Nomogram model for predicting early recurrence for resectable pancreatic cancer: A multicenter study

Pancreatic cancer is a highly aggressive malignancy that is characterized by early metastasis, high recurrence, and therapy resistance. Early recurrence after surgery is one of the important reasons affecting the prognosis of pancreatic cancer. This study aimed to establish an accurate preoperative nomogram model for predicting early recurrence (ER) for resectable pancreatic adenocarcinoma. We retrospectively analyzed patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma between January 2011 and December 2020. The training set consisted of 604 patients, while the validation set included 222 patients. Survival was estimated using Kaplan-Meier curves. The factors influencing early recurrence of resectable pancreatic cancer after surgery were investigated, then the predictive model for early recurrence was established, and subsequently the predictive model was validated based on the data of the validation group. The preoperative risk factors for ER included a Charlson age-comorbidity index ≥ 4 (odds ratio [OR]: 0.628), tumor size > 3.0 cm on computed tomography (OR: 0.628), presence of clinical symptoms (OR: 0.515), carbohydrate antigen 19-9 > 181.3 U/mL (OR 0.396), and carcinoembryonic antigen > 6.01 (OR: 0.440). The area under the curve (AUC) of the predictive model in the training group was 0.711 (95% confidence interval: 0.669-0.752), while it reached 0.730 (95% CI: 0.663-0.797) in the validation group. The predictive model may enable the prediction of the risk of postoperative ER in patients with resectable pancreatic ductal adenocarcinoma, thereby optimizing preoperative decision-making for effective treatment.

Association of serum lipids and abnormal lipid score with cancer risk: a population-based prospective study

BACKGROUND

Serum lipid levels are associated with cancer risk. However, there still have uncertainties about the single and combined effects of low lipid levels on cancer risk.

METHODS

A prospective cohort study of 33,773 adults in Shanghai between 2016 and 2017 was conducted. Total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) levels were measured. Cox proportional hazard models were used to assess the association of single and combined lipids with overall, lung, colon, rectal, thyroid gland, stomach, and female breast cancers. The effect of the combination of abnormal lipid score and lifestyle on cancer was also estimated.

RESULTS

A total of 926 incident cancer cases were identified. In the RCS analysis, hazard ratios (HRs) of overall cancer for individuals with TC < 5.18 mmol/L or with LDL-C < 3.40 mmol/L were higher. Low TC was associated with higher colorectal cancer risk (HR [95% CI] = 1.76 [1.09-2.84]) and low HDL-C increased thyroid cancer risk by 90%. Abnormal lipid score was linearly and positively associated with cancer risk, and smokers with high abnormal lipid scores had a higher cancer risk, compared to non-smokers with low abnormal lipid scores (P < 0.05).

CONCLUSIONS

Low TC levels were associated with an increased risk of overall and colorectal cancer. More attention should be paid to participants with high abnormal lipid scores and unhealthy lifestyles who may have a higher risk of developing cancer. Determining the specific and comprehensive lipid combinations that affect tumorigenesis remains a valuable challenge.

Prognostic significance of grade of malignancy based on histopathological differentiation and Ki-67 in pancreatic ductal adenocarcinoma

OBJECTIVE

Tumor cell malignancy is indicated by histopathological differentiation and cell proliferation. Ki-67, an indicator of cellular proliferation, has been used for tumor grading and classification in breast cancer and neuroendocrine tumors. However, its prognostic significance in pancreatic ductal adenocarcinoma (PDAC) remains uncertain.

METHODS

Patients who underwent radical pancreatectomy for PDAC were retrospectively enrolled, and relevant prognostic factors were examined. Grade of malignancy (GOM), a novel index based on histopathological differentiation and Ki-67, is proposed, and its clinical significance was evaluated.

RESULTS

The optimal threshold for Ki-67 was determined to be 30%. Patients with a Ki-67 expression level > 30% rather than ≤ 30% had significantly shorter 5-year overall survival (OS) and recurrence-free survival (RFS). In multivariate analysis, both histopathological differentiation and Ki-67 were identified as independent prognostic factors for OS and RFS. The GOM was used to independently stratify OS and RFS into 3 tiers, regardless of TNM stage and other established prognostic factors. The tumor-node-metastasis-GOM stage was used to stratify survival into 5 distinct tiers, and surpassed the predictive performance of TNM stage for OS and RFS.

CONCLUSIONS

Ki-67 is a valuable prognostic indicator for PDAC. Inclusion of the GOM in the TNM staging system may potentially enhance prognostic accuracy for PDAC.

EPS15-AS1 Inhibits AKR1B1 Expression to Enhance Ferroptosis in Hepatocellular Carcinoma Cells

Epidermal growth factor receptor substrate 15 (EPS15) is part of the EGFR pathway and has been implicated in various tumorigenesis. Increasing evidence suggests that long noncoding RNA (lncRNA) plays an essential role in liver hepatocellular carcinoma (LIHC) by regulating the expression of proteins and genes. Through analysis of the cancer genome atlas (TCGA) database, we found that EPS15 is highly expressed in LIHC tissue, and lncRNA EPS15-antisense1 (EPS15-AS1) decreased in LIHC cell lines. However, the function of EPS15-AS1 in LIHC is still unknown. When EPS15-AS1 was overexpressed in HepG2 cell lines, the expression of EPS15 was reduced and cell activity and invasiveness were inhibited. In addition, we observed an increase in Fe2+ ion and lipid peroxidation after overexpression of EPS15-AS1, and further analysis showed that the susceptibility to ferroptosis increased. Aldo-keto reductase family 1 member B 1 (AKR1B1) belongs to the aldo/keto reductase superfamily and is involved in maintaining the cellular redox balance. Survival analysis revealed that patients with a higher level of AKR1B1 have a lower survival rate in the TCGA database. We also found that EPS15 enhanced the AKR1B1 expression in LIHC, and AKR1B1 had the ability to promote cell invasiveness. Moreover, overexpression of AKR1B1 alleviated the promoting effect of EPS15-AS1 on ferroptosis. Therefore, EPS15-AS1 can induce ferroptosis in hepatocellular carcinoma cells by inhibiting the expression of EPS15 and AKR1B1 and disrupting the redox balance. EPS15 and AKR1B1 may serve as biomarkers for diagnosis and lncRNA EPS15-AS1 potential drug for LIHC.

Biological risk based on preoperative serum CA19-9 and histological grade predicts prognosis and improves accuracy of classification in patients with pancreatic ductal adenocarcinoma

BACKGROUND

Carbohydrate antigen (CA) 19-9 and histological grade can serve as indicators of the biological characteristics of pancreatic ductal adenocarcinoma (PDAC).

AIMS

The aim of this study was to investigate the combined impact of preoperative CA19-9 levels and histological grade on prognosis and classification accuracy in PDAC patients.

METHODS AND RESULTS

A retrospective cohort study was conducted on 612 patients with PDAC who underwent curative pancreatectomy, and a biological risk model based on preoperative CA19-9 levels and histology grade was established. The prognostic importance of the biological risk model was evaluated, and its validity was confirmed through a validation cohort of 218 patients. The survival of patients with PDAC was independently associated with preoperative CA19-9 levels and histology grade, indicating a biological risk. This biological risk was incorporated into the eighth edition of the TNM staging system, leading to the development of a modified TNM (mTNM) staging system. Receiver operating characteristic (ROC) curves demonstrated that the mTNM staging system had a significantly larger area under the curve (AUC) than the TNM staging system. The discriminatory capacity of the mTNM staging system was further validated in an independent cohort.

CONCLUSION

Biological risk based on preoperative CA19-9 and histological grade could predict the survival of patients with PDAC. The incorporation of biological risk into the TNM staging system has the potential to enhance the accuracy of patient classification in PDAC, predicting patient survival and enabling the development of individualized treatment plans.

Prognostic nutritional score based on pretreatment lymphocyte, platelet, and prealbumin predicts prognosis in patients with pancreatic cancer

BACKGROUND AND OBJECTIVES

Pretreatment immunological indicators and nutritional factors are associated with survival of many malignancies. This study aims to develop a prognostic nutritional score based on a combination of pretreatment lymphocyte, platelet, and prealbumin (Co-LPPa) in patients with pancreatic cancer (PC) and to investigate the prognostic significance of this score.

METHODS

Patients who underwent pancreatectomy with a curative intent for PC were retrospectively enrolled. A pretreatment prognostic score was established by immunological indicators and nutritional factors that were independently associated with survival.

RESULTS

Pretreatment lymphocyte (<1.6 × 109 /L), platelet (<160 × 109 /L) and prealbumin (<0.23 g/L) were independently associated with poorer overall survival (OS) and recurrence-free survival (RFS), and were used to create the Co-LPPa score. The Co-LPPa scores were inversely related to OS and RFS, and were able to stratify survival into four groups. The survival differences among the four groups were all significant. Besides, the Co-LPPa scores could stratify survival independently of pathological prognostic factors. The Co-LPPa score was superior to prognostic nutritional index and carbohydrate antigen 19-9 in predicting OS and RFS.

CONCLUSION

The Co-LPPa score could accurately predict the prognosis of PC patients who underwent curative resection. The score may be helpful for preoperative therapeutic strategies.

A new staging system for postoperative prognostication in pancreatic ductal adenocarcinoma

The current TNM staging system for pancreatic ductal adenocarcinoma (PDAC) has revised the definitions of T and N categories as well as stage groups. However, studies validating these modifications have yielded inconsistent results. The existing TNM staging system in prognostic prediction remains unsatisfactory. The prognosis of PDAC is closely associated with pathological and biological factors. Herein, we propose a new staging system incorporating distant metastasis, postoperative serum levels of CA19-9 and CEA, tumor size, lymph node metastasis, lymphovascular involvement, and perineural invasion to enhance the accuracy of prognosis assessment. The proposed staging system exhibited a strong correlation with both overall survival and recurrence-free survival, effectively stratifying survival into five distinct tiers. Additionally, it had favorable discrimination and calibration. Thus, the proposed staging system demonstrates superior prognostic performance compared to the TNM staging system, and can serve as a valuable complementary tool to address the limitations of TNM staging in prognostication.

Presence of tumor deposits is an indicator of poor prognosis in patients with pancreatic ductal adenocarcinoma

Tumor deposits (TDs) are associated with poor prognosis in several malignancies and have been incorporated into the tumor-node-metastasis (TNM) staging system for colorectal cancer. This study aims to explore the significance of TDs in pancreatic ductal adenocarcinoma (PDAC). All patients who underwent pancreatectomy with a curative intent for PDAC were retrospectively enrolled. Patients were categorized into 2 groups according to the status of TDs: the positive group, in which TDs were present, and the negative group, in which TDs were absent. The prognostic significance of TDs was evaluated. In addition, a modified staging system was developed by incorporating TDs into the eighth edition of the TNM staging system. One hundred nine (17.8%) patients had TDs. Patients with TDs demonstrated significantly lower 5-year overall survival (OS) and recurrence-free survival (RFS) rates than those without TDs (OS: 9.1% vs. 21.5%, P=0.001; RFS: 6.1% vs. 16.7%, P<0.001). Even after matching, patients with TDs still had significantly worse OS and RFS than those without TDs. In the multivariate analysis, the presence of TDs was an independent prognostic factor in patients with PDAC. The survival of patients with TDs was similar to that of patients with N2 stage disease. The modified staging system had a greater Harrell's C-index than the TNM staging system, which indicates better performance in predicting survival. The presence of TDs was an independent prognostic factor for PDAC. Categorizing patients with TDs into N2 stage improved the accuracy of the TNM staging system in predicting prognosis.

Irbesartan overcomes gemcitabine resistance in pancreatic cancer by suppressing stemness and iron metabolism via inhibition of the Hippo/YAP1/c-Jun axis

BACKGROUND

Chemoresistance is the main reason for the poor prognosis of pancreatic ductal adenocarcinoma (PDAC). Thus, there is an urgent need to screen out new targets and compounds to reverse chemotherapeutic resistance.

METHODS

We established a bio-bank of human PDAC organoid models, covering a representative range of PDAC tumor subtypes. We screened a library of 1304 FDA-approved compounds to identify candidates efficiently overcoming chemotherapy resistance. The effects of the compounds were evaluated with a CellTiter-Glo-3D assay, organoid apoptosis assay and in vivo patient-derived xenograft (PDX), patient-derived organoid (PDO) and LSL-KrasG12D/+; LSL-Trp53R172H/+; Pdx1-Cre (KPC) genetically engineered mouse models. RNA-sequencing, genome editing, sphere formation assays, iron assays and luciferase assays were conducted to elucidate the mechanism.

RESULTS

High-throughput drug screening of chemotherapy-resistant PDOs identified irbesartan, an angiotensin ‖ type 1 (AT1) receptor antagonist, which could synergistically enhance the ability of chemotherapy to kill PDAC cells. In vitro and in vivo validation using PDO, PDX and KPC mouse models showed that irbesartan efficiently sensitized PDAC tumors to chemotherapy. Mechanistically, we found that irbesartan decreased c-Jun expression by inhibiting the Hippo/YAP1 pathway and further overcame chemotherapy resistance in PDAC. We also explored c-Jun, a potential target of irbesartan, which can transcriptionally upregulate the expression of key genes involved in stemness maintenance (SOX9/SOX2/OCT4) and iron metabolism (FTH1/FTL/TFRC). More importantly, we observed that PDAC patients with high levels of c-Jun expression demonstrated poor responses to the current standard chemotherapy regimen (gemcitabine plus nab-paclitaxel). Moreover, patients with PDAC had significant survival benefits from treatment with irbesartan plus a standard chemotherapy regimen in two-center retrospective clinical cohorts and patients with high c-Jun expression exhibited a better response to combination chemotherapy.

CONCLUSIONS

Irbesartan could be used in combination with chemotherapy to improve the therapeutic efficacy in PDAC patients with high levels of c-Jun expression. Irbesartan effectively inhibited chemotherapy resistance by suppressing the Hippo/YAP1/c-Jun/stemness/iron metabolism axis. Based on our findings, we are designing an investigator-initiated phase II clinical trial on the efficacy and safety of irbesartan plus a standard gemcitabine/nab-paclitaxel regimen in the treatment of patients with advanced III/IV staged PDAC and are hopeful that we will observe patient benefits.

Artificial intelligence-based comprehensive analysis of immune-stemness-tumor budding profile to predict survival of patients with pancreatic adenocarcinoma

OBJECTIVE

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy. CD8⁺ T cells, cancer stem cells (CSCs), and tumor budding (TB) have been significantly correlated with the outcome of patients with PDAC, but the correlations have been independently reported. In addition, no integrated immune-CSC-TB profile for predicting survival in patients with PDAC has been established.

METHODS

Multiplexed immunofluorescence and artificial intelligence (AI)-based comprehensive analyses were used for quantification and spatial distribution analysis of CD8⁺ T cells, CD133⁺ CSCs, and TB. In vivo humanized patient-derived xenograft (PDX) models were established. Nomogram analysis, calibration curve, time-dependent receiver operating characteristic curve, and decision curve analyses were performed using R software.

RESULTS

The established 'anti-/pro-tumor' models showed that the CD8⁺ T cell/TB, CD8⁺ T cell/CD133⁺ CSC, TB-adjacent CD8⁺ T cell, and CD133⁺ CSC-adjacent CD8⁺ T cell indices were positively associated with survival of patients with PDAC. These findings were validated using PDX-transplanted humanized mouse models. An integrated nomogram-based immune-CSC-TB profile that included the CD8⁺ T cell/TB and CD8⁺ T cell/CD133⁺ CSC indices was established and shown to be superior to the tumor-node-metastasis stage model in predicting survival of patients with PDAC.

CONCLUSIONS

'Anti-/pro-tumor' models and the spatial relationship among CD8⁺ T cells, CSCs, and TB within the tumor microenvironment were investigated. Novel strategies to predict the prognosis of patients with PDAC were established using AI-based comprehensive analysis and machine learning workflow. The nomogram-based immune-CSC-TB profile can provide accurate prognosis prediction for patients with PDAC.

Endoscopic ultrasound-guided gallbladder endoscopic mucosal resection: a pilot porcine study

INTRODUCTION

Endoscopic ultrasound (EUS)-guided natural orifice transluminal gallbladder polypectomy provides a minimally invasive alternative to cholecystectomy. The study aimed to investigate the feasibility and safety of protocol for gallbladder endoscopic mucosal resection (gEMR) under EUS guidance using a porcine model.

MATERIAL AND METHODS

Fifteen Bama mini pigs were randomly divided into the control (CG, n = 3) and experimental (EG, n = 12) groups. EUS-guided fine needle aspiration was performed in the CG and used to establish a gallbladder pathway for polyp resection under EUS guidance in the EG. Procedural safety was evaluated using routine blood and biochemical tests, microbial bile cultures, histopathological tests, and enzyme-linked immunosorbent assays for inflammatory adhesion factors.

RESULTS

EUS-guided metal stents were successfully deployed in all 12 pigs. Two cases of stent displacement occurred postoperatively, and one pig died of infectious peritonitis on the first day after stent implantation. In 11 surviving experimental animals, mature gallbladder paths were formed at 7-14 days after gastro-cholecystostomy, through which gEMR of gallbladder polyps was successfully performed. There were no significant changes in levels of inflammatory and adhesion factors during the postoperative process.

CONCLUSIONS

EUS-gEMR may be a safe and effective minimally invasive treatment approach for gallbladder polyps.

Activin A induces growth arrest through a SMAD- dependent pathway in hepatic progenitor cells

Background

Activin A, an important member of transforming growth factor-β superfamily, is reported to inhibit proliferation of mature hepatocyte. However, the effect of activin A on growth of hepatic progenitor cells is not fully understood. To that end, we attempted to evaluate the potential role of activin A in the regulation of hepatic progenitor cell proliferation.

Results

Using the 2-acetaminofluorene/partial hepatectomy model, activin A expression decreased immediately after partial hepatectomy and then increased from the 9th to 15th day post surgery, which is associated with the attenuation of oval cell proliferation. Activin A inhibited oval cell line LE6 growth via activating the SMAD signaling pathway, which manifested as the phosphorylation of SMAD2/3, the inhibition of Rb phosphorylation, the suppression of cyclinD1 and cyclinE, and the promotion of p21^WAF1/Cip1 and p15^INK4B expression. Treatment with activin A antagonist follistatin or blocking SMAD signaling could diminish the anti-proliferative effect of activin A. By contrast, inhibition of the MAPK pathway did not contribute to this effect. Antagonizing activin A activity by follistatin administration enhanced oval cell proliferation in the 2-acetylaminofluorene/partial hepatectomy model.

Conclusion

Activin A, acting through the SMAD pathway, negatively regulates the proliferation of hepatic progenitor cells.

[Mechanism of silk hydrates on modulating the blood glucose metabolism in rats with experimental diabetes]

Thirty eight adult male Wistar rats injected with streptozotocin(STZ) 30 mg/kg BW via tail vein and fed on a diet of high fat, high sucrose and high calorie for 3 weeks and then for another 8 weeks were successfully established as the diabetes model(type II diabetes mellitus). The effects of feeding silk hydrates(SH) for 12 weeks on the activities of insulin receptors and postreceptors were observed. The results showed that: 1) SH greatly improved the glucose tolerance of diabetic rats, but no effect on the secretion of insulin in rats with or without diabetes; 2) Only the low-affinity constant of insulin binding rates(K2) in skeletal muscle cell membranes of diabetic rats fed with SH were obviously increased, the high-affinity binding constant and the number of receptors were not changed; 3) the uptake of glucose in skeletal muscle of diabetic rats fed on SH was significantly increased. 4) SH partly improved the metabolism of serum lipids. The results indicated that SH could modulate the metabolism of blood glucose mainly through the mechanism on the activity of insulin postreceptor.

[Effects of silk hydrates on the blood glucose metabolism in rats with experimental diabetes]

Male Wistar rats were divided into two groups by random. One group was injected with streptozotocin(STZ) 30 mg/kg BW via tail vein. Three weeks later, the rats were fed on diet of high fat, high sucrose and high calorie for another 8 weeks. There were 38 rats with impaired glucose tolerance and insulin level higher or equal to the control group selected as the diabetic model group. Another 36 rats not injected with STZ and fed on normal diet were selected as controls. The two groups were divided into two subgroups and fed with normal diet for another 4 weeks. The four subgroups were normal control group, normal +SH group, diabetes control group and diabetes +SH group. The rats in normal +SH group and diabetes +SH group were tube feeding every day with silk hydrate (SH) 1.0 g/kg BW for 4 weeks. The results showed that in the diabetes +SH group, the glucose tolerance, blood lipid and the predictive index of coronary heart disease were significantly improved, but no effect on their blood insulin level. There was no change in the normal +SH group. The results suggested that SH could modulate the metabolism of blood glucose and partly improve the disorder of the serum lipid of diabetic rats.

[The cytologic ultrastructure and cytochemical features of human dendritic cells from peripheral blood]

OBJECTIVE

To observe the cytomorphological, cellular ultrastructure and cytochemical features of the dendritic cell (DC) enriched populations in vitro.

METHODS

Fresh peripheral blood from healthy volunteers was collected and mononuclear cells (PBMC) were isolated on lymphocyte separating solution. The PBMC were cultured in mediums containing rhGM-CSF, rhIL-4 and rhTNF-alpha 9-12 days to generate DC-enriched populations, the morphological features and numbers of DC were identified and counted respectively by light microscope (LM) and confirmed by immunofluorescence assay (IFA), the ultrastructure characteristics of the DC populations were observed by transmission electron microscope, and the cytochemical features of them were also examined.

RESULTS

The percentage of DCs was 70%-80% in the DC-enriched populations as confirmed by IFA using mABXII. Transmission electron microscopy revealed that the DC populations contained two subsets of DC, one was considered as precursor cell derived DC(PC-DC), the cell surface of which had many irregular dendrites with a irregular nucleus, small nucleoli, numerous mitochondria, but scanty lysosomes, ribosome, rough endoplasmic reticulum and free polysomes. Cytochemical staining showed the DCs were both peroxidase (POX) and non-specific esterase (NSE) negative. The other was indentified as monocyte-derived DC(MO-DC), the features of which included: irregular shape, many ruffles and some rough lames on cell surfaces, nephritic or horseshoe nuclei with a thick rim of heterochromatin, numerous mitochondria, much more lysosomes, ribosomes, rough endoplasmic reticulum and Golgiosome. The cytochemical reactions indicated that most of them had POX-positive granules, and were NSE slightly positive.

CONCLUSION

Cytokines in vitro induced DCs from human peripheral blood are heterogeneous.