Prevalence and clinical profile of pancreatic cancer-associated diabetes mellitus

Evaluation of insulin-like growth factor (IGF-1) and retinol binding protein (RBP-4) levels in patients with newly diagnosed pancreatic adenocarcinoma (PDAC)

BACKGROUND/OBJECTIVES

The elevation of insulin-like growth factor 1 (IGF-1) and adipokine retinol-binding protein 4 (RBP-4) is known to be associated with the risk of many cancers. The aim of this study was to evaluate the serum concentrations of IGF-1 and RBP-4 in patients with PDAC and chronic pancreatitis (CP).

METHODS

The study included 43 patients with PDAC, 39 patients with CP and 10 controls. The concentrations of IGF-1 and RBP-4 were obtained using the ELISA method (Corgenix UK Ltd R&D Systems). The study protocol was approved by the Bioethics Committee at the Medical University of Lodz.

RESULTS

In PDAC patients the serum IGF-1 level was significantly higher than in patients with CP (107.79 ± 66.40 ng/ml vs 89.91 ± 74.06 ng/ml; P < 0.05). Patients with both CP and diabetes mellitus (DM) were noted to have a significantly lower level of IGF-1 compared with those who only had CP (51.33 ± 24.30 ng/ml vs 108.42 ± 82.39 ng/ml; P = 0.01). The same result was obtained for men with and without DM (58.05 ± 32.44 ng/ml vs 98.79 ± 79.47 ng/ml, P = 0.05). As regards the serum level of RBP-4, the PDAC and CP groups were not significantly different from each other.

CONCLUSIONS

Diabetes accompanying PDAC does not influence the level of IGF-1 as opposed to diabetes in the course of CP. The IGF-1 level can be useful for early diagnosis of PDAC. High concentration of RBP-4 is not specific to pancreatic cancer, so it does not appear to be a useful biomarker for PDAC.

Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection

Pancreatic cancer is an aggressive malignancy with a poor prognosis. The disease and its treatment can cause significant nutritional impairments that often adversely impact patient quality of life (QOL). The pancreas has both exocrine and endocrine functions and, in the setting of cancer, both systems may be affected. Pancreatic exocrine insufficiency (PEI) manifests as weight loss and steatorrhea, while endocrine insufficiency may result in diabetes mellitus. Surgical resection, a central component of pancreatic cancer treatment, may induce or exacerbate these dysfunctions. Nutritional and metabolic dysfunctions in patients with pancreatic cancer lack characterization, and few guidelines exist for nutritional support in patients after surgical resection. We reviewed publications from the past two decades (1995–2016) addressing the nutritional and metabolic status of patients with pancreatic cancer, grouping them into status at the time of diagnosis, status at the time of resection, and status of nutritional support throughout the diagnosis and treatment of pancreatic cancer. Here, we summarize the results of these investigations and evaluate the effectiveness of various types of nutritional support in patients after pancreatectomy for pancreatic adenocarcinoma (PDAC). We outline the following conservative perioperative strategies to optimize patient outcomes and guide the care of these patients: (1) patients with albumin < 2.5 mg/dL or weight loss > 10% should postpone surgery and begin aggressive nutrition supplementation; (2) patients with albumin < 3 mg/dL or weight loss between 5% and 10% should have nutrition supplementation prior to surgery; (3) enteral nutrition (EN) should be preferred as a nutritional intervention over total parenteral nutrition (TPN) postoperatively; and, (4) a multidisciplinary approach should be used to allow for early detection of symptoms of endocrine and exocrine pancreatic insufficiency alongside implementation of appropriate treatment to improve the patient’s quality of life.

A Clinical Prediction Model to Assess Risk for Pancreatic Cancer Among Patients With New-Onset Diabetes

BACKGROUND & AIMS

Approximately 50% of all patients with pancreatic ductal adenocarcinoma (PDA) develop diabetes mellitus before their cancer diagnosis. Screening individuals with new-onset diabetes might allow earlier diagnosis of PDA. We sought to develop and validate a PDA risk prediction model to identify high-risk individuals among those with new-onset diabetes.

METHODS

We conducted a retrospective cohort study in a population representative database from the United Kingdom. Individuals with incident diabetes after the age of 35 years and 3 or more years of follow-up after diagnosis of diabetes were eligible for inclusion. Candidate predictors consisted of epidemiologic and clinical characteristics available at the time of diabetes diagnosis. Variables with P values <.25 in the univariable analyses were evaluated using backward stepwise approach. Model discrimination was assessed using receiver operating characteristic curve analysis. Calibration was evaluated using the Hosmer-Lemeshow test. Results were internally validated using a bootstrapping procedure.

RESULTS

We analyzed data from 109,385 patients with new-onset diabetes. Among them, 390 (0.4%) were diagnosed with PDA within 3 years. The final model (area under the curve, 0.82; 95% confidence interval, 0.75-0.89) included age, body mass index, change in body mass index, smoking, use of proton pump inhibitors, and anti-diabetic medications, as well as levels of hemoglobin A1C, cholesterol, hemoglobin, creatinine, and alkaline phosphatase. Bootstrapping validation showed negligible optimism. If the predicted risk threshold for definitive PDA screening was set at 1% over 3 years, only 6.19% of the new-onset diabetes population would undergo definitive screening, which would identify patients with PDA with 44.7% sensitivity, 94.0% specificity, and a positive predictive value of 2.6%.

CONCLUSIONS

We developed a risk model based on widely available clinical parameters to help identify patients with new-onset diabetes who might benefit from PDA screening.

Impact of diabetes mellitus on clinical outcomes of pancreatic cancer after surgical resection: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Diabetes mellitus (DM) is a risk factor for pancreatic cancer but its impact on postoperative outcomes and long-term survival after cancer resection remains controversial. A meta-analysis of published studies was conducted to address this issue.

METHODS

An extensive electronic search of four databases was performed for relevant articles. Data were processed for meta-analysis using Review Manager version 5.1.

RESULTS

Seventeen observational studies involving 5407 patients were subjected to the analysis. Overall morbidity or any type of complications and mortality were comparable between diabetic and non-diabetic subjects. Overall DM has a significant negative impact on survival (risk ratio [RR], 1.24, 95% confidence interval [CI], 1.05-1.45; P = 0.01). Stratification by the type of DM revealed that new-onset DM (<2 years duration, RR, 1.54, 95% CI, 1.24-1.91; P <0.001) but not long-standing DM (≥2 years duration, RR, 1.74, 95% CI, 0.86-3.52; P = 0.12) was associated with reduced survival.

CONCLUSIONS

Diabetes mellitus does not affect perioperative outcomes in patients undergoing surgery for pancreatic cancer. However, new-onset DM confers a negative impact on survival of pancreatic cancer in patients undergoing surgical resection.

Type 3c (pancreatogenic) diabetes mellitus secondary to chronic pancreatitis and pancreatic cancer

Diabetes mellitus is a group of diseases defined by persistent hyperglycaemia. Type 2 diabetes, the most prevalent form, is characterised initially by impaired insulin sensitivity and subsequently by an inadequate compensatory insulin response. Diabetes can also develop as a direct consequence of other diseases, including diseases of the exocrine pancreas. Historically, diabetes due to diseases of the exocrine pancreas was described as pancreatogenic or pancreatogenous diabetes mellitus, but recent literature refers to it as type 3c diabetes. It is important to note that type 3c diabetes is not a single entity; it occurs because of a variety of exocrine pancreatic diseases with varying mechanisms of hyperglycaemia. The most commonly identified causes of type 3c diabetes are chronic pancreatitis, pancreatic ductal adenocarcinoma, haemochromatosis, cystic fibrosis, and previous pancreatic surgery. In this Review, we discuss the epidemiology, pathogenesis, and clinical relevance of type 3c diabetes secondary to chronic pancreatitis and pancreatic ductal adenocarcinoma, and highlight several important knowledge gaps.

The impact of diabetes mellitus on survival following resection and adjuvant chemotherapy for pancreatic cancer

BACKGROUND

Diabetes mellitus is frequently observed in pancreatic cancer patients and is both a risk factor and an early manifestation of the disease.

METHODS

We analysed the prognostic impact of diabetes on the outcome of pancreatic cancer following resection and adjuvant chemotherapy using individual patient data from three European Study Group for Pancreatic Cancer randomised controlled trials. Analyses were carried out to assess the association between clinical characteristics and the presence of preoperative diabetes, as well as the effect of diabetic status on overall survival.

RESULTS

In total, 1105 patients were included in the analysis, of whom 257 (23%) had confirmed diabetes and 848 (77%) did not. Median (95% confidence interval (CI)) unadjusted overall survival in non-diabetic patients was 22.3 (20.8-24.1) months compared with 18.8 (16.9-22.1) months for diabetic patients (P=0.24). Diabetic patients were older, had increased weight and more co-morbidities. Following adjustment, multivariable analysis demonstrated that diabetic patients had an increased risk of death (hazard ratio: 1.19 (95% CI 1.01, 1.40), P=0.034). Maximum tumour size of diabetic patients was larger at randomisation (33.6 vs 29.7 mm, P=0.026).

CONCLUSIONS

Diabetes mellitus was associated with increased tumour size and reduced survival following pancreatic cancer resection and adjuvant chemotherapy.

Diabetes associated with pancreatic ductal adenocarcinoma is just diabetes: Results of a prospective observational study in surgical patients

BACKGROUND

Identification of a specific diabetes signature associated to pancreatic ductal carcinoma (PDAC) could be a key to detect asymptomatic, early stage tumors. We aim to characterize the clinical signature and the pathogenetic factors of the different types of diabetes associated with PDAC, based on the time between diabetes and cancer diagnosis.

METHODS

Prospective observational study on 364 PDAC patients admitted to a referral center for pancreatic disease. Hospital and/or outpatient medical records were reviewed. Blood biochemical values including fasting blood glucose, insulin and/or C-peptide, glycosylated hemoglobin and anti-islet antibodies were determined. Diabetes onset was assessed after surgery and during follow-up.

RESULTS

The prevalence of diabetes in patients was 67%. Considering 174 patients (47.8%) already having diabetes when diagnosed with PDAC (long duration, short duration, concomitant), the clinical and biochemical profile was similar to that of patients with type 2 diabetes (T2D). Diabetes was associated with known risk factors (i.e., age, sex, family history for diabetes and increased BMI) and both beta-cell dysfunction and insulin resistance were present. Considering 70 patients (19.2%) with onset of diabetes after PDAC diagnosis (early and late onset), the strongest predictor was the loss of beta-cell mass following pancreatectomy in patients with risk factors for T2D.

CONCLUSION

Different types of diabetes according to the time between diabetes and PDAC diagnosis are clinical entities widely overlapping with T2D. Therefore, the success of a strategy considering diabetes onset as a marker of asymptomatic PDAC will largely depend on our ability to identify new diabetes-unrelated biomarkers of PDAC.

Weight Loss, Diabetes, Fatigue, and Depression Preceding Pancreatic Cancer

OBJECTIVES

We aimed to determine the severity and co-occurrence of established and potential paraneoplastic conditions in pancreatic cancer (weight loss, new onset diabetes, fatigue, and depression) and their relation to patient characteristics.

METHODS

Using information from personal interviews with 510 cases and 463 controls, we obtained adjusted odds ratios for weight loss, long-term and new-onset diabetes, fatigue, and depression before diagnosis. Among cases, we investigated the extent to which these factors occurred together and the characteristics of those reporting them.

RESULTS

The adjusted odds ratio for weight loss (>3% of usual weight) was 27.0 (95% confidence interval, 17.1-42.6). Severe weight loss was common (21% of cases lost >15%), and was more common in those previously obese. Diabetes was more common in cases and was strongly associated with weight loss (P < 0.0001). Diabetes in cases more often led to prescription of insulin, compared with controls.Fatigue and depression were significantly more common in cases than controls but not related to weight loss or diabetes. These conditions were not related to stage at diagnosis.

CONCLUSIONS

Weight loss, often severe, and new-onset diabetes frequently occur together before diagnosis of pancreatic cancer. Fatigue and depression are also potential precursors of diagnosis.

Impact by pancreatic stellate cells on epithelial-mesenchymal transition and pancreatic cancer cell invasion: Adding a third dimension in vitro

Pancreatic cancer is associated with a highly abundant stroma and low-grade inflammation. In the local tumour microenvironment, elevated glucose levels, the presence of tumour-associated stellate cells and macrophages are hypothesised to promote the tumour progression and invasion. The present study investigated the influence by the microenvironment on pancreatic cancer cell invasion in vitro. After co-culture with tumour-associated pancreatic stellate cells (TPSCs), pancreatic cancer cells displayed up to 8-fold reduction in levels of epithelial-mesenchymal transition (EMT) markers E-cadherin and ZO-1, while β-catenin and vimentin levels were increased. A 3D organotypic model showed that TPSCs stimulated pancreatic cancer cell invasion, both as single cell (PANC-1) and cohort (MIAPaCa-2) invasion. The combined presence of TPSCs and M2-like macrophages induced invasion of the non-invasive BxPC-3 cells. High glucose conditions further enhanced changes in EMT markers as well as the cancer cell invasion. In summary, co-culture with TPSCs induced molecular changes associated with EMT in pancreatic cancer cells, regardless of differentiation status, and the organotypic model demonstrated the influence of microenvironmental factors, such as glucose, stellate cells and macrophages, on pancreatic cancer cell invasion.

**-Postprandial pancreatic [11C]methionine uptake after pancreaticoduodenectomy mirrors basal beta cell function and insulin release

Purpose

[S-methyl-¹¹C]-L-methionine ([¹¹C]MET) uptake in the pancreas might be a central indicator of beta cell function. Since gastric emptying was recently shown to influence glycemic control in subjects after pancreaticoduodenectomy (PD, the surgical treatment of neoplasms of the pancreas head), we looked for imaginable relationships between gastric emptying, pre- and postprandial insulin concentrations, and [¹¹C]MET uptake.

Methods

Nineteen tumor-free survivors after PD (age mean ± SD: 61 ± 8.7 yrs.; 10 male, 9 female) and 10 healthy controls (age: 27 ± 8.7 yrs.; 7 male, 3 female) were given a mixed test meal. One gram of paracetamol was ingested with the meal to evaluate the speed of gastric emptying. Insulin, glucose, and paracetamol plasma concentrations were measured before and over 180 minutes after ingestion. Beta cell function was calculated from fasting glucose and insulin plasma concentrations. Simultaneously, 800 MBq of [¹¹C]MET were administered and the activity (maximum tissue standardized uptake values [SUVmax]) over the pancreas was measured at 15, 30, and 60 minutes after injection. Total integrated SUVmax (area under the curve [AUC]) and incremental SUVmax were calculated.

Results

The uptake of [¹¹C]MET in the pancreas was significantly higher (p < 0.0001) in controls compared to the PD group. Gastric emptying was significantly slower in controls compared to pancreatectomy subjects (p < 0.0001). Paracetamol AUC₃₀ correlated with the SUVmax increment between 15 and 30 minutes (R² = 0.27, p = 0.0263), suggesting a relationship between gastric emptying and the uptake of [¹¹C]MET. Total integrated SUVmax correlated with insulin AUC₆₀ (R² = 0.66,p < 0.0001) in patients after PD. Multivariate regression analysis revealed insulin AUC₆₀ and beta cell function, calculated from the fasting insulin to glucose ratio, as independent predictors of ¹¹C-methionine uptake, i.e. total integrated SUVmax, in patients after PD (R² = 0.78, p < 0.0001).

Conclusion

Postprandial [¹¹C]MET uptake may represent basal and postprandial beta cell function. The findings suggest a possible usefulness of this imaging procedure for further studying beta cell function.

Pancreatic Cancer: A Survival Analysis Study in Oklahoma

BACKGROUND

Pancreatic cancer is among the most deadly cancers. Risk factors associated with the disease include age, race, sex, smoking status, and diabetes status.

METHOD

We conducted a prospective analysis of risk factors and length of survival among pancreatic cancer patients living in Oklahoma between 1997 and 2012 (n=6,291). Kaplan-Meier survival curves were created followed by the log-rank test to compare difference in the survival time. Cox proportional hazard regression models were used to examine the strength of association through the estimated hazard ratios.

RESULTS

The median survival time of the cohort was three months. Significant risk factors for reduced survival times included age, stage at diagnosis, and year of diagnosis.

CONCLUSION

Results are in agreement with previous research findings. There have been small but noteworthy improvements in survival times for pancreatic cancer patients in Oklahoma. Length of survival during the study period was significantly associated with known risk factors such as age and stage of diagnosis.

High risk factors of pancreatic carcinoma

Over the past decades, cancer has become one of the toughest challenges for health professionals. The epidemiologists are increasingly directing their research efforts on various malignant tumor worldwide. Of note, incidence of cancers is on the rise more quickly in developed countries. Indeed, great endeavors have to be made in the control of the life-threatening disease. As we know it, pancreatic cancer (PC) is a malignant disease with the worst prognosis. While little is known about the etiology of the PC and measures to prevent the condition, so far, a number of risk factors have been identified. Genetic factors, pre-malignant lesions, predisposing diseases and exogenous factors have been found to be linked to PC. Genetic susceptibility was observed in 10% of PC cases, including inherited PC syndromes and familial PC. However, in the remaining 90%, their PC might be caused by genetic factors in combination with environmental factors. Nonetheless, the exact mechanism of the two kinds of factors, endogenous and exogenous, working together to cause PC remains poorly understood. The fact that most pancreatic neoplasms are diagnosed at an incurable stage of the disease highlights the need to identify risk factors and to understand their contribution to carcinogenesis. This article reviews the high risk factors contributing to the development of PC, to provide information for clinicians and epidemiologists.

Diabetes mellitus and pre-diabetes are frequently undiagnosed and underreported in patients referred for pancreatic surgery. A prospective observational study

OBJECTIVE

Previous reports on the prevalence of diabetes in pancreatic cancer and chronic pancreatitis patients are based on inconsistent and equivocal criteria. The objective of this study is to prospectively assess with conclusive methods the preoperative glycaemic status of patients undergoing pancreatic surgery. We hypothesise that most of those patients are unaware of these disturbances in glycaemic status and that the prevalence is underestimated.

METHODS

During the last 2 years, patients referred for pancreatic surgery and without history of diabetes underwent a prospective preoperative screening with an oral glucose tolerance test (OGTT) and determination of the glycated haemoglobin level (HbA1c). The American Diabetes Association's criteria for diabetes and pre-diabetes were used. Beta-cell function and insulin sensitivity were calculated using HOMA2 indices. Impact on surgical policy has been scored.

RESULTS

99 patients were screened, 25 had a history of diabetes. The other 74 underwent an OGTT and HbA1c determination. Only 29.7% (22/74) had a normal glucose metabolism, while 8.1% (6/74) had impaired fasting glucose, 21.6% (16/74) had impaired glucose tolerance, 6.7% (5/74) had a combination of both, and 33.8% (25/74) had undiagnosed diabetes. In 15.2% (15/99) of the patients, this preoperative assessment had an impact on surgical policy.

CONCLUSIONS

77.7% of patients referred for pancreatic surgery had some degree of (pre-)diabetes. In 70.3% of patients without a history of diabetes, these disturbances in glucose metabolism are a new finding. Physicians involved in pancreatic surgery should be aware of the frequently undiagnosed (pre-)diabetes and actively check for it. This prevalence is underestimated.

Altered profile of serum microRNAs in pancreatic cancer-associated new-onset diabetes mellitus

BACKGROUND

New-onset diabetes mellitus in pancreatic cancer has been recognized as a paraneoplastic phenomenon caused by the existence of the tumor. Circulating microRNAs (miRNAs) are emerging as non-invasive biomarkers for the detection of various cancers. In the present study, we hypothesized that a specific serum miRNA profile exists in pancreatic cancer-associated new-onset diabetes mellitus (PaC-DM).

METHODS

Initial screening of differentially expressed miRNAs in pooled serum samples from 25 PaC-DM patients, 25 non-cancer new-onset type 2 diabetes mellitus (T2DM) patients, and 25 healthy controls was performed by TaqMan low-density arrays (TLDA). A stem-loop quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was conducted to confirm the relative concentrations of candidate miRNAs in 80 PaC-DM, 85 non-cancer new-onset T2DM patients, and 80 healthy controls.

RESULTS

The TLDA identified 16 serum miRNAs that were significantly increased in PaC-DM samples. A combination of six serum miRNAs (miR-483-5p, miR-19a, miR-29a, miR-20a, miR-24, miR-25) was selected by qRT-PCR as a biomarker for PaC-DM. The area under the receiver operating characteristic curve (AUC) for the six-miRNA panel training and validation sets was 0.959 (95% confidence interval [CI] 0.890-1.028) and 0.902 (95% CI 0.844-0.955), respectively. The combination of these six miRNAs enabled the discrimination of PaC-DM from non-cancer new-onset T2DM with an AUC of 0.885 (95% CI 0.784-0.986) and 0.887 (95% CI 0.823-0.952) for the training and validation sets, respectively.

CONCLUSION

The six-serum miRNA panel may have potential as a biomarker for the accurate diagnosis and discrimination of PaC-DM from healthy controls and non-cancer new-onset T2DM.

Value of Early Check-Up of Carbohydrate Antigen 19-9 Levels for Pancreatic Cancer Screening in Asymptomatic New-Onset Diabetic Patients

OBJECTIVES

We evaluated the value of carbohydrate antigen 19-9 (CA 19-9) as a pancreatic cancer (PC) screening tool in an asymptomatic new-onset diabetic patients.

METHODS

Medical records of asymptomatic patients newly diagnosed with diabetes mellitus (DM) were reviewed retrospectively at our hospital from January 2004 to January 2013.

RESULTS

In total, 2363 asymptomatic diabetic patients with CA 19-9 measurements were enrolled. Of them, 68 (2.9%) were diagnosed with PC. In the 1719 patients who had CA 19-9 measured within 1 year after the DM diagnosis, a total of 51 (3.0 %) patients developed PC and the odds ratio (OR) of PC according to higher CA 19-9 than normal upper limit, 37 IU/mL was 5.57 (P < 0.001). In 248 patients checked CA 19-9 between 1 and 2 years after DM diagnosis, PC was detected in 9 (3.6%) cases and OR of high CA 19-9 was 4.51 (P = 0.019). However, beyond 2 years, the OR for PC showed no statistical significance. The patients with high CA 19-9 levels tended to have more advanced-stage disease.

CONCLUSIONS

Early check-up of CA 19-9 could be a useful marker for screening for PC in asymptomatic patients with new-onset DM in the first 2 years.

Type 2 Diabetes Mellitus and Its Association with the Risk of Pancreatic Carcinogenesis: A Review

The prevalence of diabetes mellitus (DM) and associated diseases such as cancers are substantially increasing worldwide. About 80% of the patients with pancreatic cancer have glucose metabolism alterations. This suggests an association between type 2 DM and pancreatic cancer risk and progression. There are hypotheses that show metabolic links between the diseases, due to insulin resistance, hyperglycemia, hyperinsulinemia, low grade chronic inflammation, and alteration in the insulin-insulin-like growth factor axis. The use of diabetes medications can influence the extent of carcinogenesis of the pancreas. This study briefly reviews recent literature on investigation of metabolic link of type 2 DM, risk of carcinogenesis of the pancreas and their association, as well as the current understanding of metabolic pathways implicated in metabolism and cellular growth. The main finding of this review, although there are discrepancies, is that according to most research long-term DM does not raise the risk of pancreatic cancer. The longest duration of DM may reflect hypoinsulinemia due to treatment for hyperglycemia, but recent onset diabetes was associated with increased risk for pancreatic cancer due to hyperinsulinemia and hyperglycemia. In conclusion, the review demonstrates that type 2 DM and the duration of diabetes pose a risk for pancreatic carcinogenesis, and that there is biological link between the diseases.

Decreased Serum Thrombospondin-1 Levels in Pancreatic Cancer Patients Up to 24 Months Prior to Clinical Diagnosis: Association with Diabetes Mellitus

PURPOSE

Identification of serum biomarkers enabling earlier diagnosis of pancreatic ductal adenocarcinoma (PDAC) could improve outcome. Serum protein profiles in patients with preclinical disease and at diagnosis were investigated.

EXPERIMENTAL DESIGN

Serum from cases up to 4 years prior to PDAC diagnosis and controls (UKCTOCS,n= 174) were studied, alongside samples from patients diagnosed with PDAC, chronic pancreatitis, benign biliary disease, type 2 diabetes mellitus, and healthy subjects (n= 298). Isobaric tags for relative and absolute quantification (iTRAQ) enabled comparisons of pooled serum from a test set (n= 150). Validation was undertaken using multiple reaction monitoring (MRM) and/or Western blotting in all 472 human samples and samples from a KPC mouse model.

RESULTS

iTRAQ identified thrombospondin-1 (TSP-1) as reduced preclinically and in diagnosed samples. MRM confirmed significant reduction in levels of TSP-1 up to 24 months prior to diagnosis. A combination of TSP-1 and CA19-9 gave an AUC of 0.86, significantly outperforming both markers alone (0.69 and 0.77, respectively;P< 0.01). TSP-1 was also decreased in PDAC patients compared with healthy controls (P< 0.05) and patients with benign biliary obstruction (P< 0.01). Low levels of TSP-1 correlated with poorer survival, preclinically (P< 0.05) and at clinical diagnosis (P< 0.02). In PDAC patients, reduced TSP-1 levels were more frequently observed in those with confirmed diabetes mellitus (P< 0.01). Significantly lower levels were also observed in PDAC patients with diabetes compared with individuals with type 2 diabetes mellitus (P= 0.01).

CONCLUSIONS

Circulating TSP-1 levels decrease up to 24 months prior to diagnosis of PDAC and significantly enhance the diagnostic performance of CA19-9. The influence of diabetes mellitus on biomarker behavior should be considered in future studies.

Can metformin change the prognosis of pancreatic cancer? Retrospective study for pancreatic cancer patients with pre-existing diabetes mellitus type 2

BACKGROUNDS

The effect of metformin on survival in patients with pancreatic cancer is controversial.

AIMS

To investigate the beneficial effect of metformin in pancreatic cancer patients.

METHODS

We retrospectively analyzed patients with pancreatic cancer and pre-existing diabetes mellitus type 2 who were treated at Severance Hospital (Seoul, South Korea) between May 2005 and December 2013.

RESULTS

Among 237 enrolled patients, 117 patients (49.4%) were exposed to metformin. The median overall survival was 13.7 months for the metformin group versus 8.9 months for the non-metformin group (P=0.001) In univariate analysis, metformin exposure, low serum carbohydrate antigen 19-9 levels (<1000 U/mL), small tumor size (≤20 mm), no tail involvement, good performance status (ECOG 0 vs. 1 or 2), and resectable cancer stage were associated with favorable survival outcomes (all P<0.05). In multivariate analysis, in addition to low serum carbohydrate antigen 19-9 levels (<1000 U/mL) and resectable cancer stage, metformin exposure was significantly associated with longer survival with a hazard ratio of 0.61 (P=0.001). Additionally, the cumulative duration of metformin use was significantly correlated with a favorable survival outcome.

CONCLUSION

Our findings supported that metformin exposure was associated with survival benefits in patients with pancreatic cancer and pre-existing type 2 diabetes mellitus, especially among those with an advanced cancer stage.

Use of incretin agents and risk of pancreatic cancer: a population-based cohort study

AIM

To investigate the association between the use of incretin agents and the risk of pancreatic cancer.

METHODS

A retrospective population-based cohort study, using data from the Clinical Practice Research Datalink, 2007-2012, was conducted. Patients (n = 182 428) with at least one non-insulin antidiabetic drug (NIAD) prescription and aged ≥18 years during data collection, were matched one-to-one to control patients without diabetes. Multivariable Cox proportional hazards models and a new user design were used to estimate the hazard ratio (HR) of pancreatic cancer in incretin users (n = 28 370) compared with control subjects without diabetes and other NIAD-treated patients. Time-dependent adjustments were made for age, sex, lifestyle, comorbidities and drug use.

RESULTS

The mean duration of follow-up was 4.1 years for incretin users. Current NIAD use was associated with a fourfold increased risk of pancreatic cancer [HR 4.28, 95% confidence interval (CI) 3.49-5.24]. This risk was almost doubled among current incretin users as compared with control subjects. Incretin use was not associated with pancreatic cancer when compared with control subjects with diabetes (HR 1.36, 95% CI 0.94-1.96); however, the 'new user' design did show an association between incretin use and pancreatic cancer when compared with control subjects with diabetes. In both cohorts with prevalent and incident users of antidiabetic drugs, the risk of pancreatic cancer almost doubled in those who had recently initiated incretin therapy (up to seven prescriptions), whereas this elevated risk dropped to baseline levels with prolonged use.

CONCLUSIONS

We found that incretin use was not associated with pancreatic cancer after adjustment for the severity of the underlying Type 2 Diabetes Mellitus (T2DM). The elevated risk of pancreatic cancer in those recently initiating incretin agents is likely to be caused by protopathic bias or other types of unknown distortion. The presence of considerable confounding by disease severity and the lack of a duration-of-use relationship do not support a causal explanation for the association between incretin agents and pancreatic cancer.

Diabetes Type 2 and Pancreatic Cancer: A History Unfolding

Pancreatic Cancer is the fourth cause of cancer-related deaths in the United States. Up to 80% of pancreatic cancer patients present with either new-onset type 2 diabetes or impaired glucose tolerance at the time of diagnosis. Recent literature suggests that diabetes mellitus type 2 is a risk factor, a manifestation and a prognostic factor for pancreatic cancer. This article is intended to clarify the evidence about diabetes as a risk factor for pancreatic cancer.

Peroxisome proliferator activated receptors at the crossroad of obesity, diabetes, and pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is the fourth cause of cancer death with an overall survival of 5% at five years. The development of PDAC is characteristically associated to the accumulation of distinctive genetic mutations and is preceded by the exposure to several risk factors. Epidemiology has demonstrated that PDAC risk factors may be non-modifiable risks (sex, age, presence of genetic mutations, ethnicity) and modifiable and co-morbidity factors related to the specific habits and lifestyle. Recently it has become evident that obesity and diabetes are two important modifiable risk factors for PDAC. Obesity and diabetes are complex systemic and intertwined diseases and, over the years, experimental evidence indicate that insulin-resistance, alteration of adipokines, especially leptin and adiponectin, oxidative stress and inflammation may play a role in PDAC. Peroxisome proliferator activated receptor-γ (PPARγ) is a nuclear receptor transcription factor that is implicated in the regulation of metabolism, differentiation and inflammation. PPARγ is a key regulator of adipocytes differentiation, regulates insulin and adipokines production and secretion, may modulate inflammation, and it is implicated in PDAC. PPARγ agonists are used in the treatment of diabetes and oxidative stress-associated diseases and have been evaluated for the treatment of PDAC. PPARγ is at the cross-road of diabetes, obesity, and PDAC and it is an interesting target to pharmacologically prevent PDAC in obese and diabetic patients.

Exosomes: potential for early detection in pancreatic cancer

Progress in the treatment of patients with pancreatic cancer at earlier stages has motivated research in identifying novel noninvasive or minimally invasive biomarkers for early detection. Exosomes, which contain bioactive molecules (such as proteins, RNAs and lipids), are membrane-structured nanovesicles that are secreted from living cells and are found in human body fluids. As functional mediators, exosomes play key roles in cell-cell communications, regulating diverse biological processes. Here we aim to examine recent findings in the potential diagnostic value of serum exosomes in pancreatic cancer.

VNN1, a potential biomarker for pancreatic cancer-associated new-onset diabetes, aggravates paraneoplastic islet dysfunction by increasing oxidative stress

In our previous clinical microarray analysis, we were the first to report on Vanin-1 (VNN1) as a novel clinically derived biomarker of pancreatic cancer-associated new-onset diabetes (PCAND). The functional mechanisms of VNN1 in the pathogenesis of PCAND, however, are not completely understood. In the present study, we further extend our previous clinical study to include laboratory research. The functions and mechanisms of neoplastic overexpressed VNN1 in PCAND have been explored using a co-culture model. Furthermore, the serum concentrations and discrimination power of downstream molecules of VNN1 were tested in a PCAND cohort. Pancreatic ductal adenocarcinoma (PDA) overexpressed VNN1 further aggravates paraneoplastic islet dysfunction; decreases in GSH/PPAR-γ concentrations and increases in ROS/cysteamine might be primary cause of this effect. Clinical serum analyses revealed that the expression profiles of these molecules were aberrant in the PCAND group. Our results further demonstrated that PCAND is a type of paraneoplastic diabetes. As the only clinically derived biomarker for PCAND screening available today, the biological role of VNN1 in triggering oxidative stress within the pancreatic microenvironment is important. The molecules downstream of VNN1 are also potential biomarkers for PCAND screening.

New-onset type 2 diabetes mellitus--A high-risk group suitable for the screening of pancreatic cancer?

BACKGROUND

Type 2 diabetes mellitus is widely considered to be associated with pancreatic cancer.

OBJECTIVE

To determine the incidence of pancreatic cancer in new-onset type 2 diabetic patients by measuring the serum level of CA 19-9 and performing abdominal ultrasonography (US).

PATIENTS AND METHODS

Consecutive type 2 diabetic patients in whom diabetes was diagnosed within 36 months were included in this prospective study. Serum CA 19-9 measurement and US were performed in all patients. If any of two was positive, abdominal computer tomography (CT) was carried out. Endoscopic ultrasound-guided fine needle aspiration or direct surgical referral was performed on patients with CT-identified lesions.

RESULTS

A total of 115 patients were enrolled. CA 19-9 was elevated in 10 patients but pancreatic cancer diagnosed in neither of them. Pancreatic cancer was revealed by morphological means in three patients without elevated CA 19-9 level. The sensitivity, specificity, positive-, negative predictive values and validity were 0%, 90.4%, 0%, 97.9% and 87.9% for CA 19-9, 66.7%, 100%, 100%, 99% and 99% for US, respectively. The value of the Standardized Incidence Ratio for pancreatic cancer in new-onset type-2 diabetic patients was 198.6 (95% CI = 6.25-46.9).

CONCLUSIONS

The prevalence of pancreatic cancer in patients with new-onset type-2 diabetes is significantly higher than that in the general population and screening is beneficial for detecting PaC in this patient population. CA 19-9 and US is not reliable screening modality for pancreatic cancer screening in this population.

Silencing pancreatic adenocarcinoma upregulated factor (PAUF) increases the sensitivity of pancreatic cancer cells to gemcitabine

Pancreatic adenocarcinoma upregulated factor (PAUF) is a new oncogene that activates signaling pathways that play a critical role in resistance to gemcitabine. We thus speculated that PAUF also plays a role in resistance to gemcitabine of pancreatic cancer cells. We established BxPC-3 cell lines with stable PAUF knockdown (BxPC-3_shPAUF) and controls (BxPC-3_shCtrl) and evaluated sensitivity to gemcitabine in vitro by MTT and flow cytometry. We established a xenograft model of human pancreatic cancer to examine PAUF function in gemcitabine resistance in vivo. Gene chip microarrays were performed to identify differentially expressed genes in BxPC-3_shPAUF and BxPC-3_shCtrl cells. Silencing PAUF increased the sensitivity of BxPC-3 cells to gemcitabine in vitro and in vivo. PAUF-knockdown BxPC-3 cell lines treated with gemcitabine showed increased proliferation inhibition and apoptosis compared with controls. Gemcitabine exhibited a more pronounced effect on reduction of BxPC-3_shPAUF tumors than BxPC-3_shCtrl tumors. Terminal deoxynucleotidyl transferase dUTP Nick-End Labeling (TUNEL) assays confirmed a significantly higher apoptotic rate of BXPC-3_shPAUF tumors compared with BXPC-3_shCtrl tumors. Gene array showed that PAUF function in gemcitabine sensitivity might involve MRP2, MRP3, MDR1, PIK3R1, and NFkB2 genes. PAUF could be considered as a key molecular target for sensitizing pancreatic cancer cells to gemcitabine.

New-onset type 2 diabetes, elevated HbA1c, anti-diabetic medications, and risk of pancreatic cancer

Background:

Associations between type 2 diabetes, anti-diabetic medications and pancreatic cancer are controversial. This study aims to clarify such associations with new-onset type 2 diabetes and repeated measurements of glycated haemoglobin (HbA1c) levels.

Methods:

A nested case–control study was initiated from the Health Improvement Network (THIN) in UK from 1996 to 2010. Information of pancreatic cancer cases was retrieved electronically from the medical records and manually validated. Control subjects were randomly selected and frequency-matched to the cases on sex, age, and calendar years. Multivariable unconditional logistic regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI), and adjusted for potential confounders.

Results:

Among 1 574 768 person-years of follow-up, 529 pancreatic cancer cases and 5000 controls were identified. Type 2 diabetes, or changed HbA1c levels (rather than HbA1c levels at diabetes diagnosis) in diabetes patients (⩾4 mmol mol⁻¹ compared with <0 mmol mol⁻¹) were followed by an increased OR of pancreatic cancer (OR, 2.16, 95% CI 1.72–2.72 and OR, 5.06, 95% CI 1.52–16.87, respectively). Among the anti-diabetic medications in diabetes patients, the OR for insulin users was 25.57 (95% CI 11.55–56.60), sulphonylureas 2.22 (95% CI 1.13, 4.40), and metformin users 1.46 (95% CI 0.85–2.52), compared with no use of any anti-diabetic medications.

Conclusions:

New-onset type 2 diabetes and, particularly, diabetes with rising HbA1c seem to be independent risk factors for pancreatic cancer. The relation between different anti-diabetic medications and pancreatic cancer seems to vary in strength, with the highest risk among users of insulin.

Pancreatic Cancer Metabolism: Breaking It Down to Build It Back Up

How do cancer cells escape tightly controlled regulatory circuits that link their proliferation to extracellular nutrient cues? An emerging theme in cancer biology is the hijacking of normal stress response mechanisms to enable growth even when nutrients are limiting. Pancreatic ductal adenocarcinoma (PDA) is the quintessential aggressive malignancy that thrives in nutrient-poor, hypoxic environments. PDAs overcome these limitations through appropriation of unorthodox strategies for fuel source acquisition and utilization. In addition, the interplay between evolving PDA and whole-body metabolism contributes to disease pathogenesis. Deciphering how these pathways function and integrate with one another can reveal novel angles of therapeutic attack.

SIGNIFICANCE

Alterations in tumor cell and systemic metabolism are central to the biology of pancreatic cancer. Further investigation of these processes will provide important insights into how these tumors develop and grow, and suggest new approaches for its detection, prevention, and treatment.

Advances in Biomedical Imaging, Bioengineering, and Related Technologies for the Development of Biomarkers of Pancreatic Disease: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop

A workshop sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Biomedical Imaging and Bioengineering focused on research gaps and opportunities in the development of new biomarkers of pancreatic disease. The session was held on July 22, 2015, and structured into 6 sessions: 1) Introduction and Overview; 2) Keynote Address; 3) New Approaches to the Diagnosis of Chronic Pancreatitis; 4) Biomarkers of Pain and Inflammation; 5) New Approaches to the Detection of Pancreatic Cancer; and 6) Shed Exosomes, Shed Cells, and Shed Proteins. Recent advances in the fields of pancreatic imaging, functional markers of pancreatic disease, proteomics, molecular and cellular imaging, and detection of circulating cancer cells and exosomes were reviewed. Knowledge gaps and research needs were highlighted. The development of new methods for the noninvasive determination of pancreatic pathology; the use of cellular markers of pancreatic function, inflammation, pain, and malignancy; and the refinement of methods to identify cells and cellular constituents of pancreatic cancer were discussed. The further refinement of sophisticated technical methods and the need for clinical studies to validate these new approaches in large-scale studies of patients at risk for the development of pancreatic disease were repeatedly emphasized.

Pancreatic Expression of Immunoglobulin G in Human Pancreatic Cancer and Associated Diabetes

OBJECTIVES

The prognosis of pancreatic cancer (PC) is poor and the pathogenesis of PC-associated diabetes is unknown. We investigated the possible expression of immunoglobulin G (IgG) in human pancreatic carcinomas and adjacent pancreatic islets to gain a better understanding of these diseases.

METHODS

We employed immunohistochemistry, Western Blot, real-time polymerase chain reaction, and in situ hybridization to examine IgG expression in PC tissues and adjacent islets with and without cancer-associated diabetes. The IgG mRNA and IgG synthesizing-related enzymes were examined in PC cell lines. The IgG expression and secretion were downregulated with specific small interfering RNA and antibody to IgG followed by flow cytometry to assess its effect on apoptosis of cultured PC cells.

RESULTS

The expression of IgG was detected in pancreatic carcinoma and adjacent islets. Small interfering RNA and antibody treatments induced apoptosis in PC cell lines. In the carcinoma tissue, the levels of IgG expression varied depending on the stages of the cancers with more malignant cancers expressing more IgG (P < 0.05). The IgG levels in cancer cells were also increased when the patients had diabetes or hyperglycemia (P < 0.05). In addition, the extent of IgG expression in the seemingly normal islet cells adjacent to the tumor varied in relation to the grade of cancer differentiation and distance to the cancer nests.

CONCLUSIONS

(1) Immunoglobulin G was locally produced by PC cells and adjacent islet cells. (2) Immunoglobulin G may promote tumor growth by inhibiting cancer cell apoptosis. (3) Locally produced IgG might play a role in PC-associated diabetes.

Predictors for Pancreatic Cancer Diagnosis Following New-Onset Diabetes Mellitus

OBJECTIVES

New-onset diabetes mellitus (NODM) in adults is often an early manifestation of pancreatic cancer (PaCa), but the incidence of PaCa in this cohort is rather low. We evaluated whether combining other patient factors such as age, smoking history, the absence of obesity, the presence of chronic pancreatitis (CP), and gallstone disease can result in a more enriched cohort.

METHODS

After a washout period of 2 years to exclude pre-existing PaCa or DM, 507,378 non-diabetic patients in the veterans' administration healthcare system were identified. Patients <40 years (n=54,465) and those with PaCa diagnosed before the diagnosis of diabetes (n=22) were excluded. A total of 452,804 veterans were followed for development of DM or PaCa.

RESULTS

73,811 patients (16.3%) developed NODM during the follow-up period. One hundred and eighty-three NODM patients (0.25%) were diagnosed with PaCa within 3 years. In comparison, 434 of 378,993 remaining patients (0.11%) developed PaCa in 3 years following inclusion into the study [relative risk (RR)=2.27, 95% confidence intervals (CI) 1.96, 2.63; P<0.0001]. The risk of PaCa diagnosis was higher among patients who were non-obese (RR=1.51), were ≥65 years old (RR=2.01), were heavy smokers (RR=1.55), and had a history of CP (RR=4.72) or gallstone disease (RR=2.02). Using a combination of these risk factors in NODM patients resulted in up to 0.72% three-year risk of PaCa but captured only 17% of patients with PaCa.

CONCLUSIONS

Based on our findings, the likelihood of PaCa in adults with NODM even after adjusting for other potential risk factors for PaCa including age, body mass index, smoking, gallstones, and CP is probably not high enough to recommend routine evaluation for all these patients for underlying PaCa.

A rapid in vivo screen for pancreatic ductal adenocarcinoma therapeutics

Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer-related deaths in the United States, and is projected to be second by 2025. It has the worst survival rate among all major cancers. Two pressing needs for extending life expectancy of affected individuals are the development of new approaches to identify improved therapeutics, addressed herein, and the identification of early markers. PDA advances through a complex series of intercellular and physiological interactions that drive cancer progression in response to organ stress, organ failure, malnutrition, and infiltrating immune and stromal cells. Candidate drugs identified in organ culture or cell-based screens must be validated in preclinical models such as KIC (p48(Cre);LSL-Kras(G12D);Cdkn2a(f/f)) mice, a genetically engineered model of PDA in which large aggressive tumors develop by 4 weeks of age. We report a rapid, systematic and robust in vivo screen for effective drug combinations to treat Kras-dependent PDA. Kras mutations occur early in tumor progression in over 90% of human PDA cases. Protein kinase and G-protein coupled receptor (GPCR) signaling activates Kras. Regulators of G-protein signaling (RGS) proteins are coincidence detectors that can be induced by multiple inputs to feedback-regulate GPCR signaling. We crossed Rgs16::GFP bacterial artificial chromosome (BAC) transgenic mice with KIC mice and show that the Rgs16::GFP transgene is a Kras(G12D)-dependent marker of all stages of PDA, and increases proportionally to tumor burden in KIC mice. RNA sequencing (RNA-Seq) analysis of cultured primary PDA cells reveals characteristics of embryonic progenitors of pancreatic ducts and endocrine cells, and extraordinarily high expression of the receptor tyrosine kinase Axl, an emerging cancer drug target. In proof-of-principle drug screens, we find that weanling KIC mice with PDA treated for 2 weeks with gemcitabine (with or without Abraxane) plus inhibitors of Axl signaling (warfarin and BGB324) have fewer tumor initiation sites and reduced tumor size compared with the standard-of-care treatment. Rgs16::GFP is therefore an in vivo reporter of PDA progression and sensitivity to new chemotherapeutic drug regimens such as Axl-targeted agents. This screening strategy can potentially be applied to identify improved therapeutics for other cancers.

Osteoprotegerin is up-regulated in pancreatic cancers and correlates with cancer-associated new-onset diabetes

New-onset diabetes might help to yield biomarkers for the early diagnosis of pancreatic cancer (PaC). In this study, we computationally predicted and experimentally validated osteoprotegerin (OPG) being associated with pancreatic cancer related new-onset diabetes. We first performed a meta-analysis on microarray datasets to search for genes specifically highly expressed in PaC, and then filtered for cytokines involved in islet dysfunction. The expression of OPG in PaC and normal pancreas were validated by immunohistochemistry. Serum OPG levels in healthy controls, non-cancerous diabetes and PaC patients with or without diabetes were detected by enzyme-linked immunosorbent assay (ELISA). In silico assay found that OPG up-regulated in PaC tissues in comparison to normal pancreas. Immunohistochemical data further confirmed that OPG was overexpressed in PaC samples. Furthermore, increased expression of OPG in PaC tissues correlated to the occurrence of new-onset diabetes, and adversely affected the patients&apos; overall survival in both univariate and multivariate analysis. In addition, the serum levels of OPG were significantly higher in pancreatic cancer patients with new-onset diabetes than other groups including pancreatic patients without diabetes, new-onset type 2 diabetes and healthy controls. In conclusion, there is a close association between OPG and pancreatic cancer related new-onset diabetes, and OPG might serve as a potential biomarker for the early diagnosis of pancreatic cancer from populations with new-onset diabetes.

Diabetes associated with pancreatic diseases

PURPOSE OF REVIEW

A relevant number of patients with pancreatic disorders suffer from secondary diabetes. Recent data have shed light on the link between pancreatic damage and subsequent impairments in glucose homeostasis. Furthermore, epidemiological studies provided insights into the relationship between diabetes and the risk of pancreatic carcinoma or pancreatitis. Pancreaticogenic diabetes requires a tailored therapeutic approach taking into account the individual properties of the available glucose-lowering drugs.

RECENT FINDINGS

We review the available literature concerning diabetes in patients with acute or chronic pancreatitis or pancreatic carcinoma. The relationship between the pancreatic damage and alterations in insulin and glucose homeostasis is summarized as well as the effect of diabetes mellitus on the risk of pancreatic cancer and pancreatitis. Caveats in the treatment of pancreaticogenic diabetes with currently available drugs are being discussed.

SUMMARY

Patients with pancreatic diseases should be screened for diabetes by means of an oral glucose tolerance test. There is a close inverse relationship between pancreatic β-cell loss and postchallenge hyperglycemia. The risk of hypoglycemia may be increased in patients with pancreaticogenic diabetes. Newly diagnosed diabetes may be a harbinger of pancreatic cancer. There is increasing evidence suggesting an increased risk for (pancreatic) cancer and pancreatitis in patients with diabetes mellitus. Further studies on the ideal glucose-lowering treatment of patients with pancreaticogenic diabetes will be required.

Blood Glucose Homeostasis in the Course of Partial Pancreatectomy--Evidence for Surgically Reversible Diabetes Induced by Cholestasis

BACKGROUND AND AIM

Partial pancreatic resection is accompanied not only by a reduction in the islet cell mass but also by a variety of other factors that are likely to interfere with glucose metabolism. The aim of this work was to characterize the patient dynamics of blood glucose homeostasis during the course of partial pancreatic resection and to specify the associated clinico-pathological variables.

METHODS

In total, 84 individuals undergoing elective partial pancreatic resection were consecutively recruited into this observational trial. The individuals were assigned based on their fasting glucose or oral glucose tolerance testing results into one of the following groups: (I) deteriorated, (II) stable or (III) improved glucose homeostasis three months after surgery. Co-variables associated with blood glucose dynamics were identified.

RESULTS

Of the 84 participants, 25 (30%) displayed a normal oGTT, 17 (20%) showed impaired glucose tolerance, and 10 (12%) exhibited pathological glucose tolerance. Elevated fasting glucose was present in 32 (38%) individuals before partial pancreatic resection. Three months after partial pancreatic resection, 14 (17%) patients deteriorated, 16 (19%) improved, and 54 (64%) retained stable glucose homeostasis. Stability and improvement was associated with tumor resection and postoperative normalization of recently diagnosed glucose dysregulation, preoperatively elevated tumor markers and markers for common bile duct obstruction, acute pancreatitis and liver cell damage. Improvement was linked to preoperatively elevated insulin resistance, which normalized after resection and was accompanied by a decrease in fasting- and glucose-stimulated insulin secretion.

CONCLUSIONS

Surgically reversible blood glucose dysregulation diagnosed concomitantly with a (peri-) pancreatic tumor appears secondary to compromised liver function due to tumor compression of the common bile duct and the subsequent increase in insulin resistance. It can be categorized as "cholestasis-induced diabetes" and thereby distinguished from other forms of hyperglycemic disorders.

Distal Enteral Feeding Helps Blood Sugar Control in Pancreatectomized Patients

BACKGROUND

The change in the route of food passage after pancreaticoduodenectomy (PD) is quite similar to the change after gastric bypass surgery; both procedures bypass the duodenum and directly connect to the distal jejunum. Moreover, both procedures result in resolution of type 2 diabetes mellitus. Therefore, more distal enteral anastomosis after PD may further improve glycemic status.

METHODS

To test the effect of distal enteral feeding on glucose metabolism in patients after PD, we performed a meal test on 20 patients via a nasogastric tube [proximal feeding group (PFG)] on post-operative day 5 and then via an intra-operatively placed jejunostomy feeding tube [distal feeding group (DFG)] on post-operative day. Blood samples were assessed for hormones and glucose.

RESULTS

The AUC0-120 min levels of GLP-1, C-peptide, and insulin after distal feeding were significantly higher than after proximal feeding. The AUC0-120 min levels of glucose in the DFG were significantly lower than in the PFG.

CONCLUSIONS

More distal enteral feeding contributed to better glucose metabolism after PD.

Current status and progress of pancreatic cancer in China

Cancer is currently one of the most important public health problems in the world. Pancreatic cancer is a fatal disease with poor prognosis. As in most other countries, the health burden of pancreatic cancer in China is increasing, with annual mortality rates almost equal to incidence rates. The increasing trend of pancreatic cancer incidence is more significant in the rural areas than in the urban areas. Annual diagnoses and deaths of pancreatic cancer in China are now beyond the number of cases in the United States. GLOBOCAN 2012 estimates that cases in China account for 19.45% (65727/337872) of all newly diagnosed pancreatic cancer and 19.27% (63662/330391) of all deaths from pancreatic cancer worldwide. The population’s growing socioeconomic status contributes to the rapid increase of China’s proportional contribution to global rates. Here, we present an overview of control programs for pancreatic cancer in China focusing on prevention, early diagnosis and treatment. In addition, we describe key epidemiological, demographic, and socioeconomic differences between China and developed countries. Facts including no nationwide screening program for pancreatic cancer, delay in early detection resulting in a late stage at presentation, lack of awareness of pancreatic cancer in the Chinese population, and low investment compared with other cancer types by government have led to backwardness in China’s pancreatic cancer diagnosis and treatment. Finally, we suggest measures to improve health outcomes of pancreatic cancer patients in China.

Glycemic Change After Pancreaticoduodenectomy: A Population-Based Study

The purpose of this population-based study was to determine the change of glucose metabolism in patients undergoing pancreaticoduodenectomy (PD).We conducted a nationwide cohort study using data from Taiwan's National Health Insurance Research Database collected between 2000 and 2010. Our sample included 861 subjects with type 2 diabetes mellitus (DM) and 3914 subjects without DM.Of 861 subjects with type 2 diabetes, 174 patients (20.2%) experienced resolution of their diabetes after PD, including patients with pancreatic ductal adenocarcinoma (PDAC) (20.5%), and non-PDAC (20.1%). Using a multiple logistic regression model, we found that subjects with comorbid chronic pancreatitis (odds ratio, 0.356; 95% CI, 0.167-0.759; P = 0.007) and use of insulin (odds ratio, 0.265; 95% CI, 0.171-0.412; P < 0.001) had significantly lower rates of resolution of diabetes. In the 3914 subjects without diabetes, the only statistically significant comorbidity contributing to pancreatogenic diabetes was chronic pancreatitis (odds ratio, 1.446; 95% CI, 1.146-1.823; P = 0.002).Subjects with comorbid chronic pancreatitis and use of insulin had lower rates of resolution of DM after PD. In subjects without diabetes, chronic pancreatitis contributed significantly to the development of pancreatogenic DM.

Pancreatic cancer and diabetes: A two-way relationship in the perspective of diabetologist

Diabetes is a risk factor for pancreatic cancer as roughly half of all patients with pancreatic cancer are found to have diabetes at time of diagnosis. Moreover, an around 2-fold risk of pancreatic malignancy in diabetic patients has even be recently resulted from two meta-analysis. Actually, there is a bidirectional association between the two entities that implies a complex and reverse causality. In fact, while the risk for pancreatic cancer is modestly but significantly increased in patients with long-standing diabetes, recent-onset diabetes appears to be very frequently associated with pancreatic malignancy. Therefore, diabetes could serve as an excellent clue for early detection of pancreatic cancer. Moreover, recent epidemiological findings support the hypothesis that chronic exposure to hyperglycemia, higher insulin concentrations, and insulin resistance may be responsible for the enhanced risk of developing pancreatic cancer. Epidemiological data suggest that the type of anti-diabetic therapy may affect the risk of developing pancreatic cancer. In particular, metformin has been shown to reduce the risk of pancreatic cancer, as well as several other malignancies. On the other hand, some hypoglycemic agents could determine an increase of pancreatic cancer risk. These last findings were not confirmed. Finally, pancreatic cancer necessitates of a multidisciplinary management, primarily including surgeons and oncologists. In this context, the diabetologist plays an important role, given that his actions may influence the prevention and early diagnosis of pancreatic cancer, the perioperative complications associated to glycemic derangement, as well as the proper treatment of postpancreactomy diabetes.

Pancreatic Cancer-Derived Exosomes Cause Paraneoplastic β-cell Dysfunction

PURPOSE

Pancreatic cancer frequently causes diabetes. We recently proposed adrenomedullin as a candidate mediator of pancreatic β-cell dysfunction in pancreatic cancer. How pancreatic cancer-derived adrenomedullin reaches β cells remote from the cancer to induce β-cell dysfunction is unknown. We tested a novel hypothesis that pancreatic cancer sheds adrenomedullin-containing exosomes into circulation, which are transported to β cells and impair insulin secretion.

EXPERIMENTAL METHODS

We characterized exosomes from conditioned media of pancreatic cancer cell lines (n = 5) and portal/peripheral venous blood of patients with pancreatic cancer (n = 20). Western blot analysis showed the presence of adrenomedullin in pancreatic cancer-exosomes. We determined the effect of adrenomedullin-containing pancreatic cancer exosomes on insulin secretion from INS-1 β cells and human islets, and demonstrated the mechanism of exosome internalization into β cells. We studied the interaction between β-cell adrenomedullin receptors and adrenomedullin present in pancreatic cancer-exosomes. In addition, the effect of adrenomedullin on endoplasmic reticulum (ER) stress response genes and reactive oxygen/nitrogen species generation in β cells was shown.

RESULTS

Exosomes were found to be the predominant extracellular vesicles secreted by pancreatic cancer into culture media and patient plasma. Pancreatic cancer-exosomes contained adrenomedullin and CA19-9, readily entered β cells through caveolin-mediated endocytosis or macropinocytosis, and inhibited insulin secretion. Adrenomedullin in pancreatic cancer exosomes interacted with its receptor on β cells. Adrenomedullin receptor blockade abrogated the inhibitory effect of exosomes on insulin secretion. β cells exposed to adrenomedullin or pancreatic cancer exosomes showed upregulation of ER stress genes and increased reactive oxygen/nitrogen species.

CONCLUSIONS

Pancreatic cancer causes paraneoplastic β-cell dysfunction by shedding adrenomedullin(+)/CA19-9(+) exosomes into circulation that inhibit insulin secretion, likely through adrenomedullin-induced ER stress and failure of the unfolded protein response.

Metformin use among type 2 diabetics and risk of pancreatic cancer in a clinic-based case-control study

A better understanding of the association between diabetes and pancreatic cancer (PC) may inform prevention and/or early detection strategies. Metformin has been associated with reduced risk of certain cancers, including PC, in some observational clinical studies. We assessed whether metformin use was associated with PC risk among those with type 2 diabetes (DM2), and whether metformin use modulated the association between DM2 and risk of PC. In total, 536 PC cases and 869 frequency-matched controls were recruited predominantly from University of California San Francisco medical clinics from 2006 to 2011. Eligible participants completed direct interviews using a structured risk factor questionnaire. The association between metformin use and PC risk was assessed using propensity score-weighted unconditional logistic regression methods in analyses restricted to diabetics and adjusted multivariable logistic models in the total study population. Ever use of metformin was not associated with PC risk in analyses restricted to DM2 (N = 170) participants (adjusted OR: 1.01, 95% CI: 0.61-1.68). In the total study population (N = 1,405) using nondiabetics as the referent group, PC risk was inversely associated with diabetes duration (ptrend  < 0.001). Further, when DM2 participants were grouped by ever/never use of metformin and compared with nondiabetics, metformin use did not affect the association between DM2 and PC risk (never users: OR: 1.44, 95% CI: 0.78-2.67; ever users: OR: 1.19, 95% CI: 0.72-1.99). Results from our clinic-based case-control study suggest that metformin use is not associated with PC risk among those with DM2 and does not alter the association between DM2 and PC risk.

The Impact of Diabetes Mellitus and Metformin Treatment on Survival of Patients with Advanced Pancreatic Cancer Undergoing Chemotherapy

PURPOSE

A causal relationship between diabetes mellitus (DM) and pancreatic cancer is well established. However, in patients with advanced pancreatic cancer (APC) who receive palliative chemotherapy, the impact of DM on the prognosis of APC is unclear.

MATERIALS AND METHODS

We retrospectively enrolled APC patients who received palliative chemotherapy between 2003 and 2010. The patients were stratified according to the status of DM, in accordance with 2010 DM criteria (American Heart Association/American Diabetes Association). DM at least 2 years' duration prior to diagnosis of APC was defined as remote-onset DM (vs. recent-onset).

RESULTS

Of the 349 APC patients, 183 (52.4%) had DM. Among the patients with DM, 160 patients had DM at the time of diagnosis of APC (remote-onset, 87; recent-onset, 73) and the remaining 23 patients developed DM during treatment of APC. Ultimately, 73.2% of patients (134/183) with DM received antidiabetic medication, including metformin (56 patients, 41.8%), sulfonylurea (62, 45.5%), and insulin (43, 32.1%). In multivariate analysis, cancer extent (hazard ratio [HR], 1.792; 95% confidence interval [CI], 1.313 to 2.445; p < 0.001) showed association with decreased overall survival (OS), whereas a diagnosis of DM (HR, 0.788; 95% CI, 0.615 to 1.009; p=0.059) conferred positive tendency on the OS. Metformin treatment itself conferred better OS in comparison within DM patients (HR 0.693; 95% CI, 0.492 to 0.977; p=0.036) and even in all APC patients (adjusted HR, 0.697; 95% CI, 0.491 to 1.990; p=0.044).

CONCLUSION

For APC patients receiving palliative chemotherapy, metformin treatment is associated with longer OS. Patients with DM tend to survive longer than those without DM.

Biomarkers for early diagnosis of pancreatic cancer

Pancreatic ductal adenocarcinoma is an aggressive malignancy with a 5-year survival rate of approximately 5%. The lack of established strategies for early detection contributes to this poor prognosis. Although several novel candidate biomarkers have been proposed for earlier diagnosis, none have been adopted into routine clinical use. In this review, the authors examine the challenges associated with finding new pancreatic cancer diagnostic biomarkers and explore why translation of biomarker research for patient benefit has thus far failed. The authors also review recent progress and highlight advances in the understanding of the biology of pancreatic cancer that may lead to improvements in biomarker detection and implementation.

Pancreatic polypeptide response to a mixed meal is blunted in pancreatic head cancer associated with diabetes mellitus

INTRODUCTION

Pancreatic polypeptide (PP) is a hormone secreted by islet cells of the ventral pancreas. It has been proposed that a blunted PP response to a mixed meal can distinguish diabetes mellitus (DM) secondary to pancreatic disease from other types of DM. We performed a proof of concept study to determine if PP response to a mixed meal discriminates DM secondary to pancreatic cancer (PaCDM) from type 2 DM (T2DM).

METHODS

We studied 18 subjects with new onset DM (PaCDM (n = 9) and T2DM (n = 9); matched for age and gender). Serum PP levels were measured at 0, 30, and 60 min following a mixed meal. Increases in PP levels from baseline were compared using the Wilcoxon test.

RESULTS

In PaCDM the PP increase following a mixed meal was less than T2DM at 30 min (median 60.0%, IQR, 33.0-119.8 vs. 134.5%, IQR, 117.5-265.9; p = 0.03), but statistically similar at 60 min (median 55.8%, interquartile range (IQR) 23.7-121.5 vs. 100.0%, IQR, 47.7-202.5; p = 0.17). In PaCDM subjects, the PP increase over baseline was smaller in those with a tumor located in the pancreatic head (n = 6) compared to the body/tail (n = 3) at 30 min (41.3% vs. 158.7%, p = 0.02) and at 60 min (37.4% vs. 167.4%,p = 0.04).

CONCLUSIONS

Subjects with PaCDM have a blunted PP response to a mixed meal compared to T2DM. However, the blunted PP response is only observed in those PaC subjects with a tumor located in the head of the pancreas. Confirmation in larger studies may suggest this could be used to aid screening for sporadic PaC.

Pancreatic cancer-associated diabetes is an "exosomopathy"

Diabetes may be a consequence of pancreatic cancer, preceding cancer diagnosis. The underlying mechanism is the release of exosomes delivering adrenomedullin to β cells, inducing endoplasmic reticulum stress and perturbations in the unfolded protein response, leading to β-cell dysfunction and death. This knowledge could lead to improved diagnostic strategies for pancreatic cancer.

Metformin reduces serum CA199 levels in type 2 diabetes Chinese patients with time-effect and gender difference

BACKGROUND

This study was designed to clarify the influence of metformin on serum carbohydrate antigen 199 (CA199) levels and its associated factors in Chinese type 2 diabetes mellitus (T2DM) patients.

SUBJECTS AND METHODS

In total, 1,253 T2DM patients were enrolled, including a non-metformin group (n = 616), a short-term metformin group (at least 1 week to 2 years; n=325), and a long-term metformin group (≥ 2 years; n = 312). Their clinical and biochemical characteristics were collected and compared. After 1 year, the biochemical parameters were re-examined in 296 patients. Sex hormones were determined, and associations between CA199 and other variables were assessed.

RESULTS

At baseline, the incidence of abnormal CA199 levels was 14.7%, 8.9%, and 4.7% in the non-metformin, short-term metformin, and long-term metformin groups, respectively. CA199 levels in females were significantly higher than in males (P < 0.01) and decreased significantly with the time of taking metformin (25.60 ± 13.68 U/mL in non-metformin controls vs. 17.62 ± 10.87 U/mL in the short-term group vs. 10.54 ± 8.14 U/mL in the long-term group; P = 0.000). The correlation and multiple stepwise regression analysis revealed that glycosylated hemoglobin, metformin, gender, total cholesterol, and follicle-stimulating hormone were independent impact factors on CA199 concentrations (all P < 0.05). Binary logistic regression revealed that the risk of abnormal CA199 concentrations of the total population with short-term metformin or long-term metformin treatment decreased 11% (odds ratio = 0.89; P = 0.001) and 30% (odds ratio = 0.70; P = 0.000), respectively, at baseline. After a 1-year follow-up, the incidence of high CA199 level decreased in both the short-term and the long-term metformin group compared with that of controls (P < 0.05). The extent of CA199 decrease in the long-term metformin group was the greatest (-17% vs. -4.9% in the short-term group vs. 3% in controls, P = 0.000), and the group's risk of high blood CA199 level was reduced 67% (odds ratio = 0.33; P = 0.023). The reduction in women was more apparent than that in men (-18% vs. -5%, P = 0.000).

CONCLUSIONS

Metformin therapy reduced the CA199 level in Chinese T2DM patients, and its greatest decrease occurred in women with longer therapeutic time.

Diabetes mellitus as a novel risk factor for gastrointestinal malignancies

Evidence of an emerging etiologic link between diabetes mellitus and several gastrointestinal malignancies is presented. Although a correlation between pancreatic cancer and diabetes mellitus has long been suspected, the potential role diabetes mellitus plays in the pathogenicity of both hepatocellular carcinoma and colon cancer is becoming increasingly well defined. Further supporting the prospect of etiologic linkage, the association of diabetes mellitus with colon cancer is consistently demonstrated to be independent of obesity. An increasing incidence of diabetes and obesity in the United States has led to a recent surge in incidence of hepatocellular cancer on the background of nonalcoholic fatty liver disease, and this disease is expected to commensurately grow in incidence. Widespread recognition of this emerging risk factor may lead to a change in screening practices. Although the mechanisms underlying the correlation are still under investigation, the role of insulin, the insulin-like growth factor-I, and related binding and signaling pathways as regulators of cell growth and cell proliferation are implicated in carcinogenesis and tumor growth. The potential role of metformin and other medications for diabetes mellitus in the chemoprevention, carcinogenesis, and treatment of gastrointestinal malignancies is also presented.

Blood glucose concentration and risk of pancreatic cancer: systematic review and dose-response meta-analysis

OBJECTIVE

To evaluate potential linear and non-linear dose-response relations between blood glucose and risk of pancreatic cancer.

DESIGN

Systematic review and dose-response meta-analysis of prospective observational studies.

DATA SOURCES

Search of PubMed, Scopus, and related reviews before 30 November 2013 without language restriction.

ELIGIBILITY CRITERIA

Prospective studies evaluating the association between blood glucose concentration and pancreatic cancer. Retrospective and cross sectional studies excluded to avoid reverse causality.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted relevant information and assessed study quality with the Newcastle-Ottawa scale. Random effects dose-response meta-analysis was conducted to assess potential linear and non-linear dose-response relations.

RESULTS

Nine studies were included for analysis, with a total of 2408 patients with pancreatic cancer. There was a strong linear dose-response association between fasting blood glucose concentration and the rate of pancreatic cancer across the range of prediabetes and diabetes. No non-linear association was detected. The pooled rate ratio of pancreatic cancer per 0.56 mmol/L (10 mg/dL) increase in fasting blood glucose was 1.14 (95% confidence interval 1.06 to 1.22; P<0.001) without significant heterogeneity. Sensitivity analysis excluding blood glucose categories in the range of diabetes showed similar results (pooled rate ratio per 0.56 mmol/L increase in fasting blood glucose was 1.15, 95% confidence interval 1.05 to 1.27; P=0.003), strengthening the association between prediabetes and pancreatic cancer.

CONCLUSIONS

Every 0.56 mmol/L increase in fasting blood glucose is associated with a 14% increase in the rate of pancreatic cancer. As prediabetes can be improved or even reversed through lifestyle changes, early detection of prediabetes coupled with lifestyle changes could represent a viable strategy to curb the increasing incidence of pancreatic cancer.

Diagnostic evaluation and staging of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDA) frequently presents at an advanced and incurable stage of the disease. Common signs and symptoms of PDA include abdominal or back pain, jaundice, weight loss, pruritus, and nausea/vomiting. Diagnostic workup includes serum chemistries and CA19-9, primarily to monitor disease status and response to treatment. Imaging studies are performed to assess resectability and stage disease, and pancreatic protocol computed tomography (CT) scan or magnetic resonance imaging (MRI) are the preferred imaging studies for this purpose. Conventional staging is based on the American Joint Cancer Committee (AJCC) Staging System, 7th Edition and informs prognosis, while surgical staging systems focus specifically on assessing the likelihood of a complete (negative margins) resection with operative management. Herein, we review the presenting signs and symptoms, the diagnostic evaluation, and staging of PDA.