Diagnostic and therapeutic approach to pancreatic cancer

Neutrophils and neutrophil extracellular traps in the liver and gastrointestinal system

Neutrophil extracellular traps (NETs) have an important role during infection by helping neutrophils to capture and kill pathogens. However, evidence is accumulating that uncontrolled or excessive production of NETs is related to the exacerbation of inflammation and the development of autoimmunity, cancer metastasis and inappropriate thrombosis. In this Review, we focus on the role of NETs in the liver and gastrointestinal system, outlining their protective and pathological effects. The latest mechanistic insights in NET formation, interactions between microorganisms and NETs and the relationship between neutrophil subtypes and their functions are also discussed. Additionally, we describe the potential importance of NET-related molecules, including cell-free DNA and hypercitrullinated histones, as biomarkers and targets for therapeutic intervention in gastrointestinal diseases.

Experimental study on the therapeutic effect and underlining mechanisms of positron in pancreatic cancer cells

The purpose of this study was to assess the potential therapeutic effect of positrons emitted by ¹⁸F-2-Deoxy-2-Fluoro-D-Glucose (¹⁸F-FDG) on pancreatic cancer cells and elucidate its underlying mechanisms. Pancreatic cancer cells were incubated with different radioactive concentrations of ¹⁸F-FDG and evaluated for anti-cancer properties and underlining mechanisms. In addition, three groups of tumor-bearing mice were treated with different doses of ¹⁸F-FDG weekly, the tumor growth rate was calculated, and the mice were imaged by positron emission tomography (PET) with ¹⁸F-FDG before and after treatment. The presence of apoptosis was detected by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) stain and immunohistochemistry analysis. All treated groups exhibited positron-inhibited proliferation and positron-induced apoptosis compared with the control group in vitro. Further, we noted that higher treatment dose correlated with a better treatment response. In vivo, the high dose administration of ¹⁸F-FDG reduced tumor growth and prolonged the survival of treated mice compared with the control group with no change in the behavior or normal tissues of the mice. Immunohistochemical analysis and TUNEL stain showed more apoptotic cells than that in control group. The results demonstrated that positron radiation inhibited the proliferation and induced apoptosis of pancreatic cancer cells in vitro and in vivo, via an endogenous mitochondria-mediated signaling pathway.

LPS induced miR-181a promotes pancreatic cancer cell migration via targeting PTEN and MAP2K4

BACKGROUND

Pancreatic cancer is aggressive; 80-90 % of pancreatic cancer patients have already developed metastatic cancer at the time of diagnosis. Inflammation has been shown to facilitate pancreatic cancer migration. The toll-like receptors (TLRs) pathway is an important inflammatory signal transduction pathway. However, the mechanism of inflammation pathway to induce pancreatic cancer migration is unclear.

AIMS

The purpose of this study was to investigate how inflammation affects pancreatic cancer migration.

METHODS

RT-PCR was used to detect the TLRs expression files in pancreatic cancer cells and tissues. Pancreatic cancer cells migration was assessed after treatment with TLR4 agonist, lipopolysaccharide (LPS). Moreover, two tumor suppressors, PTEN and MAP2K4, were detected. Then we predicted and proved the miRNA which targeted PTEN and MAP2K4.

RESULTS

We found that the expression of TLR4 was increased in pancreatic cancer cells and tissues. After treatment with LPS, the migration of pancreatic cancer cells was increased and the protein levels of two tumor suppressors, PTEN and MAP2K4, were inhibited. To investigate the possible mechanism, we checked the expression of miR-181a. The result showed that miR-181a was decreased by LPS. Furthermore, we predicted and confirmed that both PTEN and MAP2K4 were miR-181a targets. Pancreatic cancer tissues analysis showed that PTEN and MAP2K4 were all negatively correlated with miR-181a.

CONCLUSIONS

These results suggest that the LPS-TLR4-miR-181a signaling pathway plays a significant role in pancreatic cancer invasion and progression.

Extracellular DNA in pancreatic cancer promotes cell invasion and metastasis

Aggressive metastasis is the chief cause of the high morbidity and mortality associated with pancreatic cancer, yet the basis for its aggressive behavior remains elusive. Extracellular DNA (exDNA) is a recently discovered component of inflammatory tissue states. Here, we report that exDNA is present on the surface of pancreatic cancer cells where it is critical for driving metastatic behavior. exDNA was abundant on the surface and vicinity of cultured pancreatic cancer cells but absent from normal pancreas cells. Strikingly, treatment of cancer cell cultures with DNase I to degrade DNA nonspecifically reduced metastatic characters associated with matrix attachment, migration, and invasion. We further assessed the role of exDNA in pancreatic cancer metastasis in vivo using an orthotopic xenograft model established by implantation of pancreatic cancer cells expressing firefly luciferase. Noninvasive bioluminescent imaging confirmed that DNase I treatment was sufficient to suppress tumor metastasis. Mechanistic investigations suggested the existence of a positive feedback loop in which exDNA promotes expression of the inflammatory chemokine CXCL8, which leads to higher production of exDNA by pancreatic cancer cells, with a significant reduction in CXCL8 levels achieved by DNase I treatment. Taken together, our results strongly suggest that exDNA contributes to the highly invasive and metastatic character of pancreatic cancer.

Available carbohydrates, glycemic load, and pancreatic cancer: is there a link?

High-carbohydrate diets have been linked to pancreatic cancer risk in case-control studies, but prospective studies have shown mostly null results. The authors investigated the associations of glycemic load, glycemic index, and carbohydrate intake with pancreatic cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Dietary intake was assessed by using a self-administered questionnaire. Between 1998 and 2006 (median follow-up = 6.5 years), 266 incident, confirmed pancreatic cancers were identified among 109,175 participants. Hazards ratios and 95% confidence intervals were adjusted for sex, smoking, body mass index, and total energy. Overall, elevated risks for pancreatic cancer were observed in the 90th versus 10th percentile of glycemic load (hazards ratio (HR) = 1.45, 95% confidence interval (CI): 1.05, 2.00), available carbohydrate (HR = 1.47, 95% CI: 1.05, 2.06), and sucrose (HR = 1.37, 95% CI: 0.99, 1.89) intake. The positive association for available carbohydrate intake was observed during the first 4 years of follow-up (HR(<2 years) = 2.60, 95% CI: 1.34, 5.06; HR(2-<4 years) = 1.94, 95% CI: 1.06, 3.55) but not subsequently (HR = 0.86, 95% CI: 0.52, 1.44); the opposite pattern was observed for total fat and saturated fat intake. Rather than being causal, the short-term increase in pancreatic cancer risk associated with high available carbohydrate and low fat intake may be capturing dietary changes associated with subclinical disease.

Clinical efficacy of CT-guided iodine-125 seed implantation therapy in patients with advanced pancreatic cancer

OBJECTIVE

To examine the clinical efficacy of CT-guided radioactive iodine-125 (125I) seeds implantation treatment in patients with unresectable pancreatic cancer.

METHODS

Thirty-one patients with inoperable pancreatic cancer were enrolled in this study. The 125I seeds were implanted into pancreatic tumor under CT guidance. In addition, 10 patients received routine gemcitabine and 5-fluorouracil chemotherapy 1 week after brachytherapy. Median diameter of the tumor was 5.8 cm.

RESULTS

Follow-up period was 2 to 25 months. Symptoms of refractory pain were significantly resolved post-interventionally (P < 0.05), and Karnofsky physical score increased dramatically (P < 0.05). Tumor response which was demonstrated on repeated CT film 2 months post-treatment revealed complete response (CR) in 3 cases, partial response (PR) in 16 cases, stable disease (SD) in 9 cases, and progressive disease (PD) in 3 cases. Overall responding rate (CR+PR) was 61.3%. Median survival time for all patients was 10.31 months. Two seeds of radioactive 125I migrated to the liver in 2 patients. There were no serious complications detected during the follow-up period.

CONCLUSIONS

This study suggests that CT-guided brachytherapy using 125I seeds implantation appears to be safe, effective, uncomplicated, and could produce adequate pain relief for treating unresectable pancreatic cancer.

Identification of serum biomarkers for pancreatic adenocarcinoma by proteomic analysis

Diagnosis of pancreatic adenocarcinoma (PaCa) at an early stage is important for successful treatment and improving the prognosis of patients. Serum samples were applied to strong anionic exchange chromatography (SAX) protein chips for protein profiling by surface enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS) to distinguish PaCa from noncancer. The Wilcoxon rank-sum test, decision tree algorithm, and logistic regression were used to statistically analyze the multiple protein peaks. Sixty-one protein peaks between 2000 and 30,000 m/z ratios were detected to establish multiple decision classification trees for differentiating the known disease states. A sensitivity of 0.833 and a specificity of 1.000 were obtained in distinguishing PaCa from healthy controls and benign pancreatic diseases. Six protein biomarkers related to different PaCa TNM stages were detected (P < 0.01). One protein biomarker (m/z 4016) rich in PaCa had a down-regulated trend when preoperative and postoperative samples (P < 0.05) were compared. Three protein biomarkers (m/z 4155, 4791, and 28,068) were detected in the differential diagnosis of the three test groups (P < 0.05). A peak m/z 28 068 was identified as C14orf16 using ProteinChip immunoassay. C14orf166 levels were significantly higher in the serum of patients with PaCa compared with the control group using a sandwich immunoenzymatic system. Immunolabeling of tissue sections revealed that the C14orf166 protein was strongly expressed in tumor cells. The results suggest that SELDI-TOF-MS serum profiling is helpful for the diagnostic, prognostic or therapeutic effects of PaCa, which is superior to CA 19-9. The identified protein biomarker C14orf166 is a potential biomarker of PaCa.

[Early pancreatic cancer: can the methods currently available identify this disease?]

OBJECTIVES

Call attention of the gastroenterologists and surgeons on the patients with high risk of developing pancreatic carcinoma, and whether or not forms of surveillance and prevention of this disease, which can be applied to daily clinical practice. DATA SURVEY: It was used the database of PubMed (US National Library of Medicine), looked up the publications of recent years for the groups at risk, molecular biological testing and methods of image used in the identification of small tumors of the pancreas.

BACKGROUND

The survival rates of adenocarcinoma of the pancreas remain negligible, even after the significant advances in diagnosis by imaging, treatment and understanding of the molecular biology of this disease. Although embryonic strategies for surveillance and prevention for people with high risk of pancreatic cancer has developed.

CONCLUSIONS

This review summarizes how to identify people at high risk of developing this disease and what is the state of the art of genetic counseling and screening through techniques of image available.

Pancreatic Cancer Presenting with Hematemesis from Directly Invading the Duodenum: Report of an Unusual Manifestation and Review

Pancreatic cancer is a rare cause of gastrointestinal bleeding, and it is extremely rare for hematemesis to be the initial manifestation of invasive pancreatic cancer. We report the case of a 67-year-old man with hematemesis who was found to have invasive pancreatic cancer with a bleeding duodenal ulcer. The patient was not icteric, but repeated sudden hematemesis. An urgent pancreatoduodenectomy was performed with a favorable outcome. Microscopic examination revealed that an adenocarcinoma originating from the pancreatic head extended to the muscularis propria of the duodenum. Furthermore, an exposed vessel and narrow fistula were found. The diagnosis, pathological findings, preoperative events, and postoperative outcome in this unusual case are reviewed.

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The clinical use of tumor makers in select cancers: are you confident enough to discuss them with your patients?

PURPOSE/OBJECTIVES

To review the clinical use of tumor markers in select cancers and highlight future directions in tumor marker development.

DATA SOURCES

Guidelines from national and international societies, scientific literature, and Internet resources.

DATA SYNTHESIS

Tumor markers are important tools in the management of cancer. Sequencing of the human genome has led to new tumor marker development in the fields of proteomics and DNA microarray technologies.

CONCLUSIONS

Tumor marker technology is expanding rapidly; almost a dozen tumor markers currently are being used in the oncology arena, with many more in development. The use of tumor markers can be controversial, particularly because guidelines have not been established for all of the markers.

IMPLICATIONS FOR NURSING

Oncology nurses need to be well versed in the use of tumor markers to educate and counsel patients with cancer.

Risk factors for pancreatic adenocarcinoma: are we ready for screening and surveillance?

Of all common malignancies, pancreatic cancer has the lowest survival rate. According to estimates by the American Cancer Society, in 2004, 31,860 Americans were diagnosed, and 31,270 died from this near universally lethal disease. Unfortunately, only a small minority of patients are diagnosed when the extent of disease is still localized and thus potentially curable. These dismal survival results could be improved by developing successful screening and prevention strategies. Routine screening is not currently suggested for pancreatic cancer; however, there may be a benefit in a select group of patients identified to be at high risk for developing this disease. It is recommended that surveillance be performed on these high-risk individuals in a research setting to allow for the development of a successful detection strategy.

Oxaliplatin for pretreated patients with advanced or metastatic pancreatic cancer: a multicenter phase II study

A phase II study was designed to evaluate the efficacy and safety of oxaliplatin as second-line treatment in patients with locally advanced or metastatic pancreatic cancer. Eighteen patients with advanced pancreatic cancer previously treated with gemcitabine-based chemotherapy, received oxaliplatin 130 mg/m2 i.v. every 21 days. Patients were treated until tumor progression or unacceptable toxicity. No objective response was observed among the 18 treated patients. Three (16.7%) patients had stable disease for > 2 months. A clinical benefit response was observed in five (27.7%) patients. Toxicity was mild. Oxaliplatin as second-line treatment for patients with unresectable pancreatic cancer is well tolerated and associated with improvement of tumor-related symptoms despite its failure to induce objective responses. LOHP merits further investigation in combination with other drugs as palliative treatment of pretreated patients with advanced pancreatic cancer.

Noninvasive competition for endoscopic ultrasound

Endoscopic ultrasonography (EUS) is one of the most significant developments in gastrointestinal (GI) imaging in recent years. EUS now plays a key role in the pretreatment staging of GI tract tumors and in the investigation of benign pancreaticobiliary pathology. It has not replaced conventional cross-sectional imaging (eg, ultrasound, CT, and MRI), but it has distinct properties and capabilities. EUS is most beneficial when used in a complementary fashion with cross-sectional and radionuclide imaging in the management of patients with GI tract disease. This article reviews the role of noninvasive imaging modalities in several clinical situations where EUS plays a prominent role.

Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area

BACKGROUND & AIMS

Pancreatic cancer usually does not cause definitive symptoms until survival is severely compromised. Prevention and early detection are urgently needed. Our aim was to collect and analyze data in a population-based study on signs and symptoms of disease reported by patients with pancreatic cancer and control participants to contribute to earlier detection and better prognosis.

METHODS

A supplemental symptoms questionnaire was administered to 120 consecutive patients with pancreatic cancer who were part of a larger population-based case-control study conducted in the San Francisco Bay Area between 1994 and 2001. One hundred eighty age- and sex-matched population-based control participants also were queried about the same symptoms reported by at least 5% of patients with pancreatic cancer.

RESULTS

Most signs and symptoms occurred within 3 years before diagnosis with pancreatic cancer (cases) and interview (controls). Many signs and symptoms were more likely to have been reported by patients compared with control participants and included appetite loss (odds ratio [OR], 41; 95% confidence interval [CI], 14-120), pale stools (OR, 31; 95% CI, 7.3-134), abdominal pain (OR, 30; 95% CI, 9.1-101), jaundice (OR, 20; 95% CI, 8.0-49), unusual bloating (OR, 20; 95% CI, 5.9-67), unusual belching (OR, 17; 95% CI, 3.9-75), weight loss (OR, 12; 95% CI, 5.2-28), dark urine (OR, 10; 95% CI, 2.9-36), constipation (OR, 7.3; 95% CI, 2.0-26), diarrhea (OR, 5.6; 95% CI, 2.0-16), itching (OR, 5.0; 95% CI, 2.3-11), fatigue (OR, 3.8; 95% CI, 2.0-7.3), altered ability to sleep (OR, 2.9; 95% CI, 1.3-6.3), and unusual heartburn (OR, 2.3; 95% CI, 1.2-4.5).

CONCLUSIONS

Our results show that signs and symptoms likely to be indicators of pancreatic cancer occur substantially more often among patients with pancreatic cancer than among population-based controls. The large magnitude of the risk estimates indicate that common gastrointestinal symptoms may assist clinicians in earlier diagnosis of pancreatic cancer and perhaps affect survival.