tumor size, Ki-67 index, and location in the head were prognostic factors for disease recurrence, while age, plasma chromogranin A, and proliferation predicted mortality in patients with unresectable disease or residual tumors after resection.

Metabolic intervention by low carbohydrate diet suppresses the onset and progression of neuroendocrine tumors

Insulin signaling often plays a role in the regulation of cancer, including tumor initiation, progression, and response to treatment. In addition, the insulin-regulated PI3K-Akt-mTOR pathway plays an important role in the regulation of islet cell proliferation, and this pathway is hyperactivated in human non-functional pancreatic neuroendocrine tumors (PanNETs). We, therefore, investigated the effect of a very low carbohydrate diet (ketogenic diet) on a mouse model that develops non-functional PanNETs to ask how reduced PI3K-Akt-mTOR signaling might affect the development and progression of non-functional PanNET. We found that this dietary intervention resulted in lower PI3K-Akt-mTOR signaling in islet cells and a significant reduction in PanNET formation and progression. We also found that this treatment had a significant effect on the suppression of pituitary NET development. Furthermore, we found that non-functional PanNET patients with lower blood glucose levels tend to have a better prognosis than patients with higher blood glucose levels. This preclinical study shows that a dietary intervention that results in lower serum insulin levels leads to lower insulin signals within the neuroendocrine cells and has a striking suppressive effect on the development and progression of both pancreatic and pituitary NETs.

Prognostic value of preoperative diabetes mellitus in patients with non-functional pancreatic neuroendocrine neoplasms

BACKGROUND

The main aim of this study was to investigate the prevalence and prognostic value of preoperative diabetes mellitus (DM) in patients with non-functional pancreatic neuroendocrine neoplasms (NF-PNENs).

METHODS

Data were retrospectively collected from 190 patients with NF-PNENs from January 2009 to December 2019 in a single center.

RESULTS

The prevalence of longstanding DM, new-onset DM and impaired fasting glucose (IFG) was 11.6% (22/190), 8.4% (16/190), and 25.8% (49/190), respectively. Regression analysis showed that tumor size, tumor grade and lymph node metastasis were risk factors for new-onset DM and IFG. Multivariate survival analysis demonstrated preoperative new-onset DM (hazard ratio [HR], 4.33; P = 0.009) and IFG (HR, 4.53; P = 0.027) as independent predictors of poor recurrence-free survival (RFS) in patients with NF-PNENs.

CONCLUSION

Preoperative new-onset DM and IFG are associated with aggressive tumor behavior and poor RFS in patients with NF-PNENs.

Hyperglycemia is associated with adverse prognosis in patients with pancreatic neuroendocrine neoplasms

BACKGROUND

Although glucose has a well-recognized protumoral role and the pancreas is a critical organ in adjusting glucose metabolism, the clinical value of hyperglycemia in pancreatic neuroendocrine neoplasms (pNENs) remains largely unidentified.

METHODS

A retrospective study including 335 patients with pathologically confirmed pNENs was conducted. A baseline fasting blood glucose concentration ≥5.6 mmol/L was defined as hyperglycemia (otherwise, normal). Survival and regression analyses were performed.

RESULTS

Compared with patients with normal glucose, patients with hyperglycemia (47.8%) had a higher proportion of preexisting diabetes mellitus (DM) (36.9% vs. 4.6%, p < 0.001), lymph node involvement (31.0% vs. 14.6%, p = 0.002), distant metastasis (34.4% vs. 22.9%, p = 0.019), and carbohydrate antigen 19-9 (CA19-9) ≥ 37 U/mL (16.6% vs. 7.2%, p = 0.009). Hyperglycemia was associated with CA19-9 ≥ 37 U/mL (Odds Ratio (OR) = 3.19, 95% CI: 1.11-9.17, p = 0.031), lymph node involvement (OR = 2.32, 95% CI: 1.02-5.28, p = 0.045), nonfunctional tumors (OR = 9.90, 95% CI: 2.11-46.34, p = 0.004), and preexisting diabetes (OR = 18.24, 95% CI: 4.06-81.95, p < 0.001). Hyperglycemia was an independent determinant for overall survival in the multivariate analysis (hazard ratio (HR) = 2.65, 95% CI: 1.31-5.34, p = 0.006).

CONCLUSION

Hyperglycemia is an independent predictor of overall survival and is associated with preexisting DM or lymphatic metastasis in patients with pNENs. Patients with hyperglycemia and resectable pNENs may benefit from radical resection with dissection of regional lymph nodes.

Predictors of disease recurrence after curative surgery for nonfunctioning pancreatic neuroendocrine neoplasms (NF-PanNENs): a systematic review and meta-analysis

PURPOSE

Patients submitted to curative surgery for non-functioning pancreatic neuroendocrine neoplasms (NF-PanNENs) exhibit a variable risk of disease relapse. Aims of this meta-analysis were to estimate the rate of disease recurrence and to investigate the risk factors for disease relapse in patients submitted to curative surgery for NF-PanNENs.

METHODS

Medline/Pubmed and Web of Science databases were searched for relevant studies. A meta-regression analysis was performed to investigate the source of recurrence rate heterogeneity. Pooled hazard ratios (HRs) and 95% confidence intervals (95% CI) were used to assess the effect of each possible prognostic factor on disease-free survival.

RESULTS

Fifteen studies, involving 2754 patients submitted to curative surgery for NF-PanNENs, were included. The pooled rate of disease recurrence was 21% (95% CI 15-26%). Study quality (Odds ratio, OR 0.94, P = 0.016) and G3-PanNENs rate (OR 2.18, P = 0.040) independently predicted the recurrence rate variability. Nodal metastases (HR 1.63, P < 0.001), tumor grade G2-G3 (G1 versus G2: HR 1.72, P < 0.001, G1 versus G3 HR 2.57, P < 0.001), microvascular (HR 1.25, P = 0.046) and perineural (HR 1.29, P = 0.019) invasion were identified as significant prognostic factors. T stage (T1-T2 versus T3-T4, P = 0.253) and status of resection margins (R0 versus R1, P = 0.173) did not show any significant relationship with NF-PanNENs recurrence.

CONCLUSION

Disease relapse occurs in approximately one out of five patients submitted to curative surgery for NF-PanNENs. Nodal involvement, tumor grade, microvascular and perineural invasion are relevant prognostic factors, that should be taken into account for follow-up and for possible trials investigating adjuvant or neoadjuvant treatments.

The Prognostic Role of Glycemia in Patients With Pancreatic Carcinoma: A Systematic Review and Meta-Analysis

Background

Fasting blood glucose and glycated hemoglobin (HbA1c) levels are associated with the risk of pancreatic cancer.

Aim

To examine the relationship between perioperative glucose and HbA1c levels and prognosis in patients with pancreatic cancer.

Methods

PubMed, Embase, and the Cochrane Library were queried for potentially eligible studies published up to May 2021. The exposures were perioperative fasting glucose and HbA1c levels. The primary outcome was survival. The secondary outcome was complications. All analyses were performed using the random-effects model.

Results

Ten studies (48,424 patients) were included. The pre-operative (HR=1.10, 95%CI: 0.89-1.35; I² = 45.1%, P_{heterogeneity}=0.078) and postoperative (HR=1.19, 95%CI: 0.92-1.54; I² = 67.9%, P_{heterogeneity}=0.001) blood glucose levels were not associated with the survival to pancreatic cancer. Similar results were observed for HbA1c (HR=1.09, 95%CI: 0.75-1.58; I² = 64.2%, P_{heterogeneity}=0.039), fasting blood glucose (FBG)/HbA1c (HR=1.16, 95%CI: 0.67-1.68; I² = 0.0%, P_{heterogeneity}=0.928), and FBG (HR=1.75, 95%CI: 0.81-3.75; I² = 79.4%, P_{heterogeneity}=0.008). Pre-operative blood glucose levels were not associated with postoperative complications (OR=0.90, 95%CI: 0.52-1.56), but postoperative glucose levels were associated with postoperative complications (OR=3.06, 95%CI: 1.88-4.97; I² = 0.0%, P_{heterogeneity}=0.619).

Conclusion

Blood glucose, FBG, and HbA1c levels are not associated with the survival of patients with pancreatic cancer. Postoperative blood glucose levels could predict postoperative complications.