Borderline resectable pancreatic cancer. Challenges and controversies

Mechanisms and clinical landscape of N6-methyladenosine (m6A) RNA modification in gastrointestinal tract cancers

Epigenetics encompasses reversible and heritable chemical modifications of non-nuclear DNA sequences, including DNA and RNA methylation, histone modifications, non-coding RNA modifications, and chromatin rearrangements. In addition to well-studied DNA and histone methylation, RNA methylation has emerged as a hot topic in biological sciences over the past decade. N6-methyladenosine (m6A) is the most common and abundant modification in eukaryotic mRNA, affecting all RNA stages, including transcription, translation, and degradation. Advances in high-throughput sequencing technologies made it feasible to identify the chemical basis and biological functions of m6A RNA. Dysregulation of m6A levels and associated modifying proteins can both inhibit and promote cancer, highlighting the importance of the tumor microenvironment in diverse biological processes. Gastrointestinal tract cancers, including gastric, colorectal, and pancreatic cancers, are among the most common and deadly malignancies in humans. Growing evidence suggests a close association between m6A levels and the progression of gastrointestinal tumors. Global m6A modification levels are substantially modified in gastrointestinal tumor tissues and cell lines compared to healthy tissues and cells, possibly influencing various biological behaviors such as tumor cell proliferation, invasion, metastasis, and drug resistance. Exploring the diagnostic and therapeutic potential of m6A-related proteins is critical from a clinical standpoint. Developing more specific and effective m6A modulators offers new options for treating these tumors and deeper insights into gastrointestinal tract cancers.

Advances in Systemic Therapy in Pancreatic Cancer

Substantial progress has been made toward understanding biology and developing new therapies for pancreatic ductal adenocarcinoma (PDAC). In this review, new insights from genomic profiling, as well as implications for treatment and prognosis, are discussed. New standards of care approaches with a focus on drug therapies are discussed for the treatment of resectable and advanced PDAC. The role of targeted and immune therapies remains limited; cohorts likely to benefit from these approaches are discussed. Promising, preliminary results regarding experimental therapies are reviewed.

Survival benefit of neoadjuvant FOLFIRINOX for patients with borderline resectable pancreatic cancer

Backgrounds/Aims

While patients with borderline resectable pancreatic cancer (BRPC) are a target population for neoadjuvant chemotherapy (NAC), formal guidelines for neoadjuvant therapy are lacking. We assessed the perioperative and oncological outcomes in patients with BRPC undergoing NAC with FOLFIRINOX for patients undergoing upfront surgery (US).

Methods

The AHPBA criteria for borderline resectability and/or a CA19-9 level > 100 μ/mL defined borderline resectable tumors retrieved from a prospectively populated institutional registry from 2007 to 2020. The primary outcome was overall survival (OS) at 1 and 3 years. A Cox Proportional Hazard model based on intention to treat was used. A receiver-operator characteristics (ROC) curve was constructed to assess the discriminatory capability of the use of CA19-9 > 100 μ/mL to predict resectability and mortality.

Results

Forty BRPC patients underwent NAC, while 46 underwent US. The median OS with NAC was 19.8 months (interquartile range [IQR], 10.3-44.24) vs. 10.6 months (IQR, 6.37-17.6) with US. At 1 year, 70% of the NAC group and 41.3% of the US group survived (p = 0.008). At 3 years, 42.5 % of the NAC group and 10.9% of the US group survived (p = 0.001). NAC significantly reduced the hazard of death (adjusted hazard ratio, 0.20; 95% confidence interval, 0.07-0.54; p = 0.001). CA19-9 > 100 μ/mL showed poor discrimination in predicting mortality, but was a moderate predictor of resectability.

Conclusions

We found a survival benefit of NAC with FOLFIRINOX for BRPC. Greater pre-treatment of CA19-9 and multivessel involvement on initial imaging were associated with progression of the disease following NAC.

Systemic Analyses of Cuproptosis-Related lncRNAs in Pancreatic Adenocarcinoma, with a Focus on the Molecular Mechanism of LINC00853

Pancreatic cancer (PC) is a deadly malignant digestive tumor with poor prognoses and a lack of effective treatment options. Cuproptosis, a recently identified copper-dependent programmed cell death type, has been implicated in multiple cancers. Long non-coding RNAs (lncRNAs) are also linked to the progression of PC. However, the role and prognostic values of cuproptosis-related lncRNAs in pancreatic adenocarcinoma (PAAD) remain unclear. In this study, we systemically analyzed the differential expressions and prognostic values of 672 cuproptosis-related lncRNAs in PAAD. Based on this, a prognostic signature including four lncRNAs (LINC00853, AC099850.3, AC010719.1, and AC006504.7) was constructed and was able to divide PAAD patients into high- and low-risk groups with significantly different prognoses. Next, we focused on lncRNA LINC00853. The differential expressions of LINC00853 between normal tissue and PAAD samples were validated by qRT-PCR. LINC00853 was knocked down by siRNA in PC cell lines BxPC-3 and PANC-1 and the oncogenic role of LINC00853 was validated by CCK8, colony formation, and EdU assays. Subsequently, LINC00853 knockdown cells were subjected to tumor xenograft tests and exhibited decreased tumor growth in nude mice. Mechanistically, knockdown of LINC00853 significantly reduced cellular glycolysis and enhanced cellular mitochondrial respiration levels in PC cells. Moreover, knockdown of LINC00853 decreased the protein level of a glycolytic kinase PFKFB3. Finally, glycolysis tests and functional tests using LINC00853 and HA-PFKFB3 indicated that the effects of LINC00853 on glycolysis and cell proliferation were mediated by PFKFB3. In conclusion, our systemic analyses have highlighted the important roles of cuproptosis-related lncRNAs in PAAD while the prognostic signature based on them showed excellent performance in PAAD patients and is expected to provide clinical guidance for individualized treatment. In addition, our findings provide a novel mechanism by which the LINC00853-PFKFB3 axis critically regulates aerobic glycolysis and cell proliferation in PC cells.

Utility of Dark-Blood Dual-Energy CT Images for Predicting Vascular Involvement and R0 Resection in Patients With Pancreatic Cancer

BACKGROUND. Current CT criteria for assessing vascular involvement by pancreatic ductal adenocarcinoma (PDAC) use circumferential contact as an indirect indicator. Dark-blood images derived from dual-energy CT (DECT) provide high lumen-to-wall contrast and may aid assessment. OBJECTIVE. The purpose of this study was to compare the diagnostic performance of 55-keV virtual monoenergetic images (VMIs) assessed using NCCN criteria with that of dark-blood images assessed using wall-based criteria for predicting vascular involvement and surgical resection that achieves microscopically negative margins (i.e., R0 resection) in patients with PDAC who undergo contrast-enhanced DECT. METHODS. This retrospective study included 109 patients (mean age, 62.6 ± 8.8 [SD] years; 66 men, 43 women) with histologically confirmed PDAC who underwent pancreatic parenchymal and portal venous phase DECT within 4 weeks before surgery (including PDAC resection in 73 patients) between July 2020 and June 2022. Dark-blood images were derived using a two-material decomposition algorithm. Two radiologists independently reviewed 55-keV VMIs and dark-blood images in separate sessions to evaluate celiac artery, common hepatic artery, superior mesenteric artery, portal vein, and superior mesenteric vein involvement; a third radiologist resolved discrepancies. On 55-keV VMIs, vessel relationships were classified as no contact, abutment (≤ 180° contact), or encasement (> 180° contact). On dark-blood images, vessel walls were categorized as intact circumferentially, irregular, or discontinuous. Tumor resectability status was classified on the basis of vessel relationships. Surgical observation served as the reference for vascular involvement. Margin status was determined for resected tumors. RESULTS. Across the five vessels, for predicting vascular involvement, abutment or encasement on 55-keV VMIs had sensitivity of 100.0% (all vessels) and specificity of 66.2-92.9%, and an irregular or discontinuous wall on dark-blood images had sensitivity of 80.0-100.0% and specificity of 88.2-98.0%. Specificity was higher for an irregular or discontinuous wall than for abutment or encasement for all vessels (all p < .05); sensitivity was not different for any vessel (all p > .05). Resectable disease classified by dark-blood images, compared with resectable disease classified by 55-keV VMIs, showed no difference in sensitivity (89.5% vs 78.9%, p = .33) but showed higher specificity (75.9% vs 59.3%, p = .01) for predicting R0 resection. CONCLUSION. Dark-blood images showed higher diagnostic performance than 55-keV VMIs for predicting vascular involvement and R0 resection in patients with PDAC. CLINICAL IMPACT. Dark-blood images may aid decisions regarding neoadjuvant therapy and surgical planning for PDAC.

Mitochondria-Related Transcriptome Characterization Associated with the Immune Microenvironment, Therapeutic Response and Survival Prediction in Pancreatic Cancer

(1) Background: Pancreatic cancer (PC) is one of the most lethal tumors. Mitochondrial dysfunction has been reported to be involved in cancer development; however, its role in PC has remained unclear. (2) Methods: The differentially expressed NMGs were selected between PC and normal pancreatic tissue. The NMG-related prognostic signature was established by LASSO regression. A nomogram was developed based on the 12-gene signature combined with other significant pathological features. An extensive analysis of the 12 critical NMGs was performed in multiple dimensions. The expression of some key genes was verified in our external cohort. (3) Results: Mitochondria-related transcriptome features was obviously altered in PC compared with normal pancreas tissue. The 12-NMG signature showed good performance in predicting prognosis in various cohorts. The high- and low-risk groups exhibited notable diversity in gene mutation characteristics, biological characteristics, chemotherapy response, and the tumor immune microenvironment. Critical gene expression was demonstrated in our cohort at the mRNA and protein levels and in organelle localization. (4) Conclusions: Our study analyzed the mitochondrial molecular characterization of PC, proving the crucial role of NMGs in PC development. The established NMG signature helps classify patient subtypes in terms of prognosis prediction, treatment response, immunological features, and biological function, providing a potential therapeutic strategy targeting mitochondrial transcriptome characterization.

Clinical decisions in pancreatic cancer surgery: a national survey and case-vignette study

Very few surveys have been carried out of oncosurgical decisions made in patients with pancreatic cancer (PC), or of the possible differences in therapeutic approaches between low/medium and high-volume centers. A survey was sent out to centers affiliated to the Spanish Group of Pancreatic Surgery (GECP) asking about their usual pre-, intra- and post-operative management of PC patients and describing five imaginary cases of PC corresponding to common scenarios that surgeons regularly assess in oncosurgical meetings. A consensus was considered to have been reached when 80% of the answers coincided. We received 69 responses from the 72 GECP centers (response rate 96%). Pre-operative management: consensus was obtained on 7/16 questions (43.75%) with no significant differences between low- vs high-volume centers. Intra-operative: consensus was obtained on 11/28 questions (39.3%). D2 lymphadenectomy, biliary culture, intra-operative biliary margin study, pancreatojejunostomy, and two loops were significantly more frequent in high-volume hospitals (p < 0.05). Post-operative: consensus was obtained on 2/8 questions (25%). No significant differences were found between low-/medium- vs high-volume hospitals. Of the 41 questions asked regarding the cases, consensus was reached on 22 (53.7%). No differences in the responses were found according to the type of hospital. Management and cases: consensus was reached in 42/93 questions (45.2%). At GECP centers, consensus was obtained on 45% of the questions. Only 5% of the answers differed between low/medium and high-volume centers (all intra-operative). A more specific assessment of why high-volume centers obtain the best results would require the design of complex prospective studies able to measure the therapeutic decisions made and the effectiveness of their execution. Clinicaltrials.gov identifier: NCT04755036.

Functions and clinical applications of exosomes in pancreatic cancer

Pancreatic cancer (PC) is one of the most malignant tumors and has an abysmal prognosis, with a 5-year survival rate of only 11%. At present, the main clinical dilemmas in PC are the lack of biomarkers and the unsatisfactory therapeutic effects. The treatments for and outcomes of PC have improved, but remain unsatisfactory. Exosomes are nanosized extracellular vesicles, and an increasing number of studies have found that exosomes play an essential role in tumor pathology. In this review, we describe the process of exosome biogenesis, as well as exosome extraction methods and identification strategies, and we then explain in detail the roles and mechanisms of exosomes in invasion, metastasis, chemoresistance and immunosuppression in PC. Finally, we summarize the clinical applications of exosomes. Our observations indicate that exosomes represent a novel direction in the clinical treatment of PC.

Successful conversion surgery for locally advanced gallbladder cancer after gemcitabine and nab-paclitaxel chemotherapy

Objective

Gallbladder cancer (GBC) is highly malignant and is often diagnosed at the advanced stage. Lack of opportunity to surgery results in an unsatisfactory outcome. This pilot study employed gemcitabine combined with nab-paclitaxel (AG) as a conversion therapeutic measure for locally advanced GBC and successfully achieved conversion surgery in three initially unresectable GBC patients. We will introduce our experience on improving the outcome of this dismal disease.

Methods

Radiology and nuclear medicine imaging were performed in each patient, and resectability was evaluated by joint consultation of our multi-disciplinary team (MDT). Patients evaluated as unresectable were treated with the AG regimen and re-evaluated for treatment response. When complete or partial response is achieved, MDT opinion would be required to assess the possibility of performing conversion surgery with R0 resection.

Results

Three GBC patients who were initially evaluated as unresectable successfully underwent R0 resection after conversion therapy with the AG regimen. The first case was a recurrent GBC patient evaluated as locally advanced and eventually achieved pathological complete response. The second case was a GBC patient who underwent R1 resection with residual lesions in the gallbladder bed and isolated No. 16 lymph node metastasis and who had a pathologically complete response after treatment. The third case had multiple but resectable liver metastases; both objective response and partial pathologic response were achieved. None of the patients experienced serious treatment-related adverse events. All cases revealed no evidence of recurrence or metastasis after a median follow-up of 12 months.

Conclusions

Conversion therapy shows a favorable efficacy in those unresectable GBC patients. Gemcitabine plus nab-paclitaxel has the potential to be used as a preoperative treatment option for GBC patients at the advanced stage. To further explore the efficacy of AG on conversion therapy for GBC patients, a prospective clinical trial has been registered (ChiCTR2200055698).

miR‑32‑5p suppresses the proliferation and migration of pancreatic adenocarcinoma cells by targeting TLDC1

Pancreatic adenocarcinoma (PAAD) is one of the most fatal types of cancer in humans. However, the molecular mechanisms underlying the migration and invasion abilities of PAAD cells remain unclear. The aim of the present study was to explore the regulatory roles of microRNA (miR)‑32‑5p in PAAD cells. miR‑32‑5p mimic and inhibitor were used to transfect the human PAAD AsPC‑1 cell line to determine the role of miR‑32‑5p in cell proliferation and metastasis. The starBase database predicted the binding of miR‑32‑5p to the target gene TBC/LysM‑associated domain containing 1 (TLDC1). Further analyses were performed to assess miR‑32‑5p and TLDC1 expression levels in healthy and PAAD tissues, as well as the association between miR‑32‑5p or TLDC1 expression and the prognosis of patients with PAAD. The interaction between miR‑32‑5p and TLDC1 was verified using the dual‑luciferase reporter assay. miR‑32‑5p and TLDC1 expression levels were detected by reverse transcription‑quantitative PCR and western blotting, respectively. The Cell Counting Kit‑8 assay was utilised to assess cell proliferation, whereas the wound‑healing and Transwell assays were conducted to assess cell migration and invasion, respectively. miR‑32‑5p expression levels were markedly lower in PAAD tissue compared with those in healthy tissue, and were significantly lower in PAAD cell lines compared with those in the human pancreatic duct cell line HPDE6, which corresponded with poor prognosis. miR‑32‑5p significantly inhibited the proliferation of PAAD cells and markedly reduced migration and invasion compared with the negative controls. miR‑32‑5p was shown to target TLDC1, with miR‑32‑5p expression in PAAD being negatively correlated with TLDC1 expression. High TLDC1 expression levels were associated with a poorer prognosis compared with low TLDC1 expression levels. Co‑transfection of miR‑32‑5p mimic and pcDNA/TLDC1 demonstrated that TLDC1 significantly reversed miR‑32‑5p‑mediated inhibition of the proliferation, migration and invasion of PAAD cells. Overall, the present study demonstrated that miR‑32‑5p may serve as a tumor‑suppressor gene by inhibiting the proliferation and migration and invasion of PAAD cells via the downregulation of TLDC1. Therefore, miR‑32‑5p may serve as a potential diagnostic or prognostic marker for PAAD.

Non-pegylated Liposomal Doxorubicin as Palliative Chemotherapy in pre-Treated Advanced Pancreatic Cancer: A Retrospective Analysis of Twenty-Eight Patients

Background: Pancreatic cancer carries a devastating prognosis and is the fourth leading cause for cancer-related death in the United States and most European countries. Although one-third of patients receive a palliative third line therapy, the benefit of systemic therapy beyond second-line remains unclear. A plethora of clinical trials investigating novel drugs have failed over the past years. Due to the lack of established treatment regimens beyond second line, we offered nonpegylated liposomal doxorubicin, well known in other tumor entities, to pretreated pancreatic cancer patients requesting systemic therapy. Material and Methods: In this retrospective analysis, 28 patients with pancreatic carcinoma treated with nonpegylated liposomal doxorubicin (Myocet®) between 2012 and 2018 at our department were included. Results: For the majority of patients (n = 18, 64%), nonpeglyted liposomal doxorubicin was offered as a third-line therapy. Five patients received it as second line, four patients as fourth line, and one patient as fifth line of therapy. Half of the patients received at least a therapy cycle. The objective response rate to treatment was 7.1%. One patient had a period of radiologically confirmed stable disease with stable tumor markers. Another patient experienced partial remission. Conclusion: According to our findings the benefit of nonpegylated liposomal doxorubicin in pancreatic cancer beyond second line is limited.

Kaempferol potentiates the sensitivity of pancreatic cancer cells to erlotinib via inhibition of the PI3K/AKT signaling pathway and epidermal growth factor receptor

Erlotinib (ERL) is an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) of pancreatic cancer (PC). However, the clinical efficacy of ERL is limited due to the activation of alternative pathways that bypass the EGFR signaling. Kaempferol (KAE), a natural flavonoid compound, has been reported to possess potent anti-tumor and anti-inflammatory properties, and in this study, we aimed at identifying the sensitization effect of KAE on ERL monotherapy in PC cells and mouse models. Briefly, the CCK-8, colony formation, and flow cytometry were used to assess the proliferation and apoptosis of two PC cell lines in response to a treatment combination of KAE and ERL. Additionally, the drug-disease targets and related anti-PC mechanisms of KAE and ERL were predicted with a network pharmacology method. The survival outcome for PC patients with EGFR differential expression was evaluated through survival analysis. The molecular docking technique predicted the affinity between KAE and EGFR. Moreover, western blot (WB) and immunohistochemistry (IHC) analyses were applied to verify the expression levels of related proteins. As a result, in vitro results showed that the combination of KAE and ERL significantly inhibited cell proliferation and promoted cell apoptosis compared to that with ERL alone. Network pharmacology results demonstrated that KAE sensitized PC to ERL treatment may likely be related to the PI3K/AKT signaling pathway and EGFR TKI resistance. Survival analysis illustrated that PC patients with high expression of EGFR had a relative lower survival rate. Molecular docking results further suggested that KAE had a high binding affinity of  - 8.9 kcal/mol with EGFR. WB results indicated that the combination of KAE and ERL dramatically downregulated the expression levels of p-EGFR, p-AKT, p-ERK1/2, and Bcl-2, and upregulated the expression levels of cleaved caspase-9, cleaved PARP, and Bax. The in vivo results revealed that treatment combination of KAE and ERL further reduced the volume and weight of subcutaneous grafted tumors. IHC results confirmed the WB results. These data imply that KAE may be a valid therapeutic candidate to potentiate PC cell sensitivity to ERL via inhibiting PI3K/AKT and EGFR signaling.

Glutathione S-Transferases in Cancer

In humans, the glutathione S-transferases (GST) protein family is composed of seven members that present remarkable structural similarity and some degree of overlapping functionalities. GST proteins are crucial antioxidant enzymes that regulate stress-induced signaling pathways. Interestingly, overactive GST proteins are a frequent feature of many human cancers. Recent evidence has revealed that the biology of most GST proteins is complex and multifaceted and that these proteins actively participate in tumorigenic processes such as cell survival, cell proliferation, and drug resistance. Structural and pharmacological studies have identified various GST inhibitors, and these molecules have progressed to clinical trials for the treatment of cancer and other diseases. In this review, we discuss recent findings in GST protein biology and their roles in cancer development, their contribution in chemoresistance, and the development of GST inhibitors for cancer treatment.

Liquid Biopsy in Pancreatic Cancer: Are We Ready to Apply It in the Clinical Practice?

Pancreatic ductal adenocarcinoma (PDAC) exhibits the poorest prognosis of all solid tumors, with a 5-year survival of less than 10%. To improve the prognosis, it is necessary to advance in the development of tools that help us in the early diagnosis, treatment selection, disease monitoring, evaluation of the response and prognosis. Liquid biopsy (LB), in its different modalities, represents a particularly interesting tool for these purposes, since it is a minimally invasive and risk-free procedure that can detect both the presence of genetic material from the tumor and circulating tumor cells (CTCs) in the blood and therefore distantly reflect the global status of the disease. In this work we review the current status of the main LB modalities (ctDNA, exosomes, CTCs and cfRNAs) for detecting and monitoring PDAC.

Dosimetric and radiobiological comparison of treatment plan between CyberKnife and EDGE in stereotactic body radiotherapy for pancreatic cancer

To perform a comparison of the different stereotactic body radiotherapy (SBRT) plans between the Varian EDGE and CyberKnife (CK) systems for locally advanced unresectable pancreatic cancer. Fifteen patients with pancreatic cancer were selected in this study. The median planning target volume (PTV) was 28.688 cm³ (5.736–49.246 cm³). The SBRT plans for the EDGE and CK were generated in the Eclipse and Multiplan systems respectively with the same contouring and dose constrains for PTV and organs at risk (OARs). Dose distributions in PTV were evaluated in terms of coverage, conformity index (CI), new conformity index (nCI), homogeneity index (HI), and gradient index (GI). OARs, including spinal cord, bowel, stomach, duodenum and kidneys were statistically evaluated by different dose-volume metrics and equivalent uniform dose (EUD). The volume covered by the different isodose lines (ISDL) ranging from 10 to 100% for normal tissue were also analyzed. All SBRT plans for EDGE and CK met the dose constraints for PTV and OARs. For the PTV, the dosimetric metrics in EDGE plans were lower than that in CK, except that D₉₉ and GI were slightly higher. The EDGE plans with lower CI, nCI and HI were superior to generate more conformal and homogeneous dose distribution for PTV. For the normal tissue, the CK plans were better at OARs sparing. The radiobiological indices EUD of spinal cord, duodenum, stomach, and kidneys were lower for CK plans, except that liver were higher. The volumes of normal tissue covered by medium ISDLs (with range of 20–70%) were lower for CK plans while that covered by high and low ISDLs were lower for EDGE plans. This study indicated that both EDGE and CK generated equivalent plan quality, and both systems can be considered as beneficial techniques for SBRT of pancreatic cancer. EDGE plans offered more conformal and homogeneous dose distribution for PTV, while the CK plans could minimize the exposure of OARs.

Preoperative CT staging of borderline pancreatic cancer patients after neoadjuvant treatment: accuracy in the prediction of vascular invasion and resectability

OBJECTIVES

To assess the utility of MDCT tumor-vascular interface criteria for predicting vascular invasion and resectability in borderline pancreatic cancer (BRPC) patients after neoadjuvant therapy (NAT).

METHODS

This prospective study included 90 patients with BRPC who finished NAT, showed no progression in preoperative CTs and underwent surgery. Two radiologists independently assessed preoperative vessel-tumor interface criteria. The area under the ROC curve (AUC) was used to evaluate the diagnostic performance for predicting vascular invasions and resectability using surgical and pathological results as the gold standard. Inter-reader agreement was assessed using the κ coefficient.

RESULTS

Pathologic vascular invasion was confirmed in 47 (54.7%) veins and 14 (16.3%) arteries. R0 resection was achieved in (82.6%71/86) pancreatic resection. Using criteria of circumferential interface ≥ 180 degrees with contour deformity ≥ grade 3 and/or length of tumor contact > 2 cm to predict vascular invasion, the AUCs for the two readers were 0.85-0.88 for arterial invasion and 0.92-0.87 for venous invasion. Using criteria of circumferential interface ≤ 180° with contour deformity ≤ grade 2 and/or length of tumor contact < 2 cm to predict R0 resection, the AUCs was 0.85-0.86 for the two readers. The overall inter-reader agreement was good (κ = 0.75-0.80). The κ values for venous invasion, arterial invasion and R0 resection were 0.76, 0.78, and 0.80.

CONCLUSION

Tumor-vessel criteria demonstrated good diagnostic performance and reproducibility in the prediction of vascular invasion after NAT in BRPC. These criteria could be helpful in the prediction of R0 resection in cases with only venous involvement.

Defining Benchmark Outcomes for Pancreatoduodenectomy With Portomesenteric Venous Resection

OBJECTIVE

The aim of this study was to establish clinically relevant outcome benchmark values using criteria for pancreatoduodenectomy (PD) with portomesenteric venous resection (PVR) from a low-risk cohort managed in high-volume centers.

SUMMARY BACKGROUND DATA

PD with PVR is regarded as the standard of care in patients with cancer involvement of the portomesenteric venous axis. There are, however, no benchmark outcome indicators for this population which hampers comparisons of patients undergoing PD with and without PVR resection.

METHODS

This multicenter study analyzed patients undergoing PD with any type of PVR in 23 high-volume centers from 2009 to 2018. Nineteen outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers (NCT04053998).

RESULTS

Out of 1462 patients with PD and PVR, 840 (58%) formed the benchmark cohort, with a mean age was 64 (SD11) years, 413 (49%) were females. Benchmark cutoffs, among others, were calculated as follows: Clinically relevant pancreatic fistula rate (International Study Group of Pancreatic Surgery): ≤14%; in-hospital mortality rate: ≤4%; major complication rate Grade≥3 and the CCI up to 6 months postoperatively: ≤36% and ≤26, respectively; portal vein thrombosis rate: ≤14% and 5-year survival for patients with pancreatic ductal adenocarcinoma: ≥9%.

CONCLUSION

These novel benchmark cutoffs targeting surgical performance, morbidity, mortality, and oncological parameters show relatively inferior results in patients undergoing vascular resection because of involvement of the portomesenteric venous axis. These benchmark values however can be used to conclusively assess the results of different centers or surgeons operating on this high-risk group.

Relevance Function of Linc-ROR in the Pathogenesis of Cancer

Long non-coding RNAs (lncRNAs) are the key components of non-coding RNAs (ncRNAs) with a length of 200 nucleotides. They are transcribed from the so-called “dark matter” of the genome. Increasing evidence have shown that lncRNAs play an important role in the pathophysiology of human diseases, particularly in the development and progression of tumors. Linc-ROR, as a new intergenic non-protein coding RNA, has been considered to be a pivotal regulatory factor that affects the occurrence and development of human tumors, including breast cancer (BC), colorectal cancer (CRC), pancreatic cancer (PC), hepatocellular carcinoma (HCC), and so on. Dysregulation of Linc-ROR has been closely related to advanced clinicopathological factors predicting a poor prognosis. Because linc-ROR can regulate cell proliferation, apoptosis, migration, and invasion, it can thus be used as a potential biomarker for patients with tumors and has potential clinical significance as a therapeutic target. This article reviewed the role of linc-ROR in the development of tumors, its related molecular mechanisms, and clinical values.

Body Composition Influences Post-Operative Complications and 90-Day and Overall Survival in Pancreatic Surgery Patients

Introduction

Pancreatic surgery still carries a high morbidity and mortality even in specialized centers. The aim of this study was to evaluate the influence of patients' body composition on postoperative complications and survival after pancreatic surgery.

Methods

This was a retrospective study on patients undergoing pancreatic surgery between March 2012 and December 2017. Demographics, clinical data, and postoperative complications classified according to Clavien-Dindo were recorded. Body composition was assessed using routine diagnostic or staging computed tomography (CT). Multiple Cox proportional hazards models were adjusted.

Results

Ninety patients were included, 55% were male, and the mean age was 68 ± 10.9 years. Of these 90, 92% had a total pancreatectomy or pancreaticoduodenectomy, 7% a distal pancreatectomy, and 1% a pancreaticoduodenectomy with multi-visceral resection; 84% had malignant disease. The incidence of major complications was 27.8% and the 90-day mortality was 8.8%. The ratio of visceral fat area/skeletal muscle area (VFA:SMA) was associated with an increased risk of complications (OR 2.24, 95% CI 1.14-4.87, p = 0.03) and 90-day survival (HR 2.13, 95% CI 1.13-4.01, p = 0.019). On simple analysis, shorter overall survival (OS) was observed in patients aged ≥70 years (p = 0.0009), with postoperative complications ≥IIIb (p = 0.01), an increased VFA:SMA (p = 0.007), and decreased muscle radiation attenuation (p = 1.6 × 10^-5). In an OS model adjusted for age, disease malignancy, postoperative complications, and body composition parameters, muscle radiation attenuation remained significantly associated with survival (HR 0.94, 95% CI 0.90-0.98, p = 0.0016). A model which included only body composition variables had a discrimination ability (C-statistic 0.76) superior to a model which comprised conventional clinical variables (C-statistic 0.68).

Conclusion

Body composition is a major determinant of postoperative complications and survival in pancreatic surgery patients.

High baseline soluble urokinase plasminogen activator receptor (suPAR) serum levels indicate adverse outcome after resection of pancreatic adenocarcinoma

Surgical resection represents the only potentially curative therapy for patients with pancreatic adenocarcinoma (PDAC), an aggressive malignancy with a very limited 5-year survival rate. However, even after complete tumor resection, many patients are still facing an unfavorable prognosis underlining the need for better preoperative stratification algorithms. Here, we explored the role of the secreted glycoprotein soluble urokinase plasminogen activator receptor (suPAR) as a novel circulating biomarker for patients undergoing resection of PDAC. Serum levels of suPAR were measured by enzyme-linked immunosorbent assay (ELISA) in an exploratory as well as a validation cohort comprising a total of 127 PDAC patients and 75 healthy controls. Correlating with a cytoplasmic immunohistochemical expression of uPAR in PDAC tumor cells, serum levels of suPAR were significantly elevated in PDAC patients compared to healthy controls and patient with PDAC precursor lesions. Importantly, patients with high preoperative suPAR levels above a calculated cutoff value of 5.956 ng/ml showed a significantly reduced overall survival after tumor resection. The prognostic role of suPAR was further corroborated by uni- and multivariate Cox-regression analyses including parameters of systemic inflammation, liver and kidney function as well as clinico-pathological patients’ characteristics. Moreover, high baseline suPAR levels identified those patients particularly susceptible to acute kidney injury and surgical complications after surgery. In conclusion, our data suggest that circulating suPAR represents a novel prognostic marker in PDAC patients undergoing tumor resection that might be a useful addition to existing preoperative stratification algorithms for identifying patients that particularly benefit from extended tumor resection.

Emerging incidence trends and application of curative treatments of pancreatic cancer in the USA

Annual pancreatic tumor incidence rates have been increasing. We explored pancreatic tumor incidence trends by treatment and clinicopathologic features.Data from the Surveillance, Epidemiology and End Results (SEER) was retrieved to evaluate temporal trends and pancreatic cancer rates from 2000 to 2015. Joinpoint regression analyses were carried out to examine trend differences.Overall, the incidence of pancreatic cancer was on the increase. The initial APC increased at a rate of 2.22% from 2000 to 2012, and increased from 2012 to 2015 at a rate of 9.05%. Joinpoint analyses revealed that trends within different demographics of pancreatic cancer showed different characteristics. The rate of pancreatic cancer also varied with histologic types. In addition, the trends by cancer stage showed significant increase incidences of stage I and II pancreatic cancer from 2000 to 2013 (stage I: APC: 2.71%; stage II: APC: 4.87%). Incidences of patients receiving surgery increased from 2000 to 2008 (APC: 7.55%), 2008 to 2011 (APC: 2.17%) and then there was a significant acceleration from 2011 to 2015 (APC: 10.51%). The incidence of cases in stage II receiving surgery increased significantly from 2004 to 2009 (APC: 9.28%) and 2009 to 2013 (APC: 2.57%). However, for cases in stage I, the incidence of cases with surgery decreased significantly since 2009 (APC: -4.14%). Patients undergoing surgical treatment without chemotherapy and radiotherapy had the higher rates compared with those who received other combined treatments.Pancreatic cancer has been increasing overall, but patterns differ by demographics and clinicopathologic features. Efforts to identify and treat more eligible candidates for curative therapy could be beneficial.

LncRNA SNHG15: A new budding star in human cancers

OBJECTIVES

Long non-coding RNAs (lncRNAs) represent an important group of non-coding RNAs (ncRNAs) with more than 200 nucleotides in length that are transcribed from the so-called genomic "dark matter." Mounting evidence has shown that lncRNAs have manifested a paramount function in the pathophysiology of human diseases, especially in the pathogenesis and progression of cancers. Despite the exponential growth in lncRNA publications, our understanding of regulatory mechanism of lncRNAs is still limited, and a lot of controversies remain in the current lncRNA knowledge.The purpose of this article is to explore the clinical significance and molecular mechanism of SNHG15 in tumors.

MATERIALS & METHODS

We have systematically searched the Pubmed, Web of Science, Embase and Cochrane databases. We provide an overview of current evidence concerning the functional role, mechanistic models and clinical utilities of SNHG15 in human cancers in this review.

RESULTS

Small nucleolar RNA host gene 15 (SNHG15), a novel lncRNA, is identified as a key regulator in tumorigenesis and progression of various human cancers, including colorectal cancer (CRC), gastric cancer (GC), pancreatic cancer (PC) and hepatocellular carcinoma (HCC). Dysregulation of SNHG15 has been revealed to be dramatically correlated with advanced clinicopathological factors and predicts poor prognosis, suggesting its potential clinical value as a promising biomarker and therapeutic target for cancer patients.

CONCLUSIONS

LncRNA SNHG15 may serve as a prospective and novel biomarker for molecular diagnosis and therapeutics in patients with cancer.

The CRP/Albumin Ratio Predicts Survival And Monitors Chemotherapeutic Effectiveness In Patients With Advanced Pancreatic Cancer

PURPOSE

The CRP/albumin (Alb) ratio, a recently reported predictor, has shown value for prognosis in various human cancers. This study aimed to determine the prognostic value of baseline CRP/Alb and to explore the relevance between postchemotherapy CRP/Alb and the efficacy of chemotherapy in advanced pancreatic cancer patients.

PATIENTS AND METHODS

Five hundred and ninety-five patients diagnosed with locally advanced or metastatic adenocarcinoma of the pancreas were enrolled. Cut-off Finder was used to calculate the best cut‑off value for baseline CRP/Alb. The primary endpoint was overall survival, which was analyzed by Kaplan-Meier survival curves with 95% confidence intervals. The log rank test and Cox proportional hazard model were used to evaluate the univariate and multivariate analyses.

RESULTS

The optimal cut-off value for baseline CRP/Alb was determined to be 0.18. Both the baseline CRP/Alb (CRP/Alb≥0.18 vs. CRP/Alb<0.18, hazard ratio [HR] = 2.506; p<0.001) and postchemotherapy CRP/Alb (CRP/Alb≥0.18 vs. CRP/Alb<0.18, HR = 1.854; p =0.002) were significant predictors of overall survival according to multivariate analysis and were independent of other factors. Patients with a baseline and postchemotherapy CRP/Alb ≥0.18 had the worst prognosis.

CONCLUSION

CRP/Alb is a strong and useful indicator of prognosis for advanced pancreatic cancer. Both baseline and postchemotherapy CRP/Alb can be used in predicting the survival of patients and monitoring the effectiveness of chemotherapy in clinical practice.

Comparative effectiveness of primary tumor resection in patients with stage III pancreatic adenocarcinoma

BACKGROUND

Previous studies comparing primary tumor resection (PTR) to palliative treatment for advanced-stage pancreatic ductal adenocarcinoma (PDA) were limited by strong selection bias. We used multiple methods to control for confounding and selection bias to estimate the effect of PTR on survival for late-stage PDA.

METHODS

Surveillance, Epidemiology, and End Results (SEER) 18 registry database for 2004 through 2014 was retrieved for the present study. A total of 4322 patients with stage III (AJCC, 6th) PDA were included in this study. Propensity score matching (PSM) was performed to eliminate possible bias. In addition, instrumental variable (IV) analysis was utilized to adjust for both measured and unmeasured confounders.

RESULTS

A total of 4322 patients with stage III PDA including 552 (12.8%) who underwent PTR, 3770 (87.2%) without PTR, were identified. In the multivariable cohort, a clear prognostic advantage of PTR was observed in overall survival (OS) (P < 0.001) and disease-specific survival (DSS) (P < 0.001) compared to patients after non-surgery therapy. In the PSM cohort, patients in PTR group showed a better OS and DSS (both P values < 0.001) compared to patients in non-surgery group. The survival benefit of PTR for stage III PDA was not observed in the two-stage residual inclusion (2SRI) model. Estimates based on this instrument indicated that patients treated with PTR had similar OS (P = 0.448) and DSS (P = 0.719). In IV analyses stratified by chemotherapy and tumor location, patients undergoing PTR had similar OS and DSS compared to patients in non-surgery group across all subgroups.

CONCLUSIONS

Survival with PTR did not differ significantly from palliative treatment in marginal patients with stage III pancreatic adenocarcinoma. High-quality randomized trials are needed to validate these results.