PACT-UK (PAncreatic Cancer reporting Template-UK): a cross-specialty multi-institutional consensus panel development of a standardised radiological reporting proforma for pancreatic cancer

Objective

Appropriate staging of pancreatic cancer is essential to ensure patients are offered all treatment options. This multispecialty national collaborative consensus project aimed to develop a succinct radiological reporting template, using the concept of structured reporting, to allow a more standardised means of reporting pancreatic cancer and ultimately optimise both patient care and research protocol design.

Methods and analysis

In stage one, a core group of stakeholders (oncologists, radiologists and surgeons) identified the current landscape of radiological reporting, including a blinded radiological validation study and a national survey of consultant HPB surgeons. Stage two used consensus panel development methodology to generate a provisional template draft. Stage three involved trialling the template across all UK HPB units, with feedback assisting the development of a final version of the template.

Results

Stage one results identified a core dataset to develop a provisional template. Every UK Hepatopancreatobiliary (HPB) unit trialled this in clinical practice, leading to further refinements via consensus meetings. Ideal factors regarding tumour staging, extent of vascular involvement and response to systemic anticancer therapy were identified. This resulted in the generation of the PACT-UK (PAncreatic Cancer reporting Template-UK) template that is presented within the manuscript, as well as a user guide.

Conclusion

This project has successfully produced the first consensus-driven radiological reporting template for pancreatic cancer, with the aim of its use becoming standard practice in the UK, while upcoming workshops facilitated by Royal College of Radiologists/British Society of Gastrointestinal and Abdominal Radiology will establish buy-in from radiologists at all HPB units. Plans for the use of PACT-UK within national audit and clinical trials are underway.

Neoadjuvant versus Adjuvant Chemotherapy for Resectable Pancreatic Adenocarcinoma: A National Cancer Database Analysis

There is controversy regarding the role of neoadjuvant versus adjuvant chemotherapy for pancreatic cancer (PAC). Neoadjuvant therapy has been touted as a method to improve survival in PAC patients. This study's objective is to investigate predictors and potential benefits of neoadjuvant therapy in resectable PAC patients. The National Cancer Data Base was used to retrospectively analyze stage I and II surgically resected PAC patients receiving adjuvant or neoadjuvant therapy from 2004 to 2012. A total of 12,983 patients were identified. A significant increase in the rate of neoadjuvant therapy was observed over time with 5 per cent receiving neoadjuvant therapy in 2004 versus 17 per cent in 2012 (P < 0.0001). Multivariate analysis showed that patients were more likely to receive neoadjuvant therapy if they were treated at an academic facility. Private insurance was associated with higher odds of neoadjuvant chemotherapy (P < 0.0001). Pathological outcomes were improved in neoadjuvant patients compared with adjuvant patients on multivariate analysis with neoadjuvant patients having higher rates of negative surgical margins (OR: 1.273, 95% Confidence interval: 1.099–1.474) and negative lymph nodes (OR: 2.852, 95% Confidence interval: 2.547–3.194). Pathological outcomes are improved after neoadjuvant therapy compared with adjuvant therapy, with more patients achieving negative margins and negative lymph nodes. Prospective studies are needed to compare these two treatment modalities in a head to head comparison.

Gemcitabine-based chemoradiotherapy followed by surgery for borderline resectable and locally unresectable pancreatic ductal adenocarcinoma: significance of the CA19-9 reduction rate and intratumoral human equilibrative nucleoside transporter 1 expression

OBJECTIVES

This study aimed to evaluate the efficacy of gemcitabine-based chemoradiotherapy followed by surgery (gem-CRTS) for pancreatic ductal adenocarcinoma (PDAC) for borderline resectable (BR) and locally unresectable (UR) tumors.

METHODS

One hundred patients with PDAC who underwent the gem-CRTS protocol were classified into 3 groups, namely, resectable (R; 14), BR (44), and UR (42). After chemoradiotherapy, the patients were reassessed for curative-intent resection.

RESULTS

At reassessment, distant metastases became apparent in 27% of R patients, in 12% of BR patients, and in 18% of UR patients. The multivariate analysis of preoperative factors indicated that the CA19-9 reduction rate was an independent prognostic factor in the BR group. Among reassessed patients, the resection rate was 63.6% in R, 83.7% in BR, and 50.0% in UR patients. In 63 patients that underwent curative-intent resection, the 3-year survival rate was 83.3% in R, 33.0% in BR, and 7.8% in UR patients. Using multivariate analysis, the independent prognostic factor was found to be the surgical margin in BR patients and human equilibrative nucleoside transporter 1 expression in UR patients.

CONCLUSIONS

We consider that our gem-CRTS protocol, even for locally UR PDAC, allows for the identification of candidates for aggressive resection at the time of reassessment and improved prognosis in the patients with positive human equilibrative nucleoside transporter 1 expression.

Pancreatic cancer in HIV-positive patients: a clinical case-control study

OBJECTIVES

Pancreatic cancer (PC) is the fourth and fifth most common cause of cancer-related death among men in United States and in Europe, respectively. No data are available for HIV-positive patients. The aim of this study was to investigate and to compare clinical presentation and outcome between HIV-positive and HIV-negative PC patients.

METHODS

From April 1988 to June 2010, the Italian Cooperative Group on AIDS and Tumors identified 16 cases of HIV-positive PC patients. Each HIV-positive patient from our institution was randomly matched (ratio 1:2) with HIV-negative patients (32 controls) based on sex and year of PC diagnosis. Differences in clinical presentation, treatment, and overall survival were assessed.

RESULTS

At multivariate analysis, HIV-positive patients compared with HIV-negative patients had a higher risk of an unfavorable performance status (PS ≥ 2) and a younger age (<50 years) at cancer diagnosis. At multivariate analysis, HIV-positive status and PS of 2 or greater were the only 2 features that significantly reduced PC patients' survival.

CONCLUSIONS

Our data show, for the first time, that HIV-positive PC patients, compared with HIV-negative patients, are younger at cancer diagnosis. Furthermore, they share a more unfavorable PS and a shorter survival.

Adjuvant chemotherapy, with or without postoperative radiotherapy, for resectable advanced pancreatic adenocarcinoma: continue or stop?

AIMS

The aim of the article is to perform a focused review of adjuvant chemotherapy with or without radiotherapy for the treatment of resectable pancreatic adenocarcinoma (PAC).

METHODS

We performed a Medline database search from 1965 to 2010 using the terms "adjuvant," "trial" and "pancreatic cancer".

RESULTS

Adding adjuvant chemotherapy to patients with resectable PAC was associated with significantly increased median overall survival (OS) (odds ratio[OR]: 1.98, p < 0.001), disease-free survival (DFS) (OR: 2.12, p < 0.001), two-year survival (OR: 1.38, p = 0.04) and five-year survival (OR: 2.16, p = 0.007) compared to surgery alone. There was no statistically significant difference observed with regard to OS (OR:0.99, p = 0.93), DFS (OR:0.99, p = 0.95), and two-year survival (OR: 0.90, p = 0.57) between adjuvant chemoradiotherapy and surgery alone. The further analysis showed that single agent gemcitabine was as active as combined chemotherapy or chemoradiation, which was reflected by an OR of 1.13 (p = 0.26) for OS and1.08 (p = 0.47) for DFS.

CONCLUSIONS

A significant benefit with regard to DFS and median OS for adjuvant chemotherapy after PAC resection was demonstrated by this analysis. These results do not support the use of adjuvant radiotherapy for PAC.

Resection of Portovenous Structures to Obtain Microscopically Negative Margins during Pancreaticoduodenectomy for Pancreatic Adenocarcinoma is Worthwhile

Locally advanced pancreatic adenocarcinoma may require resections of the portal vein and/or its major tributaries to achieve tumor extirpation, albeit with the potential for increased morbidity and mortality. However, major venous resections can impart complete tumor extirpation and thereby a survival advantage compared with resections with residual microscopic disease. This study was undertaken to determine if resection of the portal vein and/or its splenic or superior mesenteric venous (SMV) tributaries is a worthwhile endeavor. Since 1995, patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma have been prospectively followed. The impact of portovenous resections (portal vein, SMV, and/or splenic vein) on survival was evaluated using survival curve analysis (Mantel-Cox test). Margins were codified as R0 or R1 and data are presented as median, mean ± SD where appropriate. For 220 patients undergoing PD for pancreatic adenocarcinoma, survival was 17 months. Patients undergoing RO resections had improved survival relative to patients undergoing R1 resections (20 vs 13 months, P < 0.03). Concomitant portovenous resections were undertaken in 48 patients. There was no difference in survival after PD without portovenous resection (17 months) versus PD with portovenous resection (18 months). Resections with complete tumor extirpation (i.e., RO resections) provide superior long-term survival; all efforts to obtain RO resections should be undertaken. Portovenous resections during pancreaticoduodenectomy can be undertaken safely and are worthwhile when complete tumor extirpation is attainable.

Gamma-aminobutyric acid (GABA) stimulates pancreatic cancer growth through overexpressing GABAA receptor pi subunit

Gamma-aminobutyric acid (GABA) functions primarily as an inhibitory neurotransmitter in the mature central nervous system, and GABA/GABA receptors are also present in nonneural tissues, including cancer, but their precise function in nonneuronal or cancerous cells has thus far been poorly defined. Through the genome-wide cDNA microarray analysis of pancreatic ductal adenocarcinoma (PDAC) cells as well as subsequent reverse transcription-PCR and Northern blot analyses, we identified the overexpression of GABA receptor pi subunit (GABRP) in PDAC cells. We also found the expression of this peripheral type GABAA receptor subunit in few adult human organs. Knockdown of endogenous GABRP expression in PDAC cells by small interfering RNA attenuated PDAC cell growth, suggesting its essential role in PDAC cell viability. Notably, the addition of GABA into the cell culture medium promoted the proliferation of GABRP-expressing PDAC cells, but not GABRP-negative cells, and GABAA receptor antagonists inhibited this growth-promoting effect by GABA. The HEK293 cells constitutively expressing exogenous GABRP revealed the growth-promoting effect of GABA treatment. Furthermore, GABA treatment in GABRP-positive cells increased intracellular Ca2+ levels and activated the mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/Erk) cascade. Clinical PDAC tissues contained a higher level of GABA than normal pancreas tissues due to the up-regulation of glutamate decarboxylase 1 expression, suggesting their autocrine/paracrine growth-promoting effect in PDACs. These findings imply that GABA and GABRP could play important roles in PDAC development and progression, and that this pathway can be a promising molecular target for the development of new therapeutic strategies for PDAC.

Overexpressed P-cadherin/CDH3 promotes motility of pancreatic cancer cells by interacting with p120ctn and activating rho-family GTPases

P-Cadherin/CDH3 belongs to the family of classic cadherins that are engaged in various cellular activities including motility, invasion, and signaling of tumor cells, in addition to cell adhesion. However, the biological roles of P-cadherin itself are not fully characterized. Based on information derived from a previous genome-wide cDNA microarray analysis of microdissected pancreatic ductal adenocarcinoma (PDAC), we focused on P-cadherin as one of the genes most strongly overexpressed in the great majority of PDACs. To investigate the consequences of overexpression of P-cadherin in terms of pancreatic carcinogenesis and tumor progression, we used a P-cadherin-deficient PDAC cell line, Panc-1, to construct a cell line (Panc1-CDH3) that stably overexpressed P-cadherin. Induction of P-cadherin in Panc1-CDH3 increased the motility of the cancer cells, but a blocking antibody against P-cadherin suppressed the motility in vitro. Overexpression of P-cadherin was strongly associated with cytoplasmic accumulation of one of the catenins, p120ctn, and cadherin switching in PDAC cells. Moreover, P-cadherin-dependent activation of cell motility was associated with activation of Rho GTPases, Rac1 and Cdc42, through accumulation of p120ctn in cytoplasm and cadherin switching. These findings suggest that overexpression of P-cadherin is likely to be related to the biological aggressiveness of PDACs; blocking of P-cadherin activity or its associated signaling could be a novel therapeutic approach for treatment of aggressive pancreatic cancers.

CEACAM6 is a novel biomarker in pancreatic adenocarcinoma and PanIN lesions

OBJECTIVE

The purpose of this study was to test the hypothesis that CEACAM6 expression is an indicator of adverse pathologic features and clinical outcome in pancreatic adenocarcinoma.

SUMMARY BACKGROUND DATA

Previously, we have demonstrated carcinoembryonic antigen-related cell adhesion molecule 6 (CEACAM6) to be an oncoprotein that plays an important role in the biology of pancreatic adenocarcinoma. Suppression of CEACAM6 expression reduces tumorigenesis and metastasis in vivo.

METHODS

A tissue microarray was constructed using tumor specimens obtained from 89 consecutive patients who had undergone pancreatic resection for pancreatic adenocarcinoma with curative intent. A second microarray containing 54 pancreatic intraepithelial neoplasia (PanIN) lesions was constructed using tissues from a separate cohort of 44 patients. Both arrays were immunostained using a specific anti-CEACAM6 monoclonal antibody. Tumoral CEACAM6 expression was dichotomized into negative and positive immunoreactivity groups. The log-rank test was used to evaluate univariate associations of CEACAM6 expression with prognosis. Survival curves were derived using the Kaplan-Meier method.

RESULTS

Tumoral CEACAM6 expression was detected in 82 (92%) pancreatic adenocarcinoma specimens. CEACAM6 expression was more prevalent in high-grade than in low-grade PanIN lesions (P = 0.0002). Negative tumoral CEACAM6 expression was associated with absence of lymph node metastases (P = 0.012), lower disease stage (P = 0.008), and longer postoperative survival (P = 0.047).

CONCLUSIONS

CEACAM6 is a novel biomarker for pancreatic adenocarcinoma. CEACAM6 warrants further evaluation as both a prognostic factor and a therapeutic target in pancreatic cancer.

Down-regulation of RAB6KIFL/KIF20A, a Kinesin Involved with Membrane Trafficking of Discs Large Homologue 5, Can Attenuate Growth of Pancreatic Cancer Cell

To identify novel molecular targets for treatment of pancreatic ductal adenocarcinoma (PDAC), we generated precise gene expression profiles of PDACs on a genome-wide cDNA microarray after populations of tumor cells were purified by laser microdissection. Through functional analysis of genes that were transactivated in PDACs, we identified RAB6KIFL as a candidate for development of drugs to treat PDACs at the molecular level. Knockdown of endogenous RAB6KIFL expression in PDAC cell lines by small interfering RNA drastically attenuated growth of those cells, suggesting an essential role for the gene product in maintaining viability of PDAC cells. RAB6KIFL belongs to the kinesin superfamily of motor proteins, which have critical functions in trafficking of molecules and organelles. Proteomics analyses using a polyclonal anti-RAB6KIFL antibody identified one of the cargoes transported by RAB6KIFL as discs, large homologue 5 (DLG5), a scaffolding protein that may link the vinexin-β-catenin complex at sites of cell-cell contact. Like RAB6KIFL, DLG5 was overexpressed in PDACs, and knockdown of endogenous DLG5 by small interfering RNA significantly suppressed the growth of PDAC cells as well. Decreased levels of endogenous RAB6KIFL in PDAC cells altered the subcellular localization of DLG5 from cytoplasmic membranes to cytoplasm. Our results imply that collaboration of RAB6KIFL and DLG5 is likely to be involved in pancreatic carcinogenesis. These molecules should be promising targets for development of new therapeutic strategies for PDACs.