Clinical Applications of Classical and Novel Biological Markers of Pancreatic Cancer

Distinguishing exocrine pancreas disease-associated diabetes from type 2 diabetes based on anthropometric and metabolic parameters

BACKGROUND

Adult-onset diabetes is most often considered to be type 2 diabetes. However, other types of diabetes can develop in adults, including exocrine pancreas disease-associated diabetes, also called type 3c diabetes. Differential diagnosis between these types of diabetes still remains a diagnostic challenge.

AIM

To define anthropometric and laboratory markers that will allow for early diagnosis of pancreatic disease-associated diabetes.

METHODS

The study group included 44 patients with pancreatogenic diabetes (26 with pancreatic cancer and 18 with chronic pancreatitis), while the control group consisted of 35 patients with type 2 diabetes. We analyzed several parameters, including sex, age, body mass index (BMI), fasting plasma glucose, fasting C-peptide and insulin with homeostasis model assessment of insulin resistance (HOMA-IR) index calculation, adrenomedullin, adiponectin and creatinine levels with epidermal growth factor receptor (eGFR) calculation. We also developed an equation, termed type 3c diabetes index, which utilized BMI, fasting insulin and adrenomedullin levels, and eGFR to better identify patients with type 3c diabetes.

RESULTS

Compared to patients with type 2 diabetes, patients with pancreatogenic diabetes had significantly lower BMI (25.11 ± 4.87 kg/m2 vs 30.83 ± 5.21 kg/m2), fasting C-peptide (0.81 ± 0.42 nmol/L vs 1.71 ± 0.80 nmol/L), insulin (76.81 ± 63.34 pmol/L vs 233.19 ± 164.51 pmol/L) and HOMA-IR index, despite similar fasting plasma glucose levels. Patients with pancreatogenic diabetes also had lower adrenomedullin levels (0.41 ± 0.25 ng/mL vs 0.63 ± 0.38 ng/mL) but higher adiponectin levels (13.08 ± 7.20 μg/mL vs 8.28 ± 4.01 μg/mL) and eGFR levels (100.53 ± 21.60 mL/min/1.73 m2 vs 85.14 ± 19.24 mL/min/1.73 m2). Finally, patients with pancreatogenic diabetes had significantly lower Type 3c diabetes index values.

CONCLUSION

Patients with pancreatogenic diabetes differ from patients with type 2 diabetes in anthropometric and laboratory parameters. The type 3c diabetes index had the highest discriminating value, above any single parameter.

Informatics strategies for early detection and risk mitigation in pancreatic cancer patients

This review provides a comprehensive overview of the current landscape in pancreatic cancer (PC) screening, diagnosis, and early detection. This emphasizes the need for targeted screening in high-risk groups, particularly those with familial predispositions and genetic mutations, such as BRCA1, BRCA2, and PALB2. This review highlights the sporadic nature of most PC cases and significant risk factors, including smoking, alcohol consumption, obesity, and diabetes. Advanced imaging techniques, such as Endoscopic Ultrasound (EUS) and Contrast-Enhanced Harmonic Imaging (CEH-EUS), have been discussed for their superior sensitivity in early detection. This review also explores the potential of novel biomarkers, including those found in body fluids, such as serum, plasma, urine, and bile, as well as the emerging role of liquid biopsy technologies in analyzing circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), and exosomes. AI-driven approaches, such as those employed in Project Felix and CancerSEEK, have been highlighted for their potential to enhance early detection through deep learning and biomarker discovery. This review underscores the importance of universal genetic testing and the integration of AI with traditional diagnostic methods to improve outcomes in high-risk individuals. Additionally, this review points to future directions in PC diagnostics, including next-generation imaging, molecular biomarkers, and personalized medicine, aiming to overcome current diagnostic challenges and improve survival rates. Ultimately, the review advocates the adoption of informatics and AI-driven strategies to enhance early detection, reduce morbidity, and save lives in the fight against pancreatic cancer.

Elevated tissue expression of RANKL and RANK is associated with poorer survival rates in pancreatic cancer patients

Pancreatic cancer is a highly lethal malignancy with a growing incidence reported worldwide. Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer, which is often diagnosed at advanced stages, making its prognosis and medical management difficult. The identification of histopathological biomarkers has allowed a more precise stratification of pancreatic cancer patients, providing additional information about their prognosis and offering possible therapeutic targets to be explored. The prognostic value of the receptor activator of nuclear factor-kappa B (RANK) and its ligand (RANKL) has been evaluated in breast and prostate tumors, however, their usefulness has not been assessed in pancreatic cancer. In the present work, we analyzed the relationship between the protein expression of RANK and RANKL with the survival of 41 patients with pancreatic cancer followed for 60 months, by performing immunohistochemistry and Kaplan-Meier curves. Our results demonstrate a direct association of high expression levels of RANK and RANKL with poorer survival of pancreatic cancer patients in comparison to those with low/medium and null expression levels of both markers. Further studies should be conducted to explore the carcinogenic role of both components in this type of tumor, as well as additional promising translational uses.

Abnormal Histopathological Expression of Klotho, Ferroptosis, and Circadian Clock Regulators in Pancreatic Ductal Adenocarcinoma: Prognostic Implications and Correlation Analyses

Pancreatic ductal adenocarcinoma (PDAC) is an extremely lethal tumor with increasing incidence, presenting numerous clinical challenges. The histopathological examination of novel, unexplored biomarkers offers a promising avenue for research, with significant translational potential for improving patient outcomes. In this study, we evaluated the prognostic significance of ferroptosis markers (TFRC, ALOX-5, ACSL-4, and GPX-4), circadian clock regulators (CLOCK, BMAL1, PER1, PER2), and KLOTHO in a retrospective cohort of 41 patients deceased by PDAC. Immunohistochemical techniques (IHC) and multiple statistical analyses (Kaplan-Meier curves, correlograms, and multinomial linear regression models) were performed. Our findings reveal that ferroptosis markers are directly associated with PDAC mortality, while circadian regulators and KLOTHO are inversely associated. Notably, TFRC emerged as the strongest risk marker associated with mortality (HR = 35.905), whereas CLOCK was identified as the most significant protective marker (HR = 0.01832). Correlation analyses indicate that ferroptosis markers are positively correlated with each other, as are circadian regulators, which also positively correlate with KLOTHO expression. In contrast, KLOTHO and circadian regulators exhibit inverse correlations with ferroptosis markers. Among the clinical variables examined, only the presence of chronic pathologies showed an association with the expression patterns of several proteins studied. These findings underscore the complexity of PDAC pathogenesis and highlight the need for further research into the specific molecular mechanisms driving disease progression.

Prognostic Value of Histone Acetyl Transferase 1 (HAT-1) and Inflammatory Signatures in Pancreatic Cancer

Pancreatic cancer is a type of gastrointestinal tumor with a growing incidence and mortality worldwide. Pancreatic ductal adenocarcinoma (PDAC) constitutes 90% of cases, and late-stage diagnosis is common, leading to a 5-year survival rate of less than 10% in high-income countries. The use of biomarkers has different proven translational applications, facilitating early diagnosis, accurate prognosis and identification of potential therapeutic targets. Several studies have shown a correlation between the tissue expression levels of various molecules, measured through immunohistochemistry (IHC), and survival rates in PDAC. Following the hallmarks of cancer, epigenetic and metabolic reprogramming, together with immune evasion and tumor-promoted inflammation, plays a critical role in cancer initiation and development. In this study, we aim to explore via IHC and Kaplan-Meier analyses the prognostic value of various epigenetic-related markers (histones 3 and 4 (H3/H4), histone acetyl transferase 1 (HAT-1), Anti-Silencing Function 1 protein (ASF1), Nuclear Autoantigenic Sperm Protein (NASP), Retinol Binding Protein 7 (RBBP7), importin 4 (IPO4) and IPO5), metabolic regulators (Phosphoglycerate mutase (PGAM)) and inflammatory mediators (allograft inflammatory factor 1 (AIF-1), interleukin 10 (IL-10), IL-12A and IL-18) in patients with PDAC. Also, through a correlation analysis, we have explored the possible interconnections in the expression levels of these molecules. Our results show that higher expression levels of these molecules are directly associated with poorer survival rates in PDAC patients, except in the case of IL-10, which shows an inverse association with mortality. HAT1 was the molecule more clearly associated with mortality, with a hazard risk of 21.74. The correlogram demonstrates an important correlation between almost all molecules studied (except in the case of IL-18), highlighting potential interactions between these molecules. Overall, our study demonstrates the relevance of including different markers from IHC techniques in order to identify unexplored molecules to develop more accurate prognosis methods and possible targeted therapies. Additionally, our correlation analysis reveals potential interactions among these markers, offering insights into PDAC's pathogenesis and paving the way for targeted therapies tailored to individual patient profiles. Future studies should be conducted to confirm the prognostic value of these components in PDAC in a broader sample size, as well as to evaluate the possible biological networks connecting them.

Pancreatic cancer progression and mortality predicted by depression and anxiety: a systematic review and meta-analysis protocol

Although the relationship between psychological factors and pancreatic cancer outcomes has been widely discussed, controversy remains. We will for the first time systematically summarize the literature to explore the correlation of anxiety and depression to the prognosis of patients with pancreatic cancer. The findings will fill existing research gaps, informing healthcare providers about better psychological care and medical treatment. The following databases will be retrieved from their inception to July 2023: Cochrane Library, MEDLINE (PubMed), Web of Science, EMBASE, and four Chinese databases (Chinese National Knowledge Infrastructure, Wanfang Database, Chinese Biomedical Literature Database, and Chongqing VIP Chinese Science and Technology Periodical Database). The World Health Organization Clinical Trials Registry, Chinese Clinical Registry, and ClinicalTrials.gov will be searched to identify other related studies. A manual search will be performed to identify missing eligible studies based on the reference list of selected articles. The search will focus on studies published in Chinese or English. To assess the risk of bias in the selected articles, Newcastle-Ottawa Quality Assessment Scale (NOS) will be used for the cohort study. Funnel plots and Egger's test will be used to assess whether publication bias exists. Moreover, the Grading of Recommendations Assessment Development and Evaluation (GRADE) will be utilized to analyze the credibility of the results from selected articles. Two independent evaluators will implement the study selection and data extraction, as well as evaluate the risk of bias and evidence quality. Data will be analyzed using Stata 16.0. Trial registration: PROSPERO registration number is CRD42022366232.

Identification of immunogenic cell death‑related prognostic signatures in pancreatic cancer

Targeting immunogenic cell death (ICD) may enable the response of pancreatic cancer to immune checkpoint inhibitors (ICIs). The aim of the present study was to elucidate the role of ICD-related genes in pancreatic cancer. Utilizing the k-means method, consensus clustering was employed to effectively group patients with pancreatic cancer. Subsequently, a set of differentially expressed genes was identified between the two subtypes related to ICD, facilitating the execution of a comprehensive enrichment analysis. Furthermore, the construction of an ICD-related prognostic signature (IRPS) was accomplished through LASSO Cox regression, thereby enabling the assessment of responses to both chemotherapy and immunotherapy. In addition, the biological functionality of 5'-nucleotidase ecto (NT5E) was elucidated through experimental investigations. Patients characterized as the ICD high subtype experienced a comparatively shorter overall survival. This subtype exhibited a noteworthy correlation with HLA families and immune checkpoint molecules, underscoring its immunological significance. Subsequently, patients with elevated IRPS risk scores displayed resistance towards immunotherapy interventions. Of note, synergistic downregulation of NT5E in combination with Gemcitabine was observed to significantly induce tumor cell apoptosis, emphasizing its potential therapeutic value. Leveraging ICD-related genes, a novel classification system was meticulously devised to comprehensively evaluate both the clinical outcomes and therapeutic responses of patients diagnosed with pancreatic cancer.

Is Insulin Receptor Substrate4 (IRS4) a Platform Involved in the Activation of Several Oncogenes?

The IRS (insulin receptor substrate) family of scaffold proteins includes insulin receptor substrate-4 (IRS4), which is expressed only in a few cell lines, including human kidney, brain, liver, and thymus and some cell lines. Its N-terminus carries a phosphotyrosine-binding (PTB) domain and a pleckstrin homology domain (PH), which distinguishes it as a member of this family. In this paper, we collected data about the molecular mechanisms that explain the relevance of IRS4 in the development of cancer and identify IRS4 differences that distinguish it from IRS1 and IRS2. Search engines and different databases, such as PubMed, UniProt, ENSEMBL and SCANSITE 4.0, were used. We used the name of the protein that it encodes "(IRS-4 or IRS4)", or the combination of these terms with the word "(cancer)" or "(human)", for searches. Terms related to specific tumor pathologies ("breast", "ovary", "colon", "lung", "lymphoma", etc.) were also used. Despite the lack of knowledge on IRS4, it has been reported that some cancers and benign tumors are characterized by high levels of IRS-4 expression. Specifically, the role of IRS-4 in different types of digestive tract neoplasms, gynecological tumors, lung cancers, melanomas, hematological tumors, and other less common types of cancers has been shown. IRS4 differs from IRS1 and IRS2 in that can activate several oncogenes that regulate the PI3K/Akt cascade, such as BRK and FER, which are characterized by tyrosine kinase-like activity without regulation via extracellular ligands. In addition, IRS4 can activate the CRKL oncogene, which is an adapter protein that regulates the MAP kinase cascade. Knowledge of the role played by IRS4 in cancers at the molecular level, specifically as a platform for oncogenes, may enable the identification and validation of new therapeutic targets.

An Overview of the Role of MicroRNAs on Carcinogenesis: A Focus on Cell Cycle, Angiogenesis and Metastasis

In recent years, the importance of epigenetic markers in the carcinogenesis of different malignant neoplasms has been demonstrated, also demonstrating their utility for understanding metastatic spread and tumor progression in cancer patients. Among the different biomarkers, microRNAs represent a set of non-coding RNAs that regulate gene expression, having been involved in a wide variety of neoplasia acting in different oncogenic pathways. Both the overexpression and downregulation of microRNAs represent a complex interaction with various genes whose ultimate consequence is increased cell proliferation, tumor invasion and interaction with various driver markers. It should be noted that in current clinical practice, even though the combination of different microRNAs has been shown to be useful by different authors at diagnostic and prognostic levels, there are no diagnostic kits that can be used for the initial approach or to assess recurrences of oncological diseases. Previous works have cited microRNAs as having a critical role in several carcinogenic mechanisms, ranging from cell cycle alterations to angiogenesis and mechanisms of distant metastatic dissemination. Indeed, the overexpression or downregulation of specific microRNAs seem to be tightly involved in the modulation of various components related to these processes. For instance, cyclins and cyclin-dependent kinases, transcription factors, signaling molecules and angiogenic/antiangiogenic products, among others, have been recognized as specific targets of microRNAs in different types of cancer. Therefore, the purpose of this article is to describe the main implications of different microRNAs in cell cycle alterations, metastasis and angiogenesis, trying to summarize their involvement in carcinogenesis.

Special Issue: Diagnostic and Predictive Tissue Markers in G.I. Cancers

The compelling advancements in systemic targeted therapies for cancer drastically changed the role of histopathological analyses in recent decades [...].

Autophagy-Related ncRNAs in Pancreatic Cancer

Pancreatic cancer (PC) is a malignancy accounting for only 3% of total cancers, but with a low 5-year relative survival rate. Approximately 80% of PC patients are diagnosed at a late stage when the disease has already spread from the primary site. Despite advances in PC treatment, there is an urgently needed for the identification of novel therapeutic strategies for PC, particularly for patients who cannot undergo classical surgery. Autophagy is an evolutionarily conserved process used by cells to adapt to metabolic stress via the degrading or recycling of damaged or unnecessary organelles and cellular components. This process is elevated in PC and, thus, it contributes to the onset, progression, and cancer cell resistance to chemotherapy in pancreatic tumors. Autophagy inhibition has been shown to lead to cancer regression and to increase the sensitivity of pancreatic cells to radiation and chemotherapy. Emerging studies have focused on the roles of non-coding RNAs (ncRNAs), such as miRNAs, long non-coding RNAs, and circular RNAs, in PC development and progression. Furthermore, ncRNAs have been reported as crucial regulators of many biological processes, including autophagy, suggesting that ncRNA-based autophagy targeting methods could be promising novel molecular approaches for specifically reducing autophagic flux, thus improving the management of PC patients. In this review, we briefly summarize the existing studies regarding the role and the regulatory mechanisms of autophagy-related ncRNAs in the context of this cancer.