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Bruno JS, Fregnani ER. Oral microbiome as a new research-target for supportive care and precision oncology. Curr Opin Oncol 2023; 35:276-281. [PMID: 37222190 DOI: 10.1097/cco.0000000000000947] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE OF REVIEW A growing number of studies demonstrate the oral bacterial shift in cancer patients and the enrichment of oral bacteria in distant tumours. During the oncological treatment, opportunistic oral bacteria correlate with oral toxicities. This review focused on the most recent studies to identify which genera are the most mentioned and deserved further investigation. RECENT FINDINGS This review evaluated bacterial changes in patients with head and neck, colorectal, lung and breast cancer. Greater composition of disease-related genera (e.g., Fusobacterium , Porphyromonas , Lactobacillus , Streptococcus , and Parvimonas ) are present in the oral cavity of these groups of patients. The tumour specimen characterisation of head and neck, pancreatic and colorectal cancer also describes the presence of oral taxa. No evidence indicates that commensal oral bacteria have protective roles in distant tumours. Regardless, oral care is critical to prevent the growth of oral pathogens and reduce infection foci. SUMMARY Recent evidence suggests that oral microbiota is a potential biomarker for oncological clinical outcomes and oral toxicities. Currently, the literature presents a remarkable methodological variety - from the sample collection site to the preference of the data analysis tools. For the oral microbiome to achieve the stage of being used as a clinical tool in the oncological context, more studies are necessary.
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2
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Naudin S, Sampson JN, Moore SC, Albanes D, Freedman ND, Weinstein SJ, Stolzenberg-Solomon R. Lipidomics and pancreatic cancer risk in two prospective studies. Eur J Epidemiol 2023; 38:783-793. [PMID: 37169992 PMCID: PMC11152614 DOI: 10.1007/s10654-023-01014-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
Pancreatic ductal carcinoma (PDAC) is highly fatal with limited understanding of mechanisms underlying its carcinogenesis. We comprehensively investigated whether lipidomic measures were associated with PDAC in two prospective studies. We measured 904 lipid species and 252 fatty acids across 15 lipid classes in pre-diagnostic serum (up to 24 years) in a PDAC nested-case control study within the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO, NCT00002540) with 332 matched case-control sets including 272 having serial blood samples and Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC, NCT00342992) with 374 matched case-control sets. Controls were matched to cases by cohort, age, sex, race, and date at blood draw. We used conditional logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI) per one-standard deviation increase in log-lipid concentrations within each cohort, and combined ORs using fixed-effects meta-analyses. Forty-three lipid species were associated with PDAC (false discovery rate, FDR ≤ 0.10), including lysophosphatidylcholines (LPC, n = 2), phosphatidylethanolamines (PE, n = 17), triacylglycerols (n = 13), phosphatidylcholines (PC, n = 3), diacylglycerols (n = 4), monoacylglycerols (MAG, n = 2), cholesteryl esters (CE, n = 1), and sphingomyelins (n = 1). LPC(18:2) and PE(O-16:0/18:2) showed significant inverse associations with PDAC at the Bonferroni threshold (P value < 5.5 × 10-5). The fatty acids LPC[18:2], LPC[16:0], PC[15:0], MAG[18:1] and CE[22:0] were significantly associated with PDAC (FDR < 0.10). Similar associations were observed in both cohorts. There was no significant association for the differences between PLCO serial lipidomic measures or heterogeneity by follow-up time overall. Results support that the pre-diagnostic serum lipidome, including 43 lipid species from 8 lipid classes and 5 fatty acids, is associated with PDAC.
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Affiliation(s)
- Sabine Naudin
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, DHHS, 9609 Medical Center Drive, NCI Shady Grove, Room 6E420, Rockville, MD, 20850, USA
| | - Joshua N Sampson
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, Rockville, MD, USA
| | - Steven C Moore
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, DHHS, 9609 Medical Center Drive, NCI Shady Grove, Room 6E420, Rockville, MD, 20850, USA
| | - Demetrius Albanes
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, DHHS, 9609 Medical Center Drive, NCI Shady Grove, Room 6E420, Rockville, MD, 20850, USA
| | - Neal D Freedman
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, DHHS, 9609 Medical Center Drive, NCI Shady Grove, Room 6E420, Rockville, MD, 20850, USA
| | - Stephanie J Weinstein
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, DHHS, 9609 Medical Center Drive, NCI Shady Grove, Room 6E420, Rockville, MD, 20850, USA
| | - Rachael Stolzenberg-Solomon
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, DHHS, 9609 Medical Center Drive, NCI Shady Grove, Room 6E420, Rockville, MD, 20850, USA.
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3
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Muranaka H, Hendifar A, Osipov A, Moshayedi N, Placencio-Hickok V, Tatonetti N, Stotland A, Parker S, Van Eyk J, Pandol SJ, Bhowmick NA, Gong J. Plasma Metabolomics Predicts Chemotherapy Response in Advanced Pancreatic Cancer. Cancers (Basel) 2023; 15:3020. [PMID: 37296982 PMCID: PMC10252041 DOI: 10.3390/cancers15113020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Pancreatic cancer (PC) is one of the deadliest cancers. Developing biomarkers for chemotherapeutic response prediction is crucial for improving the dismal prognosis of advanced-PC patients (pts). To evaluate the potential of plasma metabolites as predictors of the response to chemotherapy for PC patients, we analyzed plasma metabolites using high-performance liquid chromatography-mass spectrometry from 31 cachectic, advanced-PC subjects enrolled into the PANCAX-1 (NCT02400398) prospective trial to receive a jejunal tube peptide-based diet for 12 weeks and who were planned for palliative chemotherapy. Overall, there were statistically significant differences in the levels of intermediates of multiple metabolic pathways in pts with a partial response (PR)/stable disease (SD) vs. progressive disease (PD) to chemotherapy. When stratified by the chemotherapy regimen, PD after 5-fluorouracil-based chemotherapy (e.g., FOLFIRINOX) was associated with decreased levels of amino acids (AAs). For gemcitabine-based chemotherapy (e.g., gemcitabine/nab-paclitaxel), PD was associated with increased levels of intermediates of glycolysis, the TCA cycle, nucleoside synthesis, and bile acid metabolism. These results demonstrate the feasibility of plasma metabolomics in a prospective cohort of advanced-PC patients for assessing the effect of enteral feeding as their primary source of nutrition. Metabolic signatures unique to FOLFIRINOX or gemcitabine/nab-paclitaxel may be predictive of a patient's response and warrant further study.
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Affiliation(s)
- Hayato Muranaka
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew Hendifar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Arsen Osipov
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Natalie Moshayedi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Veronica Placencio-Hickok
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Nicholas Tatonetti
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | - Aleksandr Stotland
- Advanced Clinical Biosystems Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (A.S.); (S.P.); (J.V.E.)
| | - Sarah Parker
- Advanced Clinical Biosystems Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (A.S.); (S.P.); (J.V.E.)
| | - Jennifer Van Eyk
- Advanced Clinical Biosystems Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (A.S.); (S.P.); (J.V.E.)
| | - Stephen J. Pandol
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Neil A. Bhowmick
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Research, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - Jun Gong
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (H.M.); (A.H.); (A.O.); (N.M.); (V.P.-H.); (S.J.P.); (N.A.B.)
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Shockley KE, To B, Chen W, Lozanski G, Cruz-Monserrate Z, Krishna SG. The Role of Genetic, Metabolic, Inflammatory, and Immunologic Mediators in the Progression of Intraductal Papillary Mucinous Neoplasms to Pancreatic Adenocarcinoma. Cancers (Basel) 2023; 15:1722. [PMID: 36980608 PMCID: PMC10046238 DOI: 10.3390/cancers15061722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/21/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMN) have the potential to progress to pancreatic ductal adenocarcinoma (PDAC). As with any progression to malignancy, there are a variety of genetic and metabolic changes, as well as other disruptions to the cellular microenvironment including immune alterations and inflammation, that can contribute to tumorigenesis. Previous studies further characterized these alterations, revealing changes in lipid and glucose metabolism, and signaling pathways that mediate the progression of IPMN to PDAC. With the increased diagnosis of IPMNs and pancreatic cysts on imaging, the opportunity to attenuate risk with the removal of high-risk lesions is possible with the understanding of what factors accelerate malignant progression and how they can be clinically utilized to determine the level of dysplasia and stratify the risk of progression. Here, we reviewed the genetic, metabolic, inflammatory, and immunologic pathways regulating the progression of IPMN to PDAC.
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Affiliation(s)
- Kylie E. Shockley
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Briana To
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Wei Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Gerard Lozanski
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, and The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, and The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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5
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Søreide K, Ismail W, Roalsø M, Ghotbi J, Zaharia C. Early Diagnosis of Pancreatic Cancer: Clinical Premonitions, Timely Precursor Detection and Increased Curative-Intent Surgery. Cancer Control 2023; 30:10732748231154711. [PMID: 36916724 PMCID: PMC9893084 DOI: 10.1177/10732748231154711] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The overall poor prognosis in pancreatic cancer is related to late clinical detection. Early diagnosis remains a considerable challenge in pancreatic cancer. Unfortunately, the onset of clinical symptoms in patients usually indicate advanced disease or presence of metastasis. ANALYSIS AND RESULTS Currently, there are no designated diagnostic or screening tests for pancreatic cancer in clinical use. Thus, identifying risk groups, preclinical risk factors or surveillance strategies to facilitate early detection is a target for ongoing research. Hereditary genetic syndromes are a obvious, but small group at risk, and warrants close surveillance as suggested by society guidelines. Screening for pancreatic cancer in asymptomatic individuals is currently associated with the risk of false positive tests and, thus, risk of harms that outweigh benefits. The promise of cancer biomarkers and use of 'omics' technology (genomic, transcriptomics, metabolomics etc.) has yet to see a clinical breakthrough. Several proposed biomarker studies for early cancer detection lack external validation or, when externally validated, have shown considerably lower accuracy than in the original data. Biopsies or tissues are often taken at the time of diagnosis in research studies, hence invalidating the value of a time-dependent lag of the biomarker to detect a pre-clinical, asymptomatic yet operable cancer. New technologies will be essential for early diagnosis, with emerging data from image-based radiomics approaches, artificial intelligence and machine learning suggesting avenues for improved detection. CONCLUSIONS Early detection may come from analytics of various body fluids (eg 'liquid biopsies' from blood or urine). In this review we present some the technological platforms that are explored for their ability to detect pancreatic cancer, some of which may eventually change the prospects and outcomes of patients with pancreatic cancer.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, HPB unit, 60496Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, 60496Stavanger University Hospital, Stavanger, Norway
| | - Warsan Ismail
- Department of Gastrointestinal Surgery, HPB unit, 60496Stavanger University Hospital, Stavanger, Norway
| | - Marcus Roalsø
- Department of Gastrointestinal Surgery, HPB unit, 60496Stavanger University Hospital, Stavanger, Norway.,Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, 60496Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, 60496University of Stavanger, Stavanger, Norway
| | - Jacob Ghotbi
- Department of Gastrointestinal Surgery, HPB unit, 60496Stavanger University Hospital, Stavanger, Norway
| | - Claudia Zaharia
- Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, 60496Stavanger University Hospital, Stavanger, Norway.,Department of Pathology, 60496Stavanger University Hospital, Stavanger, Norway
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6
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Raut P, Nimmakayala RK, Batra SK, Ponnusamy MP. Clinical and Molecular Attributes and Evaluation of Pancreatic Cystic Neoplasm. Biochim Biophys Acta Rev Cancer 2023; 1878:188851. [PMID: 36535512 PMCID: PMC9898173 DOI: 10.1016/j.bbcan.2022.188851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) are all considered "Pancreatic cystic neoplasms (PCNs)" and show a varying risk of developing into pancreatic ductal adenocarcinoma (PDAC). These lesions display different molecular characteristics, mutations, and clinical manifestations. A lack of detailed understanding of PCN subtype characteristics and their molecular mechanisms limits the development of efficient diagnostic tools and therapeutic strategies for these lesions. Proper in vivo mouse models that mimic human PCNs are also needed to study the molecular mechanisms and for therapeutic testing. A comprehensive understanding of the current status of PCN biology, mechanisms, current diagnostic methods, and therapies will help in the early detection and proper management of patients with these lesions and PDAC. This review aims to describe all these aspects of PCNs, specifically IPMNs, by describing the future perspectives.
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Affiliation(s)
- Pratima Raut
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA
| | - Rama Krishna Nimmakayala
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA; Eppley Institute for Research in Cancer and Allied Diseases, Fred & Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA.
| | - Moorthy P Ponnusamy
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA; Eppley Institute for Research in Cancer and Allied Diseases, Fred & Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA.
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7
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Eckhoff AM, Fletcher AA, Landa K, Iyer M, Nussbaum DP, Shi C, Nair SK, Allen PJ. Multidimensional Immunophenotyping of Intraductal Papillary Mucinous Neoplasms Reveals Novel T Cell and Macrophage Signature. Ann Surg Oncol 2022; 29:7781-7788. [PMID: 35831529 PMCID: PMC9949893 DOI: 10.1245/s10434-022-12157-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/19/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMN) are the only radiographically identifiable precursor to pancreatic adenocarcinoma, yet little is known about how these lesions progress to cancer. Inflammation has been associated with dysplastic progression; however, the cause and composition of this inflammation remains poorly characterized. We sought to comprehensively profile immune cell infiltration using parallel spatial transcriptomic and flow cytometric techniques. METHODS Twelve patients with resected IPMN exhibiting both high-grade dysplasia (HGD) and low-grade dysplasia (LGD) were selected for spatial transcriptomics (NanoString GeoMx). Immune (CD45+), epithelial (PanCK+), and stromal (SMA+) compartments were analyzed separately using the GeoMx NGS Pipeline. An additional 11 patients resected for IPMN of varying degrees of dysplasia underwent immunophenotyping using flow cytometry (DURAClone IM). RESULTS Spatial transcriptomics revealed that T cells represent the dominant immune cell within IPMN stroma, which was confirmed by flow cytometry (56%). Spatial profiling found that the T-cell infiltrate was significantly higher in regions of LGD compared with HGD (62% vs. 50%, p = 0.038). Macrophages were the only other immune cell type with > 10% abundance, yet conversely, were generally more abundant in regions of HGD compared to LGD (19% vs. 11%, p = 0.058). Correspondingly, immune cells within regions of HGD demonstrated transcriptional upregulation of genes associated with macrophage activity including secretion (CXCL1) and phagocytosis (C1QA, C1S, C4B). CONCLUSIONS IPMN immune infiltrate is primarily composed of T cells and macrophages. Regions of HGD appear to be relatively deplete of T cells and show a trend toward macrophage enrichment compared with regions of LGD.
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Affiliation(s)
| | | | - Karenia Landa
- Department of Surgery, Duke University; Durham, North Carolina, USA
| | - Matthew Iyer
- Department of Surgery, Duke University; Durham, North Carolina, USA
| | | | - Chanjuan Shi
- Department of Pathology, Duke University; Durham, North Carolina, USA
| | - Smita K. Nair
- Department of Surgery, Duke University; Durham, North Carolina, USA
| | - Peter J. Allen
- Department of Surgery, Duke University; Durham, North Carolina, USA
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Herremans KM, Riner AN, Cameron ME, McKinley KL, Triplett EW, Hughes SJ, Trevino JG. The oral microbiome, pancreatic cancer and human diversity in the age of precision medicine. MICROBIOME 2022; 10:93. [PMID: 35701831 PMCID: PMC9199224 DOI: 10.1186/s40168-022-01262-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 03/23/2022] [Indexed: 05/09/2023]
Abstract
Pancreatic cancer is a deadly disease with limited diagnostic and treatment options. Not all populations are affected equally, as disparities exist in pancreatic cancer prevalence, treatment and outcomes. Recently, next-generation sequencing has facilitated a more comprehensive analysis of the human oral microbiome creating opportunity for its application in precision medicine. Oral microbial shifts occur in patients with pancreatic cancer, which may be appreciated years prior to their diagnosis. In addition, pathogenic bacteria common in the oral cavity have been found within pancreatic tumors. Despite these findings, much remains unknown about how or why the oral microbiome differs in patients with pancreatic cancer. As individuals develop, their oral microbiome reflects both their genotype and environmental influences. Genetics, race/ethnicity, smoking, socioeconomics and age affect the composition of the oral microbiota, which may ultimately play a role in pancreatic carcinogenesis. Multiple mechanisms have been proposed to explain the oral dysbiosis found in patients with pancreatic cancer though they have yet to be confirmed. With a better understanding of the interplay between the oral microbiome and pancreatic cancer, improved diagnostic and therapeutic approaches may be implemented to reduce healthcare disparities. Video Abstract.
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Affiliation(s)
- Kelly M. Herremans
- Department of Surgery, University of Florida College of Medicine, P.O. Box 100286, Gainesville, FL 32610 USA
| | - Andrea N. Riner
- Department of Surgery, University of Florida College of Medicine, P.O. Box 100286, Gainesville, FL 32610 USA
| | - Miles E. Cameron
- Department of Surgery, University of Florida College of Medicine, P.O. Box 100286, Gainesville, FL 32610 USA
| | - Kelley L. McKinley
- Department of Microbiology and Cell Science, University of Florida, P.O. Box 110700, Gainesville, FL 32611-0700 USA
| | - Eric W. Triplett
- Department of Microbiology and Cell Science, University of Florida, P.O. Box 110700, Gainesville, FL 32611-0700 USA
| | - Steven J. Hughes
- Department of Surgery, University of Florida College of Medicine, P.O. Box 100286, Gainesville, FL 32610 USA
| | - Jose G. Trevino
- Division of Surgical Oncology, Virginia Commonwealth University, 1200 E Broad St, Richmond, VA 23298-0645 USA
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9
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Halimi A, Gabarrini G, Sobkowiak MJ, Ateeb Z, Davanian H, Gaiser RA, Arnelo U, Valente R, Wong AY, Moro CF, Del Chiaro M, Özenci V, Chen MS. Isolation of pancreatic microbiota from cystic precursors of pancreatic cancer with intracellular growth and DNA damaging properties. Gut Microbes 2022; 13:1983101. [PMID: 34816784 PMCID: PMC8632270 DOI: 10.1080/19490976.2021.1983101] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Emerging research suggests gut microbiome may play a role in pancreatic cancer initiation and progression, but cultivation of the cancer microbiome remains challenging. This pilot study aims to investigate the possibility to cultivate pancreatic microbiome from pancreatic cystic lesions associated with invasive cancer. Intra-operatively acquired pancreatic cyst fluid samples showed culture-positivity mainly in the intraductal papillary mucinous neoplasm (IPMN) group of lesions. MALDI-TOF MS profiling analysis shows Gammaproteobacteria and Bacilli dominate among individual bacteria isolates. Among cultivated bacteria, Gammaproteobacteria, particularly Klebsiella pneumoniae, but also Granulicatella adiacens and Enterococcus faecalis, demonstrate consistent pathogenic properties in pancreatic cell lines tested in ex vivo co-culture models. Pathogenic properties include intracellular survival capability, cell death induction, or causing DNA double-strand breaks in the surviving cells resembling genotoxic effects. This study provides new insights into the role of the pancreatic microbiota in the intriguing link between pancreatic cystic lesions and cancer.
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Affiliation(s)
- Asif Halimi
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Giorgio Gabarrini
- Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | | | - Zeeshan Ateeb
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Haleh Davanian
- Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | | | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Roberto Valente
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Alicia Y.W. Wong
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden,Department of Clinical Microbiology F 72, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Carlos Fernández Moro
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden,Department of Clinical Pathology/Cytology, Karolinska University Hospital, Huddinge, Sweden
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Volkan Özenci
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden,Department of Clinical Microbiology F 72, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Margaret Sällberg Chen
- Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden,CONTACT Margaret Sällberg Chen Department of Dental Medicine, Karolinska Institutet, Huddinge14141, Sweden
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Abstract
The incidence of pancreatic incidentalomas (PIs) detected in otherwise asymptomatic patients is growing with the increasing quality and use of advanced imaging techniques. PI can present as isolated main pancreatic duct dilation or as a solid or cystic lesion. Although historically thought to be relatively rare, PIs are rather common, particularly cystic lesions of the pancreas, which can be detected in up to 49% of the general population. With the poor prognosis of pancreatic cancer, PIs are an opportunity for prevention and early diagnosis, but when managed poorly, they can also lead to overtreatment and unnecessary morbidity. The management of PI should begin with a dedicated pancreas protocol computed tomography (CT) scan or magnetic resonance imaging (MRI) to accurately characterize duct size, lesion characteristics and establish an accurate baseline for subsequent follow up. Diagnosis and subsequent management depends on the extent of main duct dilation and solid versus cystic appearance. Solid lesions are highly concerning for malignancy. Cystic lesions can be further categorized as intraductal papillary mucinous neoplasms of the pancreas (IPMNs) or mucinous cystic neoplasms (MCNs), both of which harbour malignant potential, or as serous cystic neoplasms (SCNs) that are benign. In this paper, we summarize the major challenges related to PI and present pragmatic suggestions for management.
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Affiliation(s)
- Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Robert J Torphy
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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11
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Perales S, Torres C, Jimenez-Luna C, Prados J, Martinez-Galan J, Sanchez-Manas JM, Caba O. Liquid biopsy approach to pancreatic cancer. World J Gastrointest Oncol 2021; 13:1263-1287. [PMID: 34721766 PMCID: PMC8529923 DOI: 10.4251/wjgo.v13.i10.1263] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/18/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) continues to pose a major clinical challenge. There has been little improvement in patient survival over the past few decades, and it is projected to become the second leading cause of cancer mortality by 2030. The dismal 5-year survival rate of less than 10% after the diagnosis is attributable to the lack of early symptoms, the absence of specific biomarkers for an early diagnosis, and the inadequacy of available chemotherapies. Most patients are diagnosed when the disease has already metastasized and cannot be treated. Cancer interception is vital, actively intervening in the malignization process before the development of a full-blown advanced tumor. An early diagnosis of PC has a dramatic impact on the survival of patients, and improved techniques are urgently needed to detect and evaluate this disease at an early stage. It is difficult to obtain tissue biopsies from the pancreas due to its anatomical position; however, liquid biopsies are readily available and can provide useful information for the diagnosis, prognosis, stratification, and follow-up of patients with PC and for the design of individually tailored treatments. The aim of this review was to provide an update of the latest advances in knowledge on the application of carbohydrates, proteins, cell-free nucleic acids, circulating tumor cells, metabolome compounds, exosomes, and platelets in blood as potential biomarkers for PC, focusing on their clinical relevance and potential for improving patient outcomes.
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Affiliation(s)
- Sonia Perales
- Department of Biochemistry and Molecular Biology I, Faculty of Sciences, University of Granada, Granada 18071, Spain
| | - Carolina Torres
- Department of Biochemistry and Molecular Biology III and Immunology, Faculty of Sciences, University of Granada, Granada 18071, Spain
| | - Cristina Jimenez-Luna
- Institute of Biopathology and Regenerative Medicine (IBIMER), Center of Biomedical Research (CIBM), University of Granada, Granada 18100, Spain
| | - Jose Prados
- Institute of Biopathology and Regenerative Medicine (IBIMER), Center of Biomedical Research (CIBM), University of Granada, Granada 18100, Spain
| | - Joaquina Martinez-Galan
- Department of Medical Oncology, Hospital Universitario Virgen de las Nieves, Granada 18011, Spain
| | | | - Octavio Caba
- Institute of Biopathology and Regenerative Medicine (IBIMER), Center of Biomedical Research (CIBM), University of Granada, Granada 18100, Spain
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12
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Shi J, Yi Z, Jin L, Zhao L, Raskind A, Yeomans L, Nwosu ZC, Simeone DM, Lyssiotis CA, Stringer KA, Kwon RS. Cyst fluid metabolites distinguish malignant from benign pancreatic cysts. Neoplasia 2021; 23:1078-1088. [PMID: 34583246 PMCID: PMC8479274 DOI: 10.1016/j.neo.2021.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Current standard of care imaging, cytology, or cystic fluid analysis cannot reliably differentiate malignant from benign pancreatic cystic neoplasms. This study sought to determine if the metabolic profile of cystic fluid could distinguish benign and malignant lesions, as well as mucinous and non-mucinous lesions. Methods Metabolic profiling by untargeted mass spectrometry and quantitative nuclear magnetic resonance was performed in 24 pancreatic cyst fluid from surgically resected samples with pathological diagnoses and clinicopathological correlation. Results (Iso)-butyrylcarnitine distinguished malignant from benign pancreatic cysts, with a diagnostic accuracy of 89%. (Iso)-butyrylcarnitine was 28-fold more abundant in malignant cyst fluid compared with benign cyst fluid (P=.048). Furthermore, 5-oxoproline (P=.01) differentiated mucinous from non-mucinous cysts with a diagnostic accuracy of 90%, better than glucose (82% accuracy), a previously described metabolite that distinguishes mucinous from non-mucinous cysts. Combined analysis of glucose and 5-oxoproline did not improve the diagnostic accuracy. In comparison, standard of care cyst fluid carcinoembryonic antigen (CEA) and cytology had a diagnostic accuracy of 40% and 60% respectively for mucinous cysts. (Iso)-butyrylcarnitine and 5-oxoproline correlated with cyst fluid CEA levels (P<.0001 and P<.05 respectively). For diagnosing malignant pancreatic cysts, the diagnostic accuracies of cyst size > 3 cm, ≥ 1 high-risk features, cyst fluid CEA, and cytology are 38%, 75%, 80%, and 75%, respectively. Conclusions (Iso)-butyrylcarnitine has potential clinical application for accurately distinguishing malignant from benign pancreatic cysts, and 5-oxoproline for distinguishing mucinous from non-mucinous cysts.
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Affiliation(s)
- Jiaqi Shi
- Department of Pathology & Clinical Labs, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA.
| | - Zhujun Yi
- Department of Pathology & Clinical Labs, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lin Jin
- Department of Pathology & Clinical Labs, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lili Zhao
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | | | - Larisa Yeomans
- NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Zeribe C Nwosu
- Department of Molecular & Integrative Physiology, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Diane M Simeone
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Costas A Lyssiotis
- Department of Molecular & Integrative Physiology, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Kathleen A Stringer
- NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Richard S Kwon
- Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
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13
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Wu YA, Oba A, Beaty L, Colborn KL, Rodriguez Franco S, Harnke B, Meguid C, Negrini D, Valente R, Ahrendt S, Schulick RD, Del Chiaro M. Ductal Dilatation of ≥5 mm in Intraductal Papillary Mucinous Neoplasm Should Trigger the Consideration for Pancreatectomy: A Meta-Analysis and Systematic Review of Resected Cases. Cancers (Basel) 2021; 13:cancers13092031. [PMID: 33922344 PMCID: PMC8122854 DOI: 10.3390/cancers13092031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study evaluates the diagnostic value of main pancreatic duct (MPD) diameter for detecting IPMN malignancy, using a meta-analysis of published data. The result suggests that malignancy is highly prevalent in IPMN with ductal dilatation of >5 mm. Abstract Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study tests the diagnostic value of the main pancreatic duct (MPD) diameter for detecting IPMN malignancy using a meta-analysis of published data of resected IPMNs. Collected from a comprehensive literature search, the articles included in this analysis must report malignancy cases (high-grade dysplasia (HGD) and invasive carcinoma (IC)) and MPD diameter so that two MPD cut-offs could be created. The sensitivity, specificity, and odds ratios of the two cutoffs for predicting malignancy were calculated. A review of 1493 articles yielded 20 retrospective studies with 3982 resected cases. A cutoff of ≥5 mm is more sensitive than the ≥10 mm cutoff and has pooled sensitivity of 72.20% and 75.60% for classification of HGD and IC, respectively. Both MPD cutoffs of ≥5 mm and ≥10 mm were associated with malignancy (OR = 4.36 (95% CI: 2.82, 6.75) vs. OR = 3.18 (95% CI: 2.25, 4.49), respectively). The odds of HGD and IC for patients with MPD ≥5 mm were 5.66 (95% CI: 3.02, 10.62) and 7.40 (95% CI: 4.95, 11.06), respectively. OR of HGD and IC for MPD ≥10 mm cutoff were 4.36 (95% CI: 3.20, 5.93) and 4.75 (95% CI: 2.39, 9.45), respectively. IPMN with MPD of >5 mm could very likely be malignant. In selected IPMN patients, pancreatectomy should be considered when MPD is >5 mm.
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Affiliation(s)
- Y.H. Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan
| | - Laurel Beaty
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kathryn L. Colborn
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- The Heart Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Ben Harnke
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - Cheryl Meguid
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Daniel Negrini
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Anesthesiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Roberto Valente
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, 907 37 Umeå, Sweden
| | - Steven Ahrendt
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Richard D. Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
- Correspondence:
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14
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Keane MG, Afghani E. A Review of the Diagnosis and Management of Premalignant Pancreatic Cystic Lesions. J Clin Med 2021; 10:1284. [PMID: 33808853 PMCID: PMC8003622 DOI: 10.3390/jcm10061284] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic lesions are an increasingly common clinical finding. They represent a heterogeneous group of lesions that include two of the three known precursors of pancreatic cancer, intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN). Given that approximately 8% of pancreatic cancers arise from these lesions, careful surveillance and timely surgery offers an opportunity for early curative resection in a disease with a dismal prognosis. This review summarizes the current evidence and guidelines for the diagnosis and management of IPMN/MCN. Current pre-operative diagnostic tests in pancreatic cysts are imperfect and a proportion of patients continue to undergo unnecessary surgical resection annually. Balancing cancer prevention while preventing surgical overtreatment, continues to be challenging when managing pancreatic cysts. Cyst fluid molecular markers, such as KRAS, GNAS, VHL, PIK3CA, SMAD4 and TP53, as well as emerging endoscopic technologies such as needle-based confocal laser endomicroscopy and through the needle microbiopsy forceps demonstrate improved diagnostic accuracy. Differences in management and areas of uncertainty between the guidelines are also discussed, including indications for surgery, surveillance protocols and if and when surveillance can be discontinued.
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Affiliation(s)
| | - Elham Afghani
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
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15
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Morgell A, Reisz JA, Ateeb Z, Davanian H, Reinsbach SE, Halimi A, Gaiser R, Valente R, Arnelo U, Del Chiaro M, Chen MS, D'Alessandro A. Metabolic Characterization of Plasma and Cyst Fluid from Cystic Precursors to Pancreatic Cancer Patients Reveal Metabolic Signatures of Bacterial Infection. J Proteome Res 2021; 20:2725-2738. [PMID: 33720736 DOI: 10.1021/acs.jproteome.1c00018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is the seventh leading cause of cancer-related death worldwide, with a 5 year survival rate as low as 9%. One factor complicating the management of pancreatic cancer is the lack of reliable tools for early diagnosis. While up to 50% of the adult population has been shown to develop precancerous pancreatic cysts, limited and insufficient approaches are currently available to determine whether a cyst is going to progress into pancreatic cancer. Recently, we used metabolomics approaches to identify candidate markers of disease progression in patients diagnosed with intraductal papillary mucinous neoplasms (IPMNs) undergoing pancreatic resection. Here, we enrolled an independent cohort to verify the candidate markers from our previous study with orthogonal quantitative methods in plasma and cyst fluid from serous cystic neoplasm and IPMN (either low- or high-grade dysplasia or pancreatic ductal adenocarcinoma). We thus validated these markers with absolute quantitative methods through the auxilium of stable isotope-labeled internal standards in a new independent cohort. Finally, we identified novel markers of IPMN status and disease progression-including amino acids, carboxylic acids, conjugated bile acids, free and carnitine-conjugated fatty acids, purine oxidation products, and trimethylamine-oxide. We show that the levels of these metabolites of potential bacterial origin correlated with the degree of bacterial enrichment in the cyst, as determined by 16S RNA. Overall, our findings are interesting per se, owing to the validation of previous markers and identification of novel small molecule signatures of IPMN and disease progression. In addition, our findings further fuel the provoking debate as to whether bacterial infections may represent an etiological contributor to the development and severity of the disease in pancreatic cancer, in like fashion to other cancers (e.g., Helicobacter pylori and gastric cancer).
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Affiliation(s)
- Ann Morgell
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm 17177, Sweden
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora 80045, Colorado, United States
| | - Zeeshan Ateeb
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm 17177, Sweden
| | - Haleh Davanian
- Department of Dental Medicine, Karolinska Institutet, Stockholm 17177, Sweden
| | - Susanne E Reinsbach
- Department of Biology and Biological Engineering, National Bioinformatics Infrastructure Sweden, Science for Life Laboratory, Chalmers University of Technology, Gothenburg 40530 Sweden
| | - Asif Halimi
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm 17177, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå 90187 Sweden
| | - Rogier Gaiser
- Department of Dental Medicine, Karolinska Institutet, Stockholm 17177, Sweden
| | - Roberto Valente
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm 17177, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå 90187 Sweden
| | - Urban Arnelo
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm 17177, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå 90187 Sweden
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Denver - Anschutz Medical Campus, Aurora 80045, Colorado, United States
| | | | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora 80045, Colorado, United States
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16
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Morgell A, Reisz JA, Ateeb Z, Davanian H, Reinsbach SE, Halimi A, Gaiser R, Valente R, Arnelo U, Chiaro MD, Sällberg Chen M, D'Alessandro A. Metabolic characterization of plasma and cyst fluid from cystic precursors to pancreatic cancer patients reveal metabolic signatures of bacterial infection. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.11.03.20225524. [PMID: 33173899 PMCID: PMC7654893 DOI: 10.1101/2020.11.03.20225524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
UNLABELLED Pancreatic cancer is the seventh leading cause of cancer-related death worldwide, with a 5-year survival rate as low as 9%. One factor complicating the management of pancreatic cancer is the lack of reliable tools for early diagnosis. While up to 50% of the adult population has been shown to develop precancerous pancreatic cysts, limited and insufficient approaches are currently available to determine whether a cyst is going to progress into pancreatic cancer. Recently, we used metabolomics approaches to identify candidate markers of disease progression in patients diagnosed with intraductal papillary mucinous neoplasms (IPMNs) undergoing pancreatic resection. Here we enrolled an independent cohort to verify the candidate markers from our previous study with orthogonal quantitative methods in plasma and cyst fluid from serous cystic neoplasm and IPMN (either low- or high-grade dysplasia or pancreatic ductal adenocarcinoma). We thus validated these markers with absolute quantitative methods through the auxilium of stable isotope-labelled internal standards in a new independent cohort. Finally, we identified novel markers of IPMN status and disease progression - including amino acids, carboxylic acids, conjugated bile acids, free and carnitine-conjugated fatty acids, purine oxidation products and TMAO. We show that the levels of these metabolites of potential bacterial origin correlated with the degree of bacterial enrichment in the cyst, as determined by 16S RNA. Overall, our findings are interesting per se, owing to the validation of previous markers and identification of novel small molecule signatures of IPMN and disease progression. In addition, our findings further fuel the provoking debate as to whether bacterial infections may represent an etiological contributor to the development and severity of the disease in pancreatic cancer, in like fashion to other cancers (e.g., Helicobacter pylori and gastric cancer). KEY POINTS We identified and quantified novel markers of IPMN cyst status and pancreatic cancer disease progression - including amino acids, carboxylic acids, conjugated bile acids, free and carnitine-conjugated fatty acids, purine oxidation products and TMAO.We show that the levels of these metabolites of potential bacterial origin correlated with the degree of bacterial enrichment in the cyst, as determined by 16S RNA.
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17
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Zhao R, Xie Y, Yang B, Wang C, Huang Q, Han Y, Yang L, Yan S, Wang X, Fu C, Wu D, Wu X. Identification of metabolic biomarkers to predict treatment outcome and disease progression in multiple myeloma. Am J Cancer Res 2020; 10:3935-3946. [PMID: 33294278 PMCID: PMC7716146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/22/2020] [Indexed: 06/12/2023] Open
Abstract
The relationship between metabolites and multiple myeloma (MM) is becoming a research focus in the field. In this study, we performed metabolic profiling of multiple myeloma and identified potential metabolites associated with clinical characteristics, therapeutic efficacy, and prognosis of the disease. Fifty-five patients with newly-diagnosed multiple myeloma and thirty-seven healthy controls from August 2016 to October 2017 were randomly collected. The serum metabolic profiling was investigated by gas chromatography-mass spectrometry (GC-MS) technique and underwent statistical analysis. Twenty-seven metabolites were found to be significantly different between healthy controls and multiple myeloma patients. Eleven metabolites were significantly elevated, while sixteen metabolites were decreased in the multiple myeloma population. Metabolic changes were also observed in patients with renal impairment and bone destruction. Levels of urea were significantly decreased after treatment while levels of hypotaurine showed significant increase in the good-effect group (P<0.05), but not in the no-good-effect group (P>0.05). In multivariate statistical analyses, high cysteine and high hypotaurine are independent risk factors for poor treatment outcome. After adjustment for critical clinical characteristics, patients with high levels of glycolic acid and xylitol were found to be less likely to experience disease progression. Multiple myeloma demonstrates different metabolic characteristics compared with the healthy population. Among multiple myeloma patients, renal impairment and bone destruction showed additional metabolic characteristics. Cysteine and hypotaurine have value in predicting the treatment outcome, while glycolic acid and xylitol may be important prognostic factors for multiple myeloma.
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Affiliation(s)
- Ranran Zhao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Yiyu Xie
- Yale New Haven Health/Bridgeport HospitalBridgeport, USA
| | - Bingyu Yang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Chang Wang
- School of Radiation Medicine and Protection, Medical College of Soochow University, Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, Jiangsu Provincial Key Laboratory of Radiation Medicine and ProtectionSuzhou, China
| | - Qianlei Huang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Yue Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Lulu Yang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Shuang Yan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Xiaogang Wang
- Department of Mathematics and Statistics, York UniversityToronto, Canada
| | - Chengcheng Fu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
| | - Xiaojin Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow UniversitySuzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow UniversitySuzhou, China
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18
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Heikelä H, Ruohonen ST, Adam M, Viitanen R, Liljenbäck H, Eskola O, Gabriel M, Mairinoja L, Pessia A, Velagapudi V, Roivainen A, Zhang FP, Strauss L, Poutanen M. Hydroxysteroid (17β) dehydrogenase 12 is essential for metabolic homeostasis in adult mice. Am J Physiol Endocrinol Metab 2020; 319:E494-E508. [PMID: 32691632 DOI: 10.1152/ajpendo.00042.2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hydroxysteroid 17β dehydrogenase 12 (HSD17B12) is suggested to be involved in the elongation of very long chain fatty acids. Previously, we have shown a pivotal role for the enzyme during mouse development. In the present study we generated a conditional Hsd17b12 knockout (HSD17B12cKO) mouse model by breeding mice homozygous for a floxed Hsd17b12 allele with mice expressing the tamoxifen-inducible Cre recombinase at the ROSA26 locus. Gene inactivation was induced by administering tamoxifen to adult mice. The gene inactivation led to a 20% loss of body weight within 6 days, associated with drastic reduction in both white (83% males, 75% females) and brown (65% males, 60% females) fat, likely due to markedly reduced food and water intake. Furthermore, the knockout mice showed sickness behavior and signs of liver toxicity, specifically microvesicular hepatic steatosis and increased serum alanine aminotransferase (4.6-fold in males, 7.7-fold in females). The hepatic changes were more pronounced in females than males. Proinflammatory cytokines, such as interleukin-6 (IL-6), IL-17, and granulocyte colony-stimulating factor, were increased in the HSD17B12cKO mice indicating an inflammatory response. Serum lipidomics study showed an increase in the amount of dihydroceramides, despite the dramatic overall loss of lipids. In line with the proposed role for HSD17B12 in fatty acid elongation, we observed accumulation of ceramides, dihydroceramides, hexosylceramides, and lactosylceramides with shorter than 18-carbon fatty acid side chains in the serum. The results indicate that HSD17B12 is essential for proper lipid homeostasis and HSD17B12 deficiency rapidly results in fatal systemic inflammation and lipolysis in adult mice.
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Affiliation(s)
- Hanna Heikelä
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Suvi T Ruohonen
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Marion Adam
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Heidi Liljenbäck
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
- Turku PET Centre, University of Turku, Turku, Finland
| | - Olli Eskola
- Turku PET Centre, University of Turku, Turku, Finland
| | - Michael Gabriel
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Laura Mairinoja
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Alberto Pessia
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Vidya Velagapudi
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Anne Roivainen
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
- Turku PET Centre, University of Turku, Turku, Finland
- Turku PET Centre, Turku University Hospital, Turku, Finland
| | - Fu-Ping Zhang
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Leena Strauss
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Matti Poutanen
- Turku Center for Disease Modeling, Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Internal Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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19
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Berberine Suppressed Tumor Growth through Regulating Fatty Acid Metabolism and Triggering Cell Apoptosis via Targeting FABPs. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:6195050. [PMID: 32328135 PMCID: PMC7168748 DOI: 10.1155/2020/6195050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
Aim To further investigate the mechanism behind the antitumor properties of berberine regarding lipid metabolism. Methods Cell viability, proliferation, and apoptosis assays were performed to determine the antigrowth effects of berberine in vitro. Ectopic xenograft models in Balb/c nude mice were established to determine the antitumor effects of berberine in vivo. Results Berberine inhibited cell viability and proliferation of MGC803 human gastric cancer cell lines in a time- and dose-dependent manner. Berberine induced apoptosis of MGC803 and increased the apoptotic rate with higher doses. Berberine induced the accumulation of fatty acid of MGC803 and suppressed the protein expression of FABPs and PPARα. The FABP inhibitor BMS309403 recapitulated the effects of berberine on MGC803 cells. In the xenograft model, berberine significantly decreased the tumor volume and tumor weight and induced apoptosis in tumor tissues. Berberine significantly elevated the fatty acid content and inhibited the expression of FABPs and PPARα in the MGC803 xenograft models. Conclusion Berberine exerted anticancer effects on human gastric cancer both in vitro and in vivo by inducing apoptosis, which was due to the reduced protein expression of FABPs and the accumulation of fatty acid.
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Unsihuay D, Qiu J, Swaroop S, Nagornov KO, Kozhinov AN, Tsybin YO, Kuang S, Laskin J. Imaging of Triglycerides in Tissues Using Nanospray Desorption Electrospray Ionization (Nano-DESI) Mass Spectrometry. INTERNATIONAL JOURNAL OF MASS SPECTROMETRY 2020; 448:116269. [PMID: 32863736 PMCID: PMC7453423 DOI: 10.1016/j.ijms.2019.116269] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Nonpolar triglycerides (TGs) are rarely detected in mass spectrometry imaging (MSI) experiments unless they are abundant in the sample. Herein, we use nanospray desorption electrospray ionization (nano-DESI) to explore the role of the solvent composition and ionic dopants on the detection of TGs in a murine gastrocnemius muscle tissue used as a model system. We evaluated three solvent mixtures for their ability to extract nonpolar TG species: MeOH:H2O 9:1 (v/v), MeOH:DCM 6:4 (v/v) and MeOH:AcN:tol 5:3.5:1.5 (v/v/v). We observe that TGs are mainly detected as [M+K]+ adducts and their extraction efficiency is improved using less polar solvents: MeOH:DCM and MeOH:AcN:tol. We also explore whether the ionization efficiency of TGs may be improved by doping the MeOH:AcN:tol solvent with ammonium formate (AF) and other ionic additives. However, the formation of [M+NH4]+ adducts of TGs is less efficient than the formation of [M+K]+ adducts in the range of AF concentrations from 0.1 to 10 mM. Chemical derivatization using 100 μM of Girard T reagent predominately generates reaction products of phosphatidylcholine rather than TG species. Moreover, the presence of the Girard T reagent suppresses ion signals of all the species in the spectrum including TGs. Nano-DESI MSI experiments performed using MeOH:AcN:tol solvent enable imaging of TGs without any detectable adverse effect on signals of other lipids and metabolites. Specifically, 10 out of 14 TG species were detected exclusively using MeOH:AcN:tol and the sensitivity towards other TGs was improved by at least an order of magnitude. Although polyunsaturated TGs may be detected using both solvents, saturated and monounsaturated TGs are only detected using MeOH:AcN:tol. Our results provide a direct path for the improved detection of TGs in tissue imaging experiments using liquid-based ambient ionization techniques.
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Affiliation(s)
- Daisy Unsihuay
- Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
| | - Jiamin Qiu
- Department of Animal Sciences, Purdue University, West Lafayette, IN 47907, USA
| | - Sneha Swaroop
- Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
| | | | | | - Yury O. Tsybin
- Spectroswiss, EPFL Innovation Park, 1015 Lausanne, Switzerland
| | - Shihuan Kuang
- Department of Animal Sciences, Purdue University, West Lafayette, IN 47907, USA
| | - Julia Laskin
- Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
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21
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Carmicheal J, Patel A, Dalal V, Atri P, Dhaliwal AS, Wittel UA, Malafa MP, Talmon G, Swanson BJ, Singh S, Jain M, Kaur S, Batra SK. Elevating pancreatic cystic lesion stratification: Current and future pancreatic cancer biomarker(s). Biochim Biophys Acta Rev Cancer 2019; 1873:188318. [PMID: 31676330 DOI: 10.1016/j.bbcan.2019.188318] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an incredibly deadly disease with a 5-year survival rate of 9%. The presence of pancreatic cystic lesions (PCLs) confers an increased likelihood of future pancreatic cancer in patients placing them in a high-risk category. Discerning concurrent malignancy and risk of future PCL progression to cancer must be carefully and accurately determined to improve survival outcomes and avoid unnecessary morbidity of pancreatic resection. Unfortunately, current image-based guidelines are inadequate to distinguish benign from malignant lesions. There continues to be a need for accurate molecular and imaging biomarker(s) capable of identifying malignant PCLs and predicting the malignant potential of PCLs to enable risk stratification and effective intervention management. This review provides an update on the current status of biomarkers from pancreatic cystic fluid, pancreatic juice, and seromic molecular analyses and discusses the potential of radiomics for differentiating PCLs harboring cancer from those that do not.
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Affiliation(s)
- Joseph Carmicheal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Asish Patel
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vipin Dalal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Pranita Atri
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amaninder S Dhaliwal
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Mokenge P Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geoffrey Talmon
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Benjamin J Swanson
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shailender Singh
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maneesh Jain
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sukhwinder Kaur
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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