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Nené NR, Ney A, Nazarenko T, Blyuss O, Johnston HE, Whitwell HJ, Sedlak E, Gentry-Maharaj A, Apostolidou S, Costello E, Greenhalf W, Jacobs I, Menon U, Hsuan J, Pereira SP, Zaikin A, Timms JF. Serum biomarker-based early detection of pancreatic ductal adenocarcinomas with ensemble learning. COMMUNICATIONS MEDICINE 2023; 3:10. [PMID: 36670203 PMCID: PMC9860022 DOI: 10.1038/s43856-023-00237-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Earlier detection of pancreatic ductal adenocarcinoma (PDAC) is key to improving patient outcomes, as it is mostly detected at advanced stages which are associated with poor survival. Developing non-invasive blood tests for early detection would be an important breakthrough. METHODS The primary objective of the work presented here is to use a dataset that is prospectively collected, to quantify a set of cancer-associated proteins and construct multi-marker models with the capacity to predict PDAC years before diagnosis. The data used is part of a nested case-control study within the UK Collaborative Trial of Ovarian Cancer Screening and is comprised of 218 samples, collected from a total of 143 post-menopausal women who were diagnosed with pancreatic cancer within 70 months after sample collection, and 249 matched non-cancer controls. We develop a stacked ensemble modelling technique to achieve robustness in predictions and, therefore, improve performance in newly collected datasets. RESULTS Here we show that with ensemble learning we can predict PDAC status with an AUC of 0.91 (95% CI 0.75-1.0), sensitivity of 92% (95% CI 0.54-1.0) at 90% specificity, up to 1 year prior to diagnosis, and at an AUC of 0.85 (95% CI 0.74-0.93) up to 2 years prior to diagnosis (sensitivity of 61%, 95% CI 0.17-0.83, at 90% specificity). CONCLUSIONS The ensemble modelling strategy explored here outperforms considerably biomarker combinations cited in the literature. Further developments in the selection of classifiers balancing performance and heterogeneity should further enhance the predictive capacity of the method.
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Affiliation(s)
- Nuno R Nené
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK.
- Institute for Women's Health, University College London, Cruciform Building 1.1, Gower Street, London, WC1E 6BT, UK.
| | - Alexander Ney
- Institute for Liver and Digestive Health, University College London, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Tatiana Nazarenko
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
- Department of Mathematics, University College London, London, WC1H 0AY, UK
| | - Oleg Blyuss
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
- Wolfson Institute of Population Health, Queen Mary University of London, Charterhouse Square, EC1M 6BQ, London, UK
| | - Harvey E Johnston
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
- Babraham Institute, Babraham Research Campus, Cambridge, CB22 3AT, UK
| | - Harry J Whitwell
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
- National Phenome Centre and Imperial Clinical Phenotyping Centre, Department of Metabolism, Digestion and Reproduction, IRDB Building, Imperial College London, Hammersmith Campus, London, W12 0NN, UK
- Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Eva Sedlak
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
| | - Aleksandra Gentry-Maharaj
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK
| | - Sophia Apostolidou
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK
| | - Eithne Costello
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - William Greenhalf
- Liverpool Experimental Cancer Medicine Centre, University of Liverpool, Liverpool, L69 3GL, UK
| | - Ian Jacobs
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
- University of New South Wales, Sydney, NSW, 2052, Australia
| | - Usha Menon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK
| | - Justin Hsuan
- Institute for Liver and Digestive Health, University College London, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, University College London, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Alexey Zaikin
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
- Department of Mathematics, University College London, London, WC1H 0AY, UK
| | - John F Timms
- Department of Women's Cancer, EGA Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
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2
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Zhao J, Liang Y, Yin Q, Liu S, Wang Q, Tang Y, Cao C. Clinical and prognostic significance of serum transforming growth factor-beta1 levels in patients with pancreatic ductal adenocarcinoma. ACTA ACUST UNITED AC 2017; 49:S0100-879X2016000800705. [PMID: 27464025 PMCID: PMC4964897 DOI: 10.1590/1414-431x20165485] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/08/2016] [Indexed: 12/24/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has a poor 5-year survival rate of 5%. Biomarkers for the early detection of pancreatic cancer are urgently needed. Transforming growth factor-beta1 (TGF-β1) is elevated in the tissues and plasma of patients with PDAC. However, no studies systemically report prognostic significance of plasma TGF-β1 levels in PDAC. In the present study, we assessed the prognostic significance of serum TGF-β levels in patients with PDAC. TGF-β levels were determined in serum from 146 PDAC patients, and 58 patients with benign pancreatic conditions. Regression models were used to correlate TGF-β levels to gender, age, stage, class, and metastasis. Survival analyses were performed using multivariate Cox models. Serum levels of TGF-β1 distinguished PDAC from benign pancreatic conditions (P<0.001) and healthy control subjects (P<0.001). Serum levels of TGF-β also distinguished tumor stage (P=0.002) and lymph node metastasis (P=0.001). High serum levels of TGF-β1 were significantly correlated with reduced patient survival. Multivariate analysis revealed that TGF-β1, lymph node metastasis and tumor stage were independent factors for PDAC survival. Our results indicate that serum TGF-β1 may be used as a potential prognostic marker for PDAC.
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Affiliation(s)
- J Zhao
- Department of Clinical Laboratory, People's Hospital of Weifang, Shandong, China
| | - Y Liang
- Department of Surgery, People's Hospital of Rizhao, Shandong, China
| | - Q Yin
- Department of Oncology, People's Hospital of Rizhao, Shandong, China
| | - S Liu
- Department of Oncology, People's Hospital of Rizhao, Shandong, China
| | - Q Wang
- Department of Surgery, People's Hospital of Rizhao, Shandong, China.,Department of Clinical Laboratory, People's Hospital of Zhangqiu, Shandong, China
| | - Y Tang
- Department of Surgery, People's Hospital of Rizhao, Shandong, China.,Department of Medical Laboratory Diagnosis Center, Jinan Central Hospital, Shandong, China
| | - C Cao
- Department of Medical Laboratory Diagnosis Center, Jinan Central Hospital, Shandong, China
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3
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Ntanasis-Stathopoulos I, Tsilimigras DI, Georgiadou D, Kanavidis P, Riccioni O, Salla C, Psaltopoulou T, Sergentanis TN. Squamous cell carcinoma of the pancreas: A systematic review and pooled survival analysis. Eur J Cancer 2017; 79:193-204. [PMID: 28511147 DOI: 10.1016/j.ejca.2017.04.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 04/03/2017] [Accepted: 04/09/2017] [Indexed: 02/06/2023]
Abstract
The diagnosis and treatment of squamous cell carcinoma of the pancreas pose dilemmas in the clinical practice. The present study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible articles were sought in MEDLINE up to 30th April 2016. A pooled Cox regression analysis was performed to evaluate factors potentially associated with overall survival (OS) and relapse-free survival (RFS). Fifty-four cases of pure squamous cell pancreatic carcinomas were identified in total. The mean age was 61.9 years, and most patients were males (61.1%). The median OS was 7 months. Resectability (p = 0.003) and more recent publication year (p < 0.001) were associated with better OS, as was low/intermediate tumour grade (p = 0.032) with RFS. Despite its poor prognosis, survival rates of pancreatic squamous cell carcinoma seem improved during the recent years; resectability and low/intermediate grade emerged as favourable prognostic factors. Collaborative epidemiological studies are deemed necessary to further validate the results stemming from the published case reports of this rare entity.
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Affiliation(s)
- Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Diamantis I Tsilimigras
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Prodromos Kanavidis
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Olga Riccioni
- School of Medicine, La Sapienza University of Rome, Rome, Italy; HIPON European Commission Educational E-learning Project, Greece
| | | | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros N Sergentanis
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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Ahmed S, Bradshaw AD, Gera S, Dewan MZ, Xu R. The TGF-β/Smad4 Signaling Pathway in Pancreatic Carcinogenesis and Its Clinical Significance. J Clin Med 2017; 6:jcm6010005. [PMID: 28067794 PMCID: PMC5294958 DOI: 10.3390/jcm6010005] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/07/2016] [Accepted: 12/27/2016] [Indexed: 12/24/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most fatal human cancers due to its complicated genomic instability. PDAC frequently presents at an advanced stage with extensive metastasis, which portends a poor prognosis. The known risk factors associated with PDAC include advanced age, smoking, long-standing chronic pancreatitis, obesity, and diabetes. Its association with genomic and somatic mutations is the most important factor for its aggressiveness. The most common gene mutations associated with PDAC include KRas2, p16, TP53, and Smad4. Among these, Smad4 mutation is relatively specific and its inactivation is found in more than 50% of invasive pancreatic adenocarcinomas. Smad4 is a member of the Smad family of signal transducers and acts as a central mediator of transforming growth factor beta (TGF-β) signaling pathways. The TGF-β signaling pathway promotes many physiological processes, including cell growth, differentiation, proliferation, fibrosis, and scar formation. It also plays a major role in the development of tumors through induction of angiogenesis and immune suppression. In this review, we will discuss the molecular mechanism of TGF-β/Smad4 signaling in the pathogenesis of pancreatic adenocarcinoma and its clinical implication, particularly potential as a prognostic factor and a therapeutic target.
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Affiliation(s)
- Sunjida Ahmed
- Department of Pathology, New York University School of Medicine, and Langone Medical Center, New York, NY 10016, USA.
| | - Azore-Dee Bradshaw
- Department of Pathology, New York University School of Medicine, and Langone Medical Center, New York, NY 10016, USA.
| | - Shweta Gera
- Department of Pathology, New York University School of Medicine, and Langone Medical Center, New York, NY 10016, USA.
| | - M Zahidunnabi Dewan
- Department of Pathology, New York University School of Medicine, and Langone Medical Center, New York, NY 10016, USA.
| | - Ruliang Xu
- Department of Pathology, New York University School of Medicine, and Langone Medical Center, New York, NY 10016, USA.
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5
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Parikh AA, Maiga A, Bentrem D, Squires MH, Kooby DA, Maithel SK, Weber SM, Cho CS, Katz M, Martin RC, Scoggins CR, Sutton J, Ahmad SA, Abbott DE, Carr J, Kim HJ, Yakoub D, Idrees K, Merchant N. Adjuvant Therapy in Pancreas Cancer: Does It Influence Patterns of Recurrence? J Am Coll Surg 2016; 222:448-56. [PMID: 26895735 DOI: 10.1016/j.jamcollsurg.2015.12.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 12/15/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Level 1 data demonstrate that adjuvant chemotherapy (ACT) improves survival after surgical resection of pancreatic ductal adenocarcinoma (PDAC), (adjuvant gemcitabine, CONKO-001 study; adjuvant 5-FU, ESPAC3 study). The role of adjuvant chemoradiation therapy (ACRT) remains controversial. What is less clear is whether adjuvant therapy influences patterns of recurrence. The purpose of this study was to perform the first multicenter study analyzing patterns of recurrence after adjuvant therapy for PDAC. STUDY DESIGN Patients undergoing resection for PDAC from 8 medical centers over a 10-year period were analyzed. Demographics, tumor characteristics, operative treatment, type of adjuvant therapy, recurrence pattern, and survival were reviewed. Using Cox-proportional hazards multivariate (MV) regression, the impact of ACT and ACRT on overall survival (OS), local recurrence (LR), and distant recurrence (DR) was investigated. RESULTS There were 1,130 patients who were divided into those having surgery alone (n = 392), ACT (n = 291), or ACRT (n = 447). Median follow-up was 18 months. Compared with patients undergoing surgery alone, ACT, but not ACRT, demonstrated a significant OS advantage on MV analysis. Patients receiving ACT had significantly fewer recurrences (LR and DR); those receiving ACRT had significantly less LR but not DR. On subset MV analysis, ACT and ACRT resulted in less LR in patients with lymph node (LN) positive and margin negative disease. No improvements in LR, DR, or OS were seen in margin positive patients with either ACT or ACRT. CONCLUSIONS This is the first analysis demonstrating differences in recurrence patterns in PDAC patients based on type of adjuvant therapy. Adjuvant chemotherapy provided an OS advantage likely related to its effect on reducing both LR and DR. Adjuvant chemoradiation therapy appears to decrease LR, but not DR, and therefore has less impact on OS. Future investigations and treatment protocols should consider additional ACT rather than ACRT in the treatment of PDAC.
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Affiliation(s)
| | - Amelia Maiga
- Department of Surgery, Vanderbilt University, Nashville, TN
| | - David Bentrem
- Department of Surgery, Northwestern University, Chicago, IL
| | | | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA
| | | | - Sharon M Weber
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Matthew Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert C Martin
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Jeff Sutton
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Jacquelyn Carr
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Hong Jin Kim
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Danny Yakoub
- Department of Surgery, University of Miami, Miami, FL
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University, Nashville, TN
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6
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Sinn M, Bahra M, Denecke T, Travis S, Pelzer U, Riess H. Perioperative treatment options in resectable pancreatic cancer - how to improve long-term survival. World J Gastrointest Oncol 2016; 8:248-57. [PMID: 26989460 PMCID: PMC4789610 DOI: 10.4251/wjgo.v8.i3.248] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
Surgery remains the only chance of cure for pancreatic cancer, but only 15%-25% of patients present with resectable disease at the time of primary diagnosis. Important goals in clinical research must therefore be to allow early detection with suitable diagnostic procedures, to further broaden operation techniques and to determine the most effective perioperative treatment of either chemotherapy and/or radiation therapy. More extensive operations involving extended pancreatectomy, portal vein resection and pancreatic resection in resectable pancreatic cancer with limited liver metastasis, performed in specialized centers seem to be the surgical procedures with a possible impact on survival. After many years of stagnation in pharmacological clinical research on advanced pancreatic ductal adenocarcinomas (PDAC) - since the approval of gemcitabine in 1997 - more effective cytotoxic substances (nab-paclitaxel) and combinations (FOLFIRINOX) are now available for perioperative treatment. Additionally, therapies with a broader mechanism of action are emerging (stroma depletion, immunotherapy, anti-inflammation), raising hopes for more effective adjuvant and neoadjuvant treatment concepts, especially in the context of "borderline resectability". Only multidisciplinary approaches including radiology, surgery, medical and radiation oncology as the backbones of the treatment of potentially resectable PDAC may be able to further improve the rate of cure in the future.
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7
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Abstract
Gemcitabine (GEM) is an approved treatment for unresectable pancreatic cancer; however, its role in treating resected pancreatic cancer is less clear. The aim of this study was to investigate the evidence of the role of adjuvant GEM therapy on survival in resected pancreatic cancer. Four phase III randomized trials of adjuvant GEM in patients with resected pancreatic cancer were identified and the hazard ratio (HR) for overall survival were used in this meta-analysis; 2 studies compared GEM treatment with best supportive care and 2 studies with 5-fluorouracil/folinic acid therapy. The pooled data (n=2017 patients) indicated that the overall survival data were homogenous among the studies (Q=4.371; I=31.37%; P=0. 224). The combined HR significantly favors GEM over the other treatments. The overall HR was 0.88 (range, 0. 720 to 0.940; P=0.014). The results indicate that GEM prolongs overall survival compared with other treatments after the resection of pancreatic cancer.
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8
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Erdmann JI, Morak MJM, Duivenvoorden HJ, van Dekken H, Kazemier G, Kok NFM, van Eijck CHJ. Long-term survival after resection for non-pancreatic periampullary cancer followed by adjuvant intra-arterial chemotherapy and concomitant radiotherapy. HPB (Oxford) 2015; 17:573-9. [PMID: 25800041 PMCID: PMC4474503 DOI: 10.1111/hpb.12401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 01/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is no consensus regarding the optimal adjuvant treatment after resection of non-pancreatic periampullary adenocarcinoma (NPPC; distal common bile duct, ampulla, duodenum). OBJECTIVES The present study was conducted to evaluate the impacts on longterm survival and recurrence of adjuvant intra-arterial chemotherapy (IAC) and concomitant radiotherapy (RT) in patients submitted to resection for NPPC or pancreatic ductal adenocarcinoma (PDAC) in a randomized controlled trial. METHODS A total of 120 patients with PDAC (n = 62) or NPPC (n = 58) were prestratified at a ratio of 1:1 for tumour origin and randomized. Half of these patients were treated with adjuvant IAC/RT and the other half were treated with surgery alone. Follow-up was completed for all patients up to 5 years after resection or until death. RESULTS There was no survival benefit in either the whole group (primary endpoint) or the PDAC group after IAC/RT. In the NPPC group, longterm survival was observed in 10 patients in the IAC/RT group and five patients in the control group: median survival was 37 months and 28 months, respectively. The occurrence of liver metastases was reduced by IAC/RT from 57% to 29% (P = 0.038). Cox regression analysis revealed a substantial effect of IAC/RT on survival (hazard ratio: 0.44, 95% confidence interval 0.23-0.83; P = 0.011). CONCLUSIONS This longterm analysis shows that median and longterm survival were improved after IAC/RT in patients with NPPC, probably because of the effective and sustained reduction of liver metastases. The present results illustrate that NPPC requires an adjuvant approach distinct from that in pancreatic cancer and indicate that further investigation of this issue is warranted.
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Affiliation(s)
- Joris I Erdmann
- Department of Surgery, Erasmus Medical CentreRotterdam, the Netherlands
| | | | - Hugo J Duivenvoorden
- Department of Surgery, Methodologist-statistician, Erasmus Medical CentreRotterdam, the Netherlands
| | - Herman van Dekken
- Department of Pathology, Erasmus Medical CentreRotterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Erasmus Medical CentreRotterdam, the Netherlands
| | - Niels F M Kok
- Department of Surgery, Erasmus Medical CentreRotterdam, the Netherlands
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9
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Marsh RDW, Talamonti MS, Katz MH, Herman JM. Pancreatic cancer and FOLFIRINOX: a new era and new questions. Cancer Med 2015; 4:853-63. [PMID: 25693729 PMCID: PMC4472208 DOI: 10.1002/cam4.433] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 01/10/2015] [Accepted: 01/12/2015] [Indexed: 12/24/2022] Open
Abstract
FOLFIRINOX (FFX) was introduced to clinical practice in 2010 following publication of the PRODIGE 4/ACCORD 11 study, which compared this novel regimen to gemcitabine in metastatic pancreatic cancer. Median overall survival, progression-free survival, and objective responses were all superior with FFX and there was improved time to definitive deterioration in quality of life. Despite initial concerns over toxicity, there has been rapid uptake of this regimen, both revolutionizing management and opening the door to innovative research. As experience with FFX has accrued, many questions have arisen including the management of toxicities, the impact of frequent modifications, the optimal number of cycles, integration with other regimens and modalities, interpretation of radiologic and serologic response, utility of molecular signatures, and potential benefit in unique clinical settings such as pre- and postsurgery. This review will closely examine these issues, not only to summarize current knowledge but also to fuel scientific debate.
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Affiliation(s)
- Robert De W Marsh
- Department of Medicine, NorthShore University HealthSystemEvanston, Illinois, 60201
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystemEvanston, Illinois, 60201
| | - Matthew Harold Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins HospitalBaltimore, Maryland
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10
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Zhu SK, Zhou Y, Cheng C, Zhong S, Wu HQ, Wang B, Fan P, Xiong JX, Yang HJ, Wu HS. Overexpression of membrane-type 2 matrix metalloproteinase induced by hypoxia-inducible factor-1α in pancreatic cancer: Implications for tumor progression and prognosis. Mol Clin Oncol 2014; 2:973-981. [PMID: 25279184 DOI: 10.3892/mco.2014.357] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/15/2014] [Indexed: 01/06/2023] Open
Abstract
Membrane-type 2 matrix metalloproteinase (MT2-MMP) has been identified as a powerful modulator of the pericellular environment that promotes tumor invasion and metastasis. In this study, we investigated the association of MT2-MMP and hypoxia-inducible factor-1α (HIF-1α) expression in pancreatic cancer with regard to their clinical prognostic significance. Of the tissue specimens obtained from the 78 patients included in this study, 46 (59%) were found to be positive for MT2-MMP immunostaining and MT2-MMP expression was colocalized with HIF-1α in pancreatic cancer. Using the Spearman's rank analysis, the protein and mRNA expression level of MT2-MMP was found to be significantly correlated with HIF-1α and CD34-microvascular density in pancreatic cancer. Furthermore, the expression of MT2-MMP in response to hypoxia was increased in a time-dependent manner and the promoter luciferase reporter revealed upregulation of MT2-MMP expression induced by HIF-1α in pancreatic cancer cells. Moreover, the Cox regression model indicated that MT2-MMP was an independent prognostic factor in patients with pancreatic cancer. Our results demonstrated that the overexpression of MT2-MMP was induced by HIF-1α in response to hypoxia and was an independent prognostic factor for pancreatic cancer progression.
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Affiliation(s)
- Shi-Kai Zhu
- Organ Transplant Center, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan 610072, P.R. China ; School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, P.R. China
| | - Yu Zhou
- Institute of Laboratory Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan 610072, P.R. China ; School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, P.R. China
| | - Chao Cheng
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Shan Zhong
- Organ Transplant Center, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan 610072, P.R. China ; School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, P.R. China
| | - Han-Qing Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Bo Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Ping Fan
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Jiong-Xin Xiong
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Hong-Ji Yang
- Organ Transplant Center, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan 610072, P.R. China ; School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, P.R. China
| | - He-Shui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
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11
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O'Brien DP, Sandanayake NS, Jenkinson C, Gentry-Maharaj A, Apostolidou S, Fourkala EO, Camuzeaux S, Blyuss O, Gunu R, Dawnay A, Zaikin A, Smith RC, Jacobs IJ, Menon U, Costello E, Pereira SP, Timms JF. Serum CA19-9 is significantly upregulated up to 2 years before diagnosis with pancreatic cancer: implications for early disease detection. Clin Cancer Res 2014; 21:622-31. [PMID: 24938522 DOI: 10.1158/1078-0432.ccr-14-0365] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Biomarkers for the early detection of pancreatic cancer are urgently needed. The primary objective of this study was to evaluate whether increased levels of serum CA19-9, CA125, CEACAM1, and REG3A are present before clinical presentation of pancreatic cancer and to assess the performance of combined markers for early detection and prognosis. EXPERIMENTAL DESIGN This nested case-control study within the UKCTOCS included 118 single and 143 serial serum samples from 154 postmenopausal women who were subsequently diagnosed with pancreatic cancer and 304 matched noncancer controls. Samples were split randomly into independent training and test sets. CA19-9, CA125, CEACAM1, and REG3A were measured using ELISA and/or CLIA. Performance of markers to detect cancers at different times before diagnosis and for prognosis was evaluated. RESULTS At 95% specificity, CA19-9 (>37 U/mL) had a sensitivity of 68% up to 1 year, and 53% up to 2 years before diagnosis. Combining CA19-9 and CA125 improved sensitivity as CA125 was elevated (>30 U/mL) in approximately 20% of CA19-9-negative cases. CEACAM1 and REG3A were late markers adding little in combined models. Average lead times of 20 to 23 months were estimated for test-positive cases. Prediagnostic levels of CA19-9 and CA125 were associated with poor overall survival (HR, 2.69 and 3.15, respectively). CONCLUSIONS CA19-9 and CA125 have encouraging sensitivity for detecting preclinical pancreatic cancer, and both markers can be used as prognostic tools. This work challenges the prevailing view that CA19-9 is upregulated late in the course of pancreatic cancer development.
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Affiliation(s)
- Darragh P O'Brien
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | - Neomal S Sandanayake
- Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, United Kingdom. Kolling Institute, University of Sydney, Royal North Shore Hospital, New South Wales, Australia
| | - Claire Jenkinson
- The NIHR Liverpool Pancreas Biomedical Research Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Sophia Apostolidou
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | | | - Stephane Camuzeaux
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | - Oleg Blyuss
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | - Richard Gunu
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | - Anne Dawnay
- Department of Clinical Biochemistry, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Alexey Zaikin
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | - Ross C Smith
- Kolling Institute, University of Sydney, Royal North Shore Hospital, New South Wales, Australia
| | - Ian J Jacobs
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom. Faculty of Medical and Human Sciences, 1.018 Core Technology Facility, University of Manchester, United Kingdom
| | - Usha Menon
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | - Eithne Costello
- The NIHR Liverpool Pancreas Biomedical Research Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, United Kingdom. Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - John F Timms
- Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom.
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Neesse A, Krug S, Gress TM, Tuveson DA, Michl P. Emerging concepts in pancreatic cancer medicine: targeting the tumor stroma. Onco Targets Ther 2013; 7:33-43. [PMID: 24379681 PMCID: PMC3872146 DOI: 10.2147/ott.s38111] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma is a stroma-rich and highly challenging cancer to treat. Over recent years, it has become increasingly evident that the complex network of soluble cytokines, growth factors, proteases, and components of the extracellular matrix collaboratively interact within the tumor microenvironment, sustaining and driving cancer cell proliferation, invasion, and early metastasis. More recently, the tumor microenvironment has also been appreciated to mediate therapeutic resistance in pancreatic ductal adenocarcinoma, thus opening numerous avenues for novel therapeutic explorations. Inert and soluble components of the tumor stroma have been targeted in order to break down the extracellular matrix scaffold, relieve vessel compression, and increase drug delivery to hypovascular tumors. Moreover, targeting of antiapoptotic, immunosuppressive, and pro-proliferative effects of the tumor stroma provides novel vantage points of attack. This review focuses on current and future developments in pancreatic cancer medicine, with a particular emphasis on biophysical and biochemical approaches that target the tumor microenvironment.
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Affiliation(s)
- Albrecht Neesse
- Department of Gastroenterology, Endocrinology, Infectiology and Metabolism, Philipps University Marburg, Marburg, Germany
| | - Sebastian Krug
- Department of Gastroenterology, Endocrinology, Infectiology and Metabolism, Philipps University Marburg, Marburg, Germany
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Infectiology and Metabolism, Philipps University Marburg, Marburg, Germany
| | | | - Patrick Michl
- Department of Gastroenterology, Endocrinology, Infectiology and Metabolism, Philipps University Marburg, Marburg, Germany
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13
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Forssell H, Wester M, Åkesson K, Johansson S. A proposed model for prediction of survival based on a follow-up study in unresectable pancreatic cancer. BMJ Open 2013; 3:e004064. [PMID: 24345902 PMCID: PMC3884621 DOI: 10.1136/bmjopen-2013-004064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To define an easy-to-use model for prediction of survival time in patients with unresectable pancreatic cancer in order to optimise patient' care. DESIGN An observational retrospective study on patients with unresectable pancreatic cancer. The initial radiographs at presentation of symptoms were reviewed and the maximum diameter of the primary tumour was determined. The occurrence of liver metastases and performance status that determines initiation of chemotherapy was also used in the regression analysis to identify prognostic subgroups. SETTING County hospital in south-east of Sweden. POPULATION Consecutive patients with unresectable pancreatic cancer who were diagnosed between January 2003 and May 2010 (n=132). MAIN OUTCOME MEASURES Statistical analyses were performed using Stata V.13. Survival time was assessed with Kaplan-Meier analysis, log-rank test for equality of survivor functions and Cox regression for calculation of individual hazard based on tumour diameter, presence of liver metastases and initiation of chemotherapy treatment according to patient performance status. RESULTS The individual hazard was log h=0.357 tumour size+1.181 liver metastases-0.989 performance status/chemotherapy. Three prognostic groups could be defined: a low-risk group with a median survival time of 6.7 (IQR 9.7) months, a medium-risk group with a median survival time of 4.5 (IQR 4.5) months and a high-risk group with a median survival time of 1.2 (IQR 1.7) months. CONCLUSIONS The maximum diameter of the primary tumour and the presence of liver metastases found at the X-ray examination of patients with pancreatic cancer, in conjunction with whether or not chemotherapy is initiated according to performance status, predict the survival time for patients who do not undergo surgical resection. The findings result in an easy-to-use model for predicting the survival time.
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Affiliation(s)
- Henrik Forssell
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
- Blekinge Centre of Competence, Karlskrona, Sweden
| | - Michael Wester
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Katrin Åkesson
- Department of Radiology, Blekinge Hospital, Karlskrona, Sweden
| | - Sigrid Johansson
- Blekinge Institute of Technology, School of Health Science, Karlskrona, Sweden
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14
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Validation of C-reactive protein levels as a prognostic indicator for survival in a large cohort of pancreatic cancer patients. Br J Cancer 2013; 110:183-8. [PMID: 24201751 PMCID: PMC3887299 DOI: 10.1038/bjc.2013.701] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 08/25/2013] [Accepted: 10/10/2013] [Indexed: 02/07/2023] Open
Abstract
Background: Recent evidence indicates that the host inflammatory response has an important role in the tumour progression. Elevated C-reactive protein (CRP) levels have been previously associated with poor prognosis in several cancer types including small-scale studies in pancreatic cancer (PC) patients. The purpose of the present study was to validate the prognostic impact of plasma CRP levels at date of diagnosis on cancer-specific survival (CSS) in a large cohort of PC patients. Methods: Data from 474 consecutive patients with adenocarcinoma of the pancreas, treated between 2004 and 2012 at a single centre, were evaluated retrospectively. CSS was analysed using the Kaplan–Meier method. To evaluate the prognostic significance of plasma CRP levels, univariate and multivariate Cox analyses were applied. Results: High plasma CRP levels at diagnosis were significantly associated with well-established prognostic factors, including high tumour stage and tumour grade and the administration of chemotherapy (P<0.05). In univariate analysis, we observed that a high plasma CRP level was a consistent factor for poor CSS in PC patients (hazard ratio (HR)=2.21; 95% confidence interval (CI)=1.68–2.92, P<0.001). In multivariate analysis, tumour stage, grade, administration of chemotherapy, a high neutrophil–lymphocyte ratio and the highest quartile of CRP levels (HR=1.60, 95% CI=1.16–2.21; P=0.005) were identified as independent prognostic factors in PC patients. Conclusion: In conclusion, we confirmed a significant association of elevated CRP levels with poor clinical outcome in PC patients. Our results indicate that the plasma CRP level might represent a useful marker for patient stratification in PC management.
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