Prognostic impact of conservative surgery for pancreatic IPMNs

BACKGROUND

The extent of pancreatic resection for intraductal papillary mucinous neoplasms (IPMNs) remains an unresolved issue. The study aims at analyzing the prognostic impact of conservative surgery (CS) i.e. of pancreatoduodenectomy or distal pancreatectomy, versus total pancreatectomy (TP), for pancreatic IPMNs.

METHODS

We retrospectively analyzed and compared data of patients who had undergone pancreatic resection for IPMNs at our center between November 2007 and April 2019. Patients were divided into two main groups based on the extent of surgery: TP-group and CS-group. Subsequently, the perioperative and the long-term outcomes were compared. Moreover, a sub-group analysis of patients with IPMN alone and patients with malignant IPMN, based on preoperative indications to surgery and post-operative histopathological findings, was also performed.

RESULTS

Fifty-three patients were included in the TP-group and 73 in the CS-group. In 50 (39.7%) cases the frozen section changed the pre-operative surgical planning, with an extension of the pancreatic resection, in 43 (34.1%) cases up to a total pancreatectomy. Twenty-six patients (20.6%) with low-grade dysplasia at the frozen section underwent CS, while twenty (15.8%) underwent TP. Comparing these two sub-groups no differences were found in surgical IPMN recurrence, nor progression. The rate of overall postoperative complications was 56.6% in the TP-group and 57.5% in the CS-group (p = 0.940). Fifteen patients (20.5%) developed diabetes in the CS-group. None of the patients treated with CS developed a surgical IPMN recurrence or progression during the follow-up period. Comparing OS and DFS of the two groups, we did not find any statistically significant difference (p = 0.619 and 0.315).

CONCLUSION

A timely CS can be considered an appropriate and valid strategy in the surgical treatment of the majority of pancreatic IPMNs, as it can avoid the serious long-term metabolic consequences of TP in patients with a long-life expectancy. On the contrary, TP remains mandatory in case of PDAC or high-risk features involving the entire gland.

Detailing the ultrastructure's increase of prion protein in pancreatic adenocarcinoma

BACKGROUND

Recent evidences have shown a relationship between prion protein (PrPc) expression and pancreatic ductal adenocarcinoma (PDAC). Indeed, PrPc could be one of the markers explaining the aggressiveness of this tumor. However, studies investigating the specific compartmentalization of increased PrPc expression within PDAC cells are lacking, as well as a correlation between ultrastructural evidence, ultrastructural morphometry of PrPc protein and clinical data. These data, as well as the quantitative stoichiometry of this protein detected by immuno-gold, provide a significant advancement in understanding the biology of disease and the outcome of surgical resection.

AIM

To analyze quantitative stoichiometry and compartmentalization of PrPc in PDAC cells and to correlate its presence with prognostic data.

METHODS

Between June 2018 and December 2020, samples from pancreatic tissues of 45 patients treated with pancreatic resection for a preoperative suspicion of PDAC at our Institution were collected. When the frozen section excluded a PDAC diagnosis, or the nodules were too small for adequate sampling, patients were ruled out from the present study. Western blotting was used to detect, quantify and compare the expression of PrPc in PDAC and control tissues, such as those of non-affected neighboring pancreatic tissue of the same patient. To quantify the increase of PrPc and to detect the subcellular compartmentalization of PrPc within PDAC cells, immuno-gold stoichiometry within specific cell compartments was analyzed with electron microscopy. Finally, an analysis of quantitative PrPc expression according to prognostic data, such as cancer stage, recurrence of the disease at 12 mo after surgery and recurrence during adjuvant chemotherapy was made.

RESULTS

The amount of PrPc within specimen from 38 out of 45 patients was determined by semi-quantitative analysis by using Western blotting, which indicates that PrPc increases almost three-fold in tumor pancreatic tissue compared with healthy pancreatic regions [242.41 ± 28.36 optical density (OD) vs 95 ± 17.40 OD, P < 0.0001]. Quantitative morphometry carried out by using immuno-gold detection at transmission electron microscopy confirms an increased PrPc expression in PDAC ductal cells of all patients and allows to detect a specific compartmentalization of PrPc within tumor cells. In particular, the number of immuno-gold particles of PrPc was significantly higher in PDAC cells respect to controls, when considering the whole cell (19.8 ± 0.79 particles vs 9.44 ± 0.45, P < 0.0001). Remarkably, considering PDAC cells, the increase of PrPc was higher in the nucleus than cytosol of tumor cells, which indicates a shift in PrPc compartmentalization within tumor cells. In fact, the increase of immuno-gold within nuclear compartment exceeds at large the augment of PrPc which was detected in the cytosol (nucleus: 12.88 ± 0.59 particles vs 5.12 ± 0.32, P < 0.0001; cytosol: 7.74. ± 0.44 particles vs 4.3 ± 0.24, P < 0.0001). In order to analyze the prognostic impact of PrPc, we found a correlation between PrPc expression and cancer stage according to pathology results, with a significantly higher expression of PrPc for advanced stages. Moreover, 24 patients with a mean follow-up of 16.8 mo were considered. Immuno-blot analysis revealed a significantly higher expression of PrPc in patients with disease recurrence at 12 mo after radical surgery (360.71 ± 69.01 OD vs 170.23 ± 23.06 OD, P = 0.023), also in the subgroup of patients treated with adjuvant CT (368.36 ± 79.26 OD in the recurrence group vs 162.86 ± 24.16 OD, P = 0.028), which indicates a correlation with a higher chemo-resistance.

CONCLUSION

Expression of PrPc is significantly higher in PDAC cells compared with control, with the protein mainly placed in the nucleus. Preliminary clinical data confirm the correlation with a poorer prognosis.

Pancreatoduodenectomy without Vascular Resection in Patients with Primary Resectable Adenocarcinoma and Unilateral Venous Contact: A Matched Case Study

PURPOSE

To investigate the oncological outcome and survival of patients following a conservative approach on the portal-mesenteric axis, in an intraoperative ultrasound-selected group of pancreatoduodenectomy (PD), performed on patients with primary resectable with vascular contact (prVC) pancreatic ductal adenocarcinoma (PDAC).

METHODS

A consecutive series of patients who underwent PD for PDAC at our tertiary care center, between 2008 and 2017, were reviewed. A total of 156 PDs and 88 total pancreatectomies were performed during the study period, including 35 vascular resections. We identified a group of 40 (25.6%) patients with prVC-PDAC in whom after checking the feasibility with intraoperative ultrasound, we were able to perform PD by separation of the tumor from the portomesenteric axis avoiding vascular resection, without residual macroscopic disease (no vascular resection, nvrPD), and compared this group, using case-matched methodology, with the standard PD (sPD) group of primary resectable without vascular contact- (prwVC-) PDAC.

RESULTS

The median follow-up was 28.5 ± 23.2 months in the sPD group and 23.8 ± 20.8 months in the nvrPD group (p = 0.35). Isolated local recurrence rate was 2/40 (5%) in both groups. Additionally, there were no statistical differences in the systemic progression of the disease (42.5% sPD vs. 45% nvrPD, p = 0.82) or local plus synchronous systemic disease rates (2.5% sPD vs. 7.5% nvrPD, p = 0.30). The median survival was 22 months for the sPD group and 23 months for the nvrPD group, p = 0.86. The overall survival was similar in the two groups (1 y: 76.3% sPD vs. 70.0% nvrPD; 3 y: 35.6% vs. 31.6%; and 5 y: 28.5% vs. 25.3%; p = 0.80). Conclusions. PD without vascular resection can be considered safe and oncologically acceptable in selected patients with preoperative diagnosis of prVC-PDAC. The poor prognosis of PDAC is related to the aggressive biology and systemic spread of the tumor, rather than the local control of the disease.

Polynucleotides High Purification Technology (PN HPTTM) Injection Improves Pain Status and Functional Impairment in Hip and Shoulder Tendinitis

Background/Objectives: Tendinopathy is the preferred term to describe various tendon pathologies, including paratendinitis, tendinitis, and tendinosis, in the absence of histopathological evidence in biopsy specimens. The management of tendinopathies is challenging; rest, physiotherapy (such as eccentric training), injections, shock waves, orthotics, medical therapy, and surgery are the main therapeutic options offered to the patient. The conservative treatment of tendinopathies is still difficult, but several options have been proposed, including the use of anti-inflammatory molecules. In this retrospective study, we aimed to assess the efficacy of a conservative approach in improving pain and functional improvement in hip bursitis (HB) and biceps tendinitis (BT) patients. Methods: A series of data concerning the application of Polynucleotides High Purification Technology (PN HPTTM) in 47 patients with BT and HB was analyzed. All patients received three bi-weekly injections of PN HPTTM (T0-T2). Follow-up visits were performed at T3 (8 weeks from T2) and T4 (24 weeks from T2). Both the visual analog scale (VAS) for pain assessment and functional impairment (FI) scores were processed in the form of anonymized series for clinical improvement evaluations. Results: Statistically significant differences (p < 0.001) in pain reduction (-85%) and functional improvement (+86%) were found at the end of treatment. The levels of patient satisfaction (PS) and Clinical Global Improvement-Impression (CGI-I) were equal to 93% and 98%, respectively. According to the analyses, other patient data (e.g., gender, age, and BMI) did not appear to influence the positive treatment outcomes. Conclusions: The application of High Purification Technology (PN HPTTM) was shown to improve both pain and functional deterioration in patients with tendonitis in a similar manner to other conservative treatments. These retrospective analyses may open up new avenues for the implementation of conservative approaches in patients with tendinitis.

Complete blood count in neonatal Intensive care Unit (NICU): Performance comparison between POCT Sight OLO® and Sysmex XN-9100™ hematology analyzers

BACKGROUND AND AIMS

The use of a POCT (Point Of Care Test) could help in reducing the impact of pre-analytical errors in particular in challenging newborn samples.The study purpose is to compare the POCT Sight OLO® hematology analyzer, validated for >3 months patients, with the reference system Sysmex XN-9100™ in Neonatal Intensive Care Unit (NICU).

MATERIAL AND METHODS

The two analyzers were compared through Passing-Bablok regression analysis and Bland-Altman plot.

RESULTS

We analyzed 65 blood samples, in detail 38 from adults and 27 from newborns.The regression analysis results performed in the newborn and adult patients showed a good agreement between the two instruments. The evaluation of the Bland-Altman plots showed comparable values of bias <10 % for the most of parameters.The evaluation of sample flags for the presence of distributional and morphological abnormalities showed a partial accordance between the two approaches, but the POCT exhibited good performance compared to the final report revised by the laboratory specialist.

CONCLUSIONS

The comparison of the two instruments demonstrated that they provide comparable blood counts, also in patients aged <3 months. The POCT allows having reliable analytical data and faster turning around time, particularly useful in NICU.

Antiproliferative effects of novel aliphatic acetogenin analogs against aggressive solid tumor cell lines

The antiproliferative effects of three synthetic analogs of aliphatic acetogenins selected from a previous screening were compared to those of the drugs used for the treatment of malignant pleural mesothelioma (MPM) and pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

Four PDAC and three MPM cell lines were used in the study. Cell growth inhibition was determined after 48 h exposure to the drugs. Cell-cycle disruption and apoptosis induction were studied by flow cytometry. The modulation of Akt phosphorylation was studied using a specific ELISA for P-Ser473 Akt.

RESULTS

The new compounds inhibited cell growth, induced apoptosis and cell-cycle abrogation in all cell lines. Phosphorylated Akt levels rose after treatment.

CONCLUSION

The results demonstrated better performance of aliphatic acetogenin analogs against PDAC cells when compared to standard anticancer drugs. For MPM cells, the application of the new compounds may play an important role in overcoming the resistance to conventional treatments.

Dysregulated insulin secretion is associated with pancreatic β-cell hyperplasia and direct acinar-β-cell trans-differentiation in partially eNOS-deficient mice

eNOS-deficient mice were previously shown to develop hypertension and metabolic alterations associated with insulin resistance either in standard dietary conditions (eNOS-/- homozygotes) or upon high-fat diet (HFD) (eNOS+/- heterozygotes). In the latter heterozygote model, the present study investigated the pancreatic morphological changes underlying the abnormal glycometabolic phenotype. C57BL6 wild type (WT) and eNOS+/- mice were fed with either chow or HFD for 16 weeks. After being longitudinally monitored for their metabolic state after 8 and 16 weeks of diet, mice were euthanized and fragments of pancreas were processed for histological, immuno-histochemical and ultrastructural analyses. HFD-fed WT and eNOS+/- mice developed progressive glucose intolerance and insulin resistance. Differently from WT animals, eNOS+/- mice showed a blunted insulin response to a glucose load, regardless of the diet regimen. Such dysregulation of insulin secretion was associated with pancreatic β-cell hyperplasia, as shown by larger islet fractional area and β-cell mass, and higher number of extra-islet β-cell clusters than in chow-fed WT animals. In addition, only in the pancreas of HFD-fed eNOS+/- mice, there was ultrastructural evidence of a number of hybrid acinar-β-cells, simultaneously containing zymogen and insulin granules, suggesting the occurrence of a direct exocrine-endocrine transdifferentiation process, plausibly triggered by metabolic stress associated to deficient endothelial NO production. As suggested by confocal immunofluorescence analysis of pancreatic histological sections, inhibition of Notch-1 signaling, likely due to a reduced NO availability, is proposed as a novel mechanism that could favor both β-cell hyperplasia and acinar-β-cell transdifferentiation in eNOS-deficient mice with impaired insulin response to a glucose load.

A bile-based microRNA signature for differentiating malignant from benign pancreaticobiliary disease

Differentiating between pancreatic ductal adenocarcinoma (PDAC) and cholangiocarcinoma (CCA) is crucial for the appropriate course of treatment, especially with advancements in the role of neoadjuvant chemotherapies for PDAC, compared to CCA. Furthermore, benign pancreaticobiliary diseases can mimic malignant disease, and indeterminate lesions may require repeated investigations to achieve a diagnosis. As bile flows in close proximity to these lesions, we aimed to establish a bile-based microRNA (miRNA) signature to discriminate between malignant and benign pancreaticobiliary diseases. We performed miRNA discovery by global profiling of 800 miRNAs using the NanoString nCounter platform in prospectively collected bile samples from malignant (n = 43) and benign (n = 14) pancreaticobiliary disease. Differentially expressed miRNAs were validated by RT-qPCR and further assessed in an independent validation cohort of bile from malignant (n = 37) and benign (n = 38) pancreaticobiliary disease. MiR-148a-3p was identified as a discriminatory marker that effectively distinguished malignant from benign pancreaticobiliary disease in the discovery cohort (AUC = 0.797 [95% CI 0.68-0.92]), the validation cohort (AUC = 0.772 [95% CI 0.66-0.88]), and in the combined cohorts (AUC = 0.752 [95% CI 0.67-0.84]). We also established a two-miRNA signature (miR-125b-5p and miR-194-5p) that distinguished PDAC from CCA (validation: AUC = 0.815 [95% CI 0.67-0.96]; and combined cohorts: AUC = 0.814 [95% CI 0.70-0.93]). Our research stands as the largest, multicentric, global profiling study of miRNAs in the bile from patients with pancreaticobiliary disease. We demonstrated their potential as clinically useful diagnostic tools for the detection and differentiation of malignant pancreaticobiliary disease. These bile miRNA biomarkers could be developed to complement current approaches for diagnosing pancreaticobiliary cancers.