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Wang H, Yuan Y, Lu C, Zhou S, Zhang Y, Zhao J, Xu C, Yang J, Su H, Li B, Li X, Wang P, Xu G, Wang L, Zou X, Bao S, Zhang S, Lv Y. Analysis of T-cell receptor repertoire in peripheral blood of patients with pancreatic cancer and other pancreatic diseases. J Cell Mol Med 2021; 25:3991-4000. [PMID: 33682267 PMCID: PMC8051704 DOI: 10.1111/jcmm.16358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 02/07/2023] Open
Abstract
Pancreatic cancer (PC) has been the fourth cancer‐related death worldwide, diagnosed at an unresectable stage due to its rapid progression and few symptoms of this disease at early stages. The aim of this study was to determine the association between the diversity of T‐cell receptor (TCR) repertoire and clinicopathological characteristics of patients with PC and other benign pancreatic diseases. In order to make a comprehensive analysis the TCR repertoire, high‐throughput sequencing was used to differentiate complementarity determining region 3 (CDR3) of the TCR β chain in peripheral blood samples from 3 PC, 3 chronic pancreatitis, 3 pancreatic cystic lesions and 3 pancreatic neuroendocrine tumour patients. We found that there were significant differences related to TCR repertoire between PC and other pancreatic diseases, and PC is a relatively immunosuppressive tumour. Changes of peripheral TCR repertoire may be used to predict the progression of PC and the response to immunotherapy. And there may exist novel‐specific antigens in PC patients which could be used to design targeting immunotherapy in the nearly future.
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Affiliation(s)
- Hui Wang
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Yue Yuan
- Department of Gastroenterology, Nanjing Medical University Affiliated Drum Tower Clinical Medical College, Nanjing, China
| | - Chenglin Lu
- Department of General Surgery, The Afflicted Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Siqi Zhou
- Department of Gastroenterology, Jiangsu University Affiliated Drum Tower Hospital, Nanjing, China
| | - Yixuan Zhang
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Jing Zhao
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Chenghu Xu
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Jie Yang
- Department of Gastroenterology, Nanjing Medical University Affiliated Drum Tower Clinical Medical College, Nanjing, China
| | - Haochen Su
- Department of Gastroenterology, Nanjing Medical University Affiliated Drum Tower Clinical Medical College, Nanjing, China
| | - Borui Li
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Xihan Li
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Pin Wang
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Guifang Xu
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Shanhua Bao
- Department of General Surgery, The Afflicted Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Shu Zhang
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Ying Lv
- Department of Gastroenterology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China.,Department of Gastroenterology, Nanjing Medical University Affiliated Drum Tower Clinical Medical College, Nanjing, China
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Huang H, Chen J, Peng L, Yao Y, Deng D, Zhang Y, Liu Y, Wang H, Li Z, Bi Y, Haddock AN, Zhan X, Lu W, Logsdon CD, Ji B. Transgenic expression of cyclooxygenase-2 in pancreatic acinar cells induces chronic pancreatitis. Am J Physiol Gastrointest Liver Physiol 2019; 316:G179-G186. [PMID: 30431318 PMCID: PMC6383372 DOI: 10.1152/ajpgi.00096.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Replacement of the exocrine parenchyma by fibrous tissue is a main characteristic of chronic pancreatitis. Understanding the mechanisms of pancreatic fibrogenesis is critical for the development of preventive and therapeutic interventions. Cyclooxygenase-2 (COX-2), a rate-limiting enzyme for prostaglandin synthesis, is expressed in patients with chronic pancreatitis. However, it is unknown whether COX-2 can cause chronic pancreatitis. To investigate the roles of pancreatic acinar COX-2 in fibrogenesis and the development of chronic pancreatitis, COX-2 was ectopically expressed specifically in pancreatic acinar cells in transgenic mice. Histopathological changes and expression levels of several profibrogenic factors related to chronic pancreatitis were evaluated. COX-2 was expressed in the pancreas of the transgenic mice, as detected by Western blot analysis. Immunohistochemical staining showed COX-2 was specifically expressed in pancreatic acinar cells. COX-2 expression led to progressive changes in the pancreas, including pancreas megaly, persistent inflammation, collagen deposition, and acinar-to-ductal metaplasia. Quantitative RT-PCR and immunostaining showed that profibrogenic factors were upregulated and pancreatic stellate cells were activated in the COX-2 transgenic mice. Expression of COX-2 in pancreatic acinar cells is sufficient to induce chronic pancreatitis. Targeting this pathway may be valuable in the prevention of chronic pancreatitis. NEW & NOTEWORTHY COX-2 expression is observed in pancreatic tissues of human chronic pancreatitis. In this study, we showed that COX-2 expression caused the development of chronic pancreatitis in transgenic mice, supporting the idea that COX-2 inhibition may be an effective preventive and therapeutic strategy.
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Affiliation(s)
- Haojie Huang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University , Shanghai , China
- Department of Cancer Biology, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Jiaxiang Chen
- Department of Cancer Biology, Mayo Clinic , Jacksonville, Florida
| | - Lisi Peng
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University , Shanghai , China
| | - Yao Yao
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University , Shanghai , China
- Department of Cancer Biology, Mayo Clinic , Jacksonville, Florida
| | - Defeng Deng
- Department of Cancer Biology, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Yang Zhang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University , Shanghai , China
- Department of Cancer Biology, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Yan Liu
- Department of Cancer Biology, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Huamin Wang
- Departments of Anatomic Pathology and Translational Molecular Pathology, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University , Shanghai , China
| | - Yan Bi
- Department of Cancer Biology, Mayo Clinic , Jacksonville, Florida
- Department of Gastroenterology, Mayo Clinic , Jacksonville, Florida
| | - Ashley N Haddock
- Department of Cancer Biology, Mayo Clinic , Jacksonville, Florida
| | - Xianbao Zhan
- Department of Cancer Biology, Mayo Clinic , Jacksonville, Florida
- Department of Oncology, Changhai Hospital, Second Military Medical University , Shanghai , China
| | - Weiqin Lu
- Department of Medicine, Stony Brook University , Stony Brook, New York
| | - Craig D Logsdon
- Department of Cancer Biology, University of Texas, MD Anderson Cancer Center , Houston, Texas
- Department of Gastrointestinal Medical Oncology, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Baoan Ji
- Department of Cancer Biology, Mayo Clinic , Jacksonville, Florida
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3
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Lee J, Snyder ER, Liu Y, Gu X, Wang J, Flowers BM, Kim YJ, Park S, Szot GL, Hruban RH, Longacre TA, Kim SK. Reconstituting development of pancreatic intraepithelial neoplasia from primary human pancreas duct cells. Nat Commun 2017; 8:14686. [PMID: 28272465 PMCID: PMC5344977 DOI: 10.1038/ncomms14686] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/24/2017] [Indexed: 12/14/2022] Open
Abstract
Development of systems that reconstitute hallmark features of human pancreatic intraepithelial neoplasia (PanINs), the precursor to pancreatic ductal adenocarcinoma, could generate new strategies for early diagnosis and intervention. However, human cell-based PanIN models with defined mutations are unavailable. Here, we report that genetic modification of primary human pancreatic cells leads to development of lesions resembling native human PanINs. Primary human pancreas duct cells harbouring oncogenic KRAS and induced mutations in CDKN2A, SMAD4 and TP53 expand in vitro as epithelial spheres. After pancreatic transplantation, mutant clones form lesions histologically similar to native PanINs, including prominent stromal responses. Gene expression profiling reveals molecular similarities of mutant clones with native PanINs, and identifies potential PanIN biomarker candidates including Neuromedin U, a circulating peptide hormone. Prospective reconstitution of human PanIN development from primary cells provides experimental opportunities to investigate pancreas cancer development, progression and early-stage detection. Models of human pancreatic intraepithelial neoplasia (PanIN) development do not exist. Here, the authors induce oncogenic KRAS and mutations in CDKN2A, SMAD4 and TP53 in primary human pancreatic cells to generate a PanIN model that recapitulates molecular and pathologic features of native PanINs.
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Affiliation(s)
- Jonghyeob Lee
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Emily R Snyder
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Yinghua Liu
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Xueying Gu
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Jing Wang
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Brittany M Flowers
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Yoo Jung Kim
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Sangbin Park
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
| | - Gregory L Szot
- UCSF Transplantation Surgery, University of California, San Francisco, San Francisco, California 94143, USA
| | - Ralph H Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | - Teri A Longacre
- Department of Pathology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Seung K Kim
- Department of Developmental Biology, Stanford University School of Medicine, 279 Campus Drive, Beckman Center B300, Stanford, California 94305, USA
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Conway EM, Pikor LA, Kung SHY, Hamilton MJ, Lam S, Lam WL, Bennewith KL. Macrophages, Inflammation, and Lung Cancer. Am J Respir Crit Care Med 2016; 193:116-30. [PMID: 26583808 DOI: 10.1164/rccm.201508-1545ci] [Citation(s) in RCA: 189] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Lung cancer is the leading cause of cancer mortality worldwide, and at only 18%, it has one of the lowest 5-year survival rates of all malignancies. With its highly complex mutational landscape, treatment strategies against lung cancer have proved largely ineffective. However with the recent success of immunotherapy trials in lung cancer, there is renewed enthusiasm in targeting the immune component of tumors. Macrophages make up the majority of the immune infiltrate in tumors and are a key cell type linking inflammation and cancer. Although the mechanisms through which inflammation promotes cancer are not fully understood, two connected hypotheses have emerged: an intrinsic pathway, driven by genetic alterations that lead to neoplasia and inflammation, and an extrinsic pathway, driven by inflammatory conditions that increase cancer risk. Here, we discuss the contribution of macrophages to these pathways and subsequently their roles in established tumors. We highlight studies investigating the association of macrophages with lung cancer prognosis and discuss emerging therapeutic strategies for targeting macrophages in the tumor microenvironment.
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Affiliation(s)
- Emma M Conway
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Larissa A Pikor
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Sonia H Y Kung
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Melisa J Hamilton
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Stephen Lam
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Wan L Lam
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Kevin L Bennewith
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
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5
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Birtolo C, Go VLW, Ptasznik A, Eibl G, Pandol SJ. Phosphatidylinositol 3-Kinase: A Link Between Inflammation and Pancreatic Cancer. Pancreas 2016; 45:21-31. [PMID: 26658038 PMCID: PMC4859755 DOI: 10.1097/mpa.0000000000000531] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Even though a strong association between inflammation and cancer has been widely accepted, the underlying precise molecular mechanisms are still largely unknown. A complex signaling network between tumor and stromal cells is responsible for the infiltration of inflammatory cells into the cancer microenvironment. Tumor stromal cells such as pancreatic stellate cells (PSCs) and immune cells create a microenvironment that protects cancer cells through a complex interaction, ultimately facilitating their local proliferation and their migration to different sites. Furthermore, PSCs have multiple functions related to local immunity, angiogenesis, inflammation, and fibrosis. Recently, many studies have shown that members of the phosphoinositol-3-phosphate kinase (PI3K) family are activated in tumor cells, PSCs, and tumor-infiltrating inflammatory cells to promote cancer growth. Proinflammatory cytokines and chemokines secreted by immune cells and fibroblasts within the tumor environment can activate the PI3K pathway both in cancer and inflammatory cells. In this review, we focus on the central role of the PI3K pathway in regulating the cross talk between immune/stromal cells and cancer cells. Understanding the role of the PI3K pathway in the development of chronic pancreatitis and cancer is crucial for the discovery of novel and efficacious treatment options.
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Affiliation(s)
- Chiara Birtolo
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA,Department of Internal Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Vay Liang W. Go
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Andrzej Ptasznik
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Guido Eibl
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Stephen J. Pandol
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA,VA Greater Los Angeles Health Care System, Los Angeles, CA
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6
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Nakano I. Proneural-mesenchymal transformation of glioma stem cells: do therapies cause evolution of target in glioblastoma? Future Oncol 2015; 10:1527-30. [PMID: 25145421 DOI: 10.2217/fon.14.86] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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7
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Han YM, Park JM, Lee HJ, Kim EH, Hahm KB. Short-term Intervention to Revert Premalignant Lesions as Strategy to Prevent Gastrointestinal Cancers. J Cancer Prev 2014; 18:289-97. [PMID: 25337558 PMCID: PMC4189441 DOI: 10.15430/jcp.2013.18.4.289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 09/11/2013] [Accepted: 09/12/2013] [Indexed: 12/20/2022] Open
Abstract
"Prevention might be better than treatment in cancer treatment" is brief conclusion drawn from war on cancer through National Cancer Act of 1971 by U.S. President Richard Nixon. However, the clinical practice of chemoprevention is still in its infancy in spite of a wealth of data showing its effectiveness in experimental animals as well as in vitro mechanism research. Recent advances in either high throughput analysis including cancer genomes and tailored medicine or molecular targeted therapeutics, preventive strategies also should be changes as previous preventive strategies including phytoceuticals, life-style modification, and some empirical agents. Furthermore, molecular targeted therapeutics achieved high goal of effectiveness under the concept of therapeutic or preventive "synthetic lethality", of which extended application can be included within the scope of chemoprevention. Here, we will summarize several recent advances in chemopreventive strategy objected to justify optimism that chemoprevention will be an effective approach for the control of human cancer. siTRP (short-term intervention to revert premalignancy) strategy will be introduced for cancers in gastroenterology.
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Affiliation(s)
- Young-Min Han
- CHA Cancer Prevention Research Center, CHA Cancer Institute, CHA University, Seoul ; College of Pharmacy, CHA University, Pocheon
| | - Jong-Min Park
- CHA Cancer Prevention Research Center, CHA Cancer Institute, CHA University, Seoul
| | - Ho-Jae Lee
- Lee Gil Ya Cancer and Diabetes Research Institute, Gachon University, Incheon
| | - Eun-Hee Kim
- CHA Cancer Prevention Research Center, CHA Cancer Institute, CHA University, Seoul ; Lee Gil Ya Cancer and Diabetes Research Institute, Gachon University, Incheon
| | - Ki Baik Hahm
- CHA Cancer Prevention Research Center, CHA Cancer Institute, CHA University, Seoul ; Department of Gastroenterology, CHA Bundang Medical Center, Seongnam, Korea
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8
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Hassid BG, Lucas AL, Salomao M, Weng C, Liu F, Khanna LG, Kumar S, Hwang C, Chabot JA, Frucht H. Absence of pancreatic intraepithelial neoplasia predicts poor survival after resection of pancreatic cancer. Pancreas 2014; 43:1073-7. [PMID: 24987871 PMCID: PMC4161626 DOI: 10.1097/mpa.0000000000000161] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Pancreatic intraepithelial neoplasia (PanIN), thought to represent the dominant precursor of pancreatic adenocarcinoma (PDAC), is often found synchronously adjacent to resected PDAC tumors. However, its prognostic significance on outcome after PDAC resection is unknown. METHODS A total of 342 patients who underwent resection for PDAC between 2005 and 2010 at a single institution were identified and stratified according to highest grade of PanIN demonstrated surrounding the tumor. Clinical and pathologic characteristics of each patient and tissue were recorded and analyzed. The primary outcome was length of survival after resection. RESULTS An absence of PanIN lesions was identified in 32 patients (9%), low grade PanIN without synchronous high grade lesions was identified in 52 patients (15%), and high grade PanIN was found in 258 patients (75%). Median survival were 12.8 months for the non-PanIN group, 26.3 months for the low-grade PanIN group, and 23.8 months for the high-grade PanIN groups (P = 0.043). In multivariable analysis, absence of PanIN was independently associated with poor survival (P = 0.002). CONCLUSIONS The patients who demonstrate an absence of PanIN in the pancreatic tissue adjacent to the resected PDAC tumor have shorter postresection survival compared with those who demonstrate a PanIN lesion.
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Affiliation(s)
- Benjamin G. Hassid
- Department of Medicine, Columbia University, New York, New York, United States
| | - Aimee L. Lucas
- Department of Medicine, Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Marcela Salomao
- Department of Pathology and Cell Biology, Columbia University New York, New York, United States
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
| | - Feng Liu
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
| | - Lauren G. Khanna
- Department of Medicine, Columbia University, New York, New York, United States
| | - Sheila Kumar
- Department of Medicine,Stanford University, Stanford, California, United States
| | - Caroline Hwang
- Department of Medicine, Keck School of Medicine of University of Southern California, California, United States
| | - John A. Chabot
- Department of Surgery, Columbia University, New York, New York, United States
| | - Harold Frucht
- Department of Medicine, Columbia University, New York, New York, United States
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9
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Pomianowska E, Schjølberg AR, Clausen OPF, Gladhaug IP. COX-2 overexpression in resected pancreatic head adenocarcinomas correlates with favourable prognosis. BMC Cancer 2014; 14:458. [PMID: 24950702 PMCID: PMC4230243 DOI: 10.1186/1471-2407-14-458] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 06/11/2014] [Indexed: 12/16/2022] Open
Abstract
Background Overexpression of cyclooxygenase-2 (COX-2) has been implicated in oncogenesis and progression of adenocarcinomas of the pancreatic head. The data on the prognostic importance of COX expression in these tumours is inconsistent and conflicting. We evaluated how COX-2 overexpression affected overall postoperative survival in pancreatic head adenocarcinomas. Methods The study included 230 consecutive pancreatoduodenectomies for pancreatic cancer (PC, n = 92), ampullary cancer (AC, n = 62) and distal bile duct cancer (DBC, n = 76). COX-2 expression was assessed by immunohistochemistry. Associations between COX-2 expression and histopathologic variables including degree of differentiation, histopathologic type of differentiation (pancreatobiliary vs. intestinal) and lymph node ratio (LNR) were evaluated. Unadjusted and adjusted survival analysis was performed. Results COX-2 staining was positive in 71% of PC, 77% in AC and 72% in DBC. Irrespective of tumour origin, overall patient survival was more favourable in patients with COX-2 positive tumours than COX-2 negative (p = 0.043 in PC, p = 0.011 in AC, p = 0.06 in DBC). In tumours of pancreatobiliary type of histopathological differentiation, COX-2 expression did not significantly affect overall patient survival. In AC with intestinal differentiation COX-2 expression significantly predicted favourable survival (p = 0.003). In PC, COX-2 expression was significantly associated with high degree of differentiation (p = 0.002). COX-2 and LNR independently predicted good prognosis in a multivariate model. Conclusions COX-2 is overexpressed in pancreatic cancer, ampullary cancer and distal bile duct cancer and confers a survival benefit in all three cancer types. In pancreatic cancer, COX-2 overexpression is significantly associated with the degree of differentiation and independently predicts a favourable prognosis.
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Affiliation(s)
- Ewa Pomianowska
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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10
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Ling S, Feng T, Jia K, Tian Y, Li Y. Inflammation to cancer: The molecular biology in the pancreas (Review). Oncol Lett 2014; 7:1747-1754. [PMID: 24932227 PMCID: PMC4049733 DOI: 10.3892/ol.2014.2003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 03/11/2014] [Indexed: 02/07/2023] Open
Abstract
Inflammatory responses are known to be correlated with cancer initiation and progression, and exploration of the route from inflammation to cancer makes a great contribution in elucidating the mechanisms underlying cancer development. Pancreatic cancer (PC) is a lethal disease with a low radical-resection rate and a poor prognosis. As chronic pancreatitis is considered to be a significant etiological factor for PC development, the current review aims to describe the molecular pathways from inflammation to pancreatic carcinogenesis, in support of the strategies for the prevention, diagnosis and treatment of PC.
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Affiliation(s)
- Sunbin Ling
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Tingting Feng
- Department of Medical Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Kaiqi Jia
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Yu Tian
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Yan Li
- Institute of Cancer Stem Cells, Dalian Medical University, Dalian, Liaoning 116044, P.R. China ; College of Basic Medical Sciences, Dalian Medical University, Dalian, Liaoning 116044, P.R. China
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11
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Zhou L, Qi L, Jiang L, Zhou P, Ma J, Xu X, Li P. Antitumor activity of gemcitabine can be potentiated in pancreatic cancer through modulation of TLR4/NF-κB signaling by 6-shogaol. AAPS J 2014; 16:246-57. [PMID: 24424498 PMCID: PMC3933586 DOI: 10.1208/s12248-013-9558-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 12/16/2013] [Indexed: 12/15/2022] Open
Abstract
Advanced pancreatic cancer still has a poor prognosis, even with the approval of several drugs, such as gemcitabine. Therefore, developing effective and safe antitumor agents is urgently needed. 6-Shogaol, a phenol extracted from ginger, has been linked to suppression of proliferation and survival of cancer with different mechanisms. In the present study, we investigated whether 6-shogaol could suppress pancreatic cancer progress and potentiate pancreatic cancer to gemcitabine treatment in vitro and in vivo. We found that 6-shogaol prevented the activation of toll like receptor 4 (TLR4)/NF-κB signaling. The modulation of NF-κB signaling by 6-shogaol was ascertained by electrophoretic mobility shift assay and western blot analysis. The suppression of NF-κB signaling and key cell survival regulators including COX-2, cyclinD1, survivin, cIAP-1, XIAP, Bcl-2, and MMP-9 brought the anti-proliferation effects in pancreatic cancer cells and sensitized them to gemcitabine treatment. Furthermore, in a pancreatic cancer xenograft model, we found a decreased proliferation index (Ki-67) and increased apoptosis by TUNEL staining in 6-shogaol treated tumors. It was also shown that 6-shogaol combined with gemcitabine treatment was more effective than drug alone, consistent with the downregulation of NF-κB activity along with its target genes COX-2, cyclinD1, survivin, cIAP-1, and XIAP. Overall, our results suggest that 6-shogaol can inhibit the growth of human pancreatic tumors and sensitize them to gemcitabine by suppressing of TLR4/NF-κB-mediated inflammatory pathways linked to tumorigenesis.
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Affiliation(s)
- Ling Zhou
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing, 210009 China
| | - Lianwen Qi
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing, 210009 China
| | - Lifeng Jiang
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing, 210009 China
| | - Ping Zhou
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing, 210009 China
| | - Jiang Ma
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing, 210009 China
| | - Xiaojun Xu
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing, 210009 China
| | - Ping Li
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing, 210009 China
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12
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Liou GY, Döppler H, Necela B, Krishna M, Crawford HC, Raimondo M, Storz P. Macrophage-secreted cytokines drive pancreatic acinar-to-ductal metaplasia through NF-κB and MMPs. ACTA ACUST UNITED AC 2013; 202:563-77. [PMID: 23918941 PMCID: PMC3734091 DOI: 10.1083/jcb.201301001] [Citation(s) in RCA: 217] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In response to inflammation, pancreatic acinar cells can undergo acinar-to-ductal metaplasia (ADM), a reprogramming event that induces transdifferentiation to a ductlike phenotype and, in the context of additional oncogenic stimulation, contributes to development of pancreatic cancer. The signaling mechanisms underlying pancreatitis-inducing ADM are largely undefined. Our results provide evidence that macrophages infiltrating the pancreas drive this transdifferentiation process. We identify the macrophage-secreted inflammatory cytokines RANTES and tumor necrosis factor α (TNF) as mediators of such signaling. Both RANTES and TNF induce ADM through activation of nuclear factor κB and its target genes involved in regulating survival, proliferation, and degradation of extracellular matrix. In particular, we identify matrix metalloproteinases (MMPs) as targets that drive ADM and provide in vivo data suggesting that MMP inhibitors may be efficiently applied to block pancreatitis-induced ADM in therapy.
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Affiliation(s)
- Geou-Yarh Liou
- Department of Cancer Biology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Jacksonville, FL 32224, USA
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Abstract
Pancreatic ductal adenocarcinoma (PDA) remains a highly lethal disease; new therapeutic modalities are urgently needed. A number of immunotherapies tested in preclinical models have shown promise. Early-phase clinical trials have demonstrated evidence of immune activation that in some cases correlates with clinical response. Moreover, recent evidence delineates the intricate role of inflammation in PDA, even at its earliest stages. Pancreatic ductal adenocarcinoma is thus ripe for immunotherapy; however, significant challenges remain before success can be realized. Future studies will need to focus on the discovery of novel PDA antigens and the identification of the multiple immune suppressive pathways within the PDA tumor microenvironment that inhibit an effective PDA-targeted immune response. Technologies are now available to rapidly advance discovery. Rapid translation of new discoveries into scientifically driven clinical trials testing combinations of immune agents will likely continue to shift the procarcinogenic tumor environment toward the most potent anticancer response.
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Charo C, Holla V, Arumugam T, Hwang R, Yang P, Dubois RN, Menter DG, Logsdon CD, Ramachandran V. Prostaglandin E2 regulates pancreatic stellate cell activity via the EP4 receptor. Pancreas 2013; 42:467-74. [PMID: 23090667 PMCID: PMC3600062 DOI: 10.1097/mpa.0b013e318264d0f8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreatic stellate cells are source of dense fibrotic stroma, a constant pathological feature of chronic pancreatitis and pancreatic adenocarcinoma. We observed correlation between levels of cyclooxygenase 2 (COX-2) and its product prostaglandin E2 (PGE2) and the extent of pancreatic fibrosis. The aims of this study were to delineate the effects of PGE2 on immortalized human pancreatic stellate cells (HPSCs) and to identify the receptor involved. METHODS Immunohistochemistry, reverse transcription-polymerase chain reaction and quantitative reverse transcription-polymerase chain reaction were used to assess COX-2, extracellular matrix, and matrix metalloproteinase gene expression. Eicosanoid profile was determined by liquid chromatography-tandem mass spectrometry. Human pancreatic stellate cell proliferation was assessed by MTS assay, migration by Boyden chamber assay, and invasion using an invasion chamber. Transient silencing was obtained by small interfering RNA. RESULTS Human pancreatic stellate cells express COX-2 and synthesize PGE2. Prostaglandin E2 stimulated HPSC proliferation, migration, and invasion and stimulated expression of both extracellular matrix and matrix metalloproteinase genes. Human pancreatic stellate cells expressed all 4 EP receptors. Only blocking the EP4 receptor resulted in abrogation of PGE2-mediated HPSC activation. Specificity of EP4 for the effects of PGE2 on stellate cells was confirmed using specific antagonists. CONCLUSIONS Our data indicate that PGE2 regulates pancreatic stellate cell profibrotic activities via EP4 receptor, thus suggesting EP4 receptor as useful therapeutic target for pancreatic cancer to reduce desmoplasia.
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Affiliation(s)
- Chantale Charo
- Department of Cancer Biology, UT MD Anderson Cancer Center, Houston, TX
| | - Vijaykumar Holla
- Department of Cancer Biology, UT MD Anderson Cancer Center, Houston, TX
| | | | - Rosa Hwang
- Department of Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX
| | - Peiying Yang
- Department of Cancer Biology, UT MD Anderson Cancer Center, Houston, TX
| | - Raymond N. Dubois
- Department of Cancer Biology and Gastrointestinal Oncology, UT MD Anderson Cancer Center, Houston, TX
| | - David G. Menter
- Department of Cancer Biology, UT MD Anderson Cancer Center, Houston, TX
| | - Craig D. Logsdon
- Department of Cancer Biology and Medical Oncology, UT MD Anderson Cancer Center, Houston, TX
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Hillion J, Smail SS, Di Cello F, Belton A, Shah S, Huso T, Schuldenfrei A, Nelson DM, Cope L, Campbell N, Karikari C, Aderinto A, Maitra A, Huso DL, Resar LMS. The HMGA1-COX-2 axis: a key molecular pathway and potential target in pancreatic adenocarcinoma. Pancreatology 2012; 12:372-9. [PMID: 22898640 PMCID: PMC3466102 DOI: 10.1016/j.pan.2012.05.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONTEXT Although pancreatic cancer is a common, highly lethal malignancy, the molecular events that enable precursor lesions to become invasive carcinoma remain unclear. We previously reported that the high-mobility group A1 (HMGA1) protein is overexpressed in >90% of primary pancreatic cancers, with absent or low levels in early precursor lesions. METHODS Here, we investigate the role of HMGA1 in reprogramming pancreatic epithelium into invasive cancer cells. We assessed oncogenic properties induced by HMGA1 in non-transformed pancreatic epithelial cells expressing activated K-RAS. We also explored the HMGA1-cyclooxygenase (COX-2) pathway in human pancreatic cancer cells and the therapeutic effects of COX-2 inhibitors in xenograft tumorigenesis. RESULTS HMGA1 cooperates with activated K-RAS to induce migration, invasion, and anchorage-independent cell growth in a cell line derived from normal human pancreatic epithelium. Moreover, HMGA1 and COX-2 expression are positively correlated in pancreatic cancer cell lines (r(2) = 0.93; p < 0.001). HMGA1 binds directly to the COX-2 promoter at an AT-rich region in vivo in three pancreatic cancer cell lines. In addition, HMGA1 induces COX-2 expression in pancreatic epithelial cells, while knock-down of HMGA1 results in repression of COX-2 in pancreatic cancer cells. Strikingly, we also discovered that Sulindac (a COX-1/COX-2 inhibitor) or Celecoxib (a more specific COX-2 inhibitor) block xenograft tumorigenesis from pancreatic cancer cells expressing high levels of HMGA1. CONCLUSIONS Our studies identify for the first time an important role for the HMGA1-COX-2 pathway in pancreatic cancer and suggest that targeting this pathway could be effective to treat, or even prevent, pancreatic cancer.
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Affiliation(s)
- Joelle Hillion
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Shamayra S. Smail
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Pathobiology Graduate Program, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Francescopaolo Di Cello
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Amy Belton
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Sandeep Shah
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Tait Huso
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Andrew Schuldenfrei
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Dwella Moton Nelson
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Leslie Cope
- Oncology Center-Biostatistics/Bioinformatics, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Nathaniel Campbell
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Collins Karikari
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Abimbola Aderinto
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Anirban Maitra
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - David L. Huso
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Molecular and Comparative Pathobiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Linda M. S. Resar
- Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Pathobiology Graduate Program, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
- Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
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Daniluk J, Liu Y, Deng D, Chu J, Huang H, Gaiser S, Cruz-Monserrate Z, Wang H, Ji B, Logsdon CD. An NF-κB pathway-mediated positive feedback loop amplifies Ras activity to pathological levels in mice. J Clin Invest 2012; 122:1519-28. [PMID: 22406536 DOI: 10.1172/jci59743] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 01/25/2012] [Indexed: 12/12/2022] Open
Abstract
Genetic mutations that give rise to active mutant forms of Ras are oncogenic and found in several types of tumor. However, such mutations are not clear biomarkers for disease, since they are frequently detected in healthy individuals. Instead, it has become clear that elevated levels of Ras activity are critical for Ras-induced tumorigenesis. However, the mechanisms underlying the production of pathological levels of Ras activity are unclear. Here, we show that in the presence of oncogenic Ras, inflammatory stimuli initiate a positive feedback loop involving NF-κB that further amplifies Ras activity to pathological levels. Stimulation of Ras signaling by typical inflammatory stimuli was transient and had no long-term sequelae in wild-type mice. In contrast, these stimuli generated prolonged Ras signaling and led to chronic inflammation and precancerous pancreatic lesions (PanINs) in mice expressing physiological levels of oncogenic K-Ras. These effects of inflammatory stimuli were disrupted by deletion of inhibitor of NF-κB kinase 2 (IKK2) or inhibition of Cox-2. Likewise, expression of active IKK2 or Cox-2 or treatment with LPS generated chronic inflammation and PanINs only in mice expressing oncogenic K-Ras. The data support the hypothesis that in the presence of oncogenic Ras, inflammatory stimuli trigger an NF-κB-mediated positive feedback mechanism involving Cox-2 that amplifies Ras activity to pathological levels. Because a large proportion of the adult human population possesses Ras mutations in tissues including colon, pancreas, and lung, disruption of this positive feedback loop may be an important strategy for cancer prevention.
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Affiliation(s)
- Jaroslaw Daniluk
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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Bergmann F, Moldenhauer G, Herpel E, Gaida MM, Strobel O, Werner J, Esposito I, Müerköster SS, Schirmacher P, Kern MA. Expression of L1CAM, COX-2, EGFR, c-KIT and Her2/neu in anaplastic pancreatic cancer: putative therapeutic targets? Histopathology 2011; 56:440-8. [PMID: 20459551 DOI: 10.1111/j.1365-2559.2010.03499.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS Undifferentiated (anaplastic) pancreatic cancer and undifferentiated pancreatic carcinoma with osteoclast-like giant cells (giant cell tumour) are rare variants of pancreatic ductal adenocarcinoma. Representing biologically highly aggressive neoplasms, they are frequently diagnosed at an advanced stage. The response to established chemo- or radiochemotherapeutic treatment regimens is poor, and undifferentiated pancreatic cancer generally has a dismal prognosis. As additional therapeutic options have not yet been investigated in undifferentiated pancreatic cancer, the aim was to analyse the expression of putative therapeutic targets that have shown promising results in various other neoplasms. METHODS AND RESULTS Fifteen cases of undifferentiated pancreatic cancer (seven containing osteoclast-like giant cells) were investigated clinicopathologically and immunohistochemically for putative therapeutic targets. Whereas L1CAM, cyclooxygenase (COX)-2 and epidermal growth factor receptor (EGFR) were found to be significantly expressed in 80%, 93% and 87% of the investigated tumours, respectively, there was no substantial expression of c-kit (CD117) and there was no detectable expression of Her2/neu. CONCLUSIONS The expression of L1CAM, COX-2 and EGFR in the majority of undifferentiated pancreatic carcinomas suggests that they might represent targets for adjuvant therapy in anaplastic pancreatic cancer. On the other hand, c-kit and Her2/neu seem to have no relevance for the therapy of these tumours.
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Affiliation(s)
- Frank Bergmann
- Institute of Pathology, University of Heidelberg, Im Neuenheimer Feld 220, D-69120 Heidelberg, Germany.
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Strimpakos AS, Syrigos KN, Saif MW. The molecular targets for the diagnosis and treatment of pancreatic cancer. Gut Liver 2010; 4:433-49. [PMID: 21253292 PMCID: PMC3021599 DOI: 10.5009/gnl.2010.4.4.433] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Accepted: 10/18/2010] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is considered an aggressive malignancy that responds poorly to current treatments and therefore has a dismal survival rate. This disease is usually not diagnosed until a late stage, at which point palliative chemotherapy with the purine analogue gemcitabine and/or a fluoropyrimidine or a platinum agent is the standard approach. There are some new data on the molecular and genetic changes that take place in pancreatic cancer, which may facilitate the accuracy of diagnosis and efficacy of treatments. However, translational efforts in clinical practice have increased clinicians' options with a targeted agent, erlotinib, in combination with the standard gemcitabine chemotherapy. Many other novel drugs currently being tested in the field of pharmaco-oncology target various altered biological pathways and molecules. Nevertheless, the lack of clinically significant improvements in treatments is rendering efforts to develop methods of early diagnosis both more urgent and promising. The aim of this review was to summarize the molecular basis of pancreatic carcinogenesis and the latest developments in diagnosis by molecular means, focusing on the results of clinical research into targeted and personalized treatments.
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Affiliation(s)
| | - Kostas N. Syrigos
- Oncology Unit, 3rd Department of Medicine, Sotiria General Hospital, Athens, Greece
| | - Muhammad Wasif Saif
- Division of Hematology/Oncology, Department of Medicine, Columbia University College of Physicians and Surgeons and Pancreas Center at the New York-Presbyterian Hospital, New York, NY, USA
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Haugk B. Pancreatic intraepithelial neoplasia-can we detect early pancreatic cancer? Histopathology 2010; 57:503-14. [PMID: 20875068 DOI: 10.1111/j.1365-2559.2010.03610.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Haugk B
(2010) Histopathology 57, 503-514
Pancreatic intraepithelial neoplasia - can we detect early pancreatic cancer? Pancreatic cancer is one of the most lethal cancers, with an incidence equalling mortality. Pancreatic cancer is a heterogeneous group in which pancreatic ductal adenocarcinoma (PDAC) is the most common. It is now established that PDAC develops through stepwise progression from precursor lesions. Detection and treatment of these precursor lesions would allow curative treatment. Three precursor lesions for PDAC have been identified. Two of these - mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs) - are rare, radiologically detectable, cystic precursor lesions which can be cured if treated at the preinvasive stage. The third and most common precursor lesion has recently been defined as pancreatic intraepithelial neoplasia (PanIN). PanINs are microscopic lesions with no clinical correlate. They display a spectrum of cyto-architectural changes (PanIN-1, PanIN-2 and PanIN-3) mirrored in an increasing accumulation of molecular genetic changes, with PanIN-3 sharing many of the alterations with PDAC. Great advances in the understanding of pancreatic carcinogenesis have opened avenues for diagnosis and chemoprevention. However, access to the pancreas is limited, molecular tests are at the early stages and too little is known about the natural history of early PanINs to justify resection. Currently, screening focuses upon high-risk individuals only.
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Affiliation(s)
- Beate Haugk
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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Hermanova M, Karasek P, Tomasek J, Lenz J, Jarkovsky J, Dite P. Comparative analysis of clinicopathological correlations of cyclooxygenase-2 expression in resectable pancreatic cancer. World J Gastroenterol 2010; 16:1879-84. [PMID: 20397266 PMCID: PMC2856829 DOI: 10.3748/wjg.v16.i15.1879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To perform a comparative analysis of clinicopathological correlations of cyclooxygenase-2 (COX-2) expression in pancreatic cancer, examined by monoclonal and polyclonal antibodies.
METHODS: The COX-2 expression in 85 resection specimens of pancreatic ductal adenocarcinoma was immunohistochemically examined using both monoclonal and polyclonal antibodies. The final immunoscores were obtained by multiplying the percentage of positive cells with the numeric score reflecting the staining intensity. COX-2 expression levels were classified into three categories (0, 1+, and 2+) and the clinicopathological correlations were statistically evaluated and analyzed.
RESULTS: The positive tumor expression rates of COX-2 were 80.5% using monoclonal antibody and 69.4% using polyclonal antibody. In the Kaplan-Meier analysis, no significant correlations were found between levels of COX-2 expression and overall survival (OS), but trends to longer OS were found in COX-2 negative cases using monoclonal antibody. Significantly longer disease free survival was revealed in COX-2 negative cases using monoclonal antibody (P = 0.019). No correlations between COX-2 expression levels and grade (G), tumor (T) status and nodal (N) status were demonstrated. Low histological grade showed a strong association with a longer OS (P < 0.001). Correlation of survival and T status revealed a shorter OS in T3 tumors, but the results reached only marginal statistical significance (P = 0.070). In the multivariate Cox proportional hazards regression model, histological grade, T and N status remained valuable predictors of a worse survival with borderline significance for T [hazards ratio (HR) = 4.18 for G (if G = 3, P < 0.001); HR = 1.64 for T (if T = 3, P = 0.065); HR = 2.53 for N (if N = 1, P = 0.006)]. Higher grade, T or N status was associated with a worse OS.
CONCLUSION: The immunohistochemically assessed level of COX-2 expression does not seem to represent a valuable independent prognostic factor and is not superior to the conventional prognostic factors.
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Clinicopathological correlations of cyclooxygenase-2, MDM2, and p53 expressions in surgically resectable pancreatic invasive ductal adenocarcinoma. Pancreas 2009; 38:565-71. [PMID: 19346994 DOI: 10.1097/mpa.0b013e31819fef8b] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Cyclooxygenase-2 (COX-2) and p53 represent molecules linked to oncogenesis of pancreatic cancer, and there is also a known regulatory loop between mouse double minute 2 (MDM2) and p53. The complex cross talks between p53 and COX-2 and scenarios explaining patterns of p53 and COX-2 expressions in precursor and cancer lesions have been recently reported. METHODS The expressions of COX-2, p53, and MDM2 were examined using immunohistochemistry in 85 resection specimens of pancreatic ductal adenocarcinoma. RESULTS The positive tumor expression rates of COX-2, p53, and MDM2 were 69.4%, 60.0%, and 41.2%, respectively. Significant correlations between COX-2 and p53 expressions and between p53 and MDM2 expressions were revealed. In the Kaplan-Meier analysis, no statistically significant correlations were found among the levels of COX-2, p53, and MDM2 expressions and survival rates. In the multivariate Cox proportional hazards regression model, grade and nodal status showed to be a valuable predictor of a worse overall survival. CONCLUSIONS The reported findings confirmed the relationship of p53, MDM2, and COX-2 with the biological process of pancreatic cancer. The expression of none of the examined proteins showed to be a valuable independent prognostic factor. On the contrary, grade and nodal status showed to be a valuable predictor of a worse survival.
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Antitumor Activity of Gemcitabine and Oxaliplatin Is Augmented by Thymoquinone in Pancreatic Cancer. Cancer Res 2009; 69:5575-83. [DOI: 10.1158/0008-5472.can-08-4235] [Citation(s) in RCA: 182] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Zhao D, Xu D, Zhang X, Wang L, Tan W, Guo Y, Yu D, Li H, Zhao P, Lin D. Interaction of cyclooxygenase-2 variants and smoking in pancreatic cancer: a possible role of nucleophosmin. Gastroenterology 2009; 136:1659-68. [PMID: 19422084 DOI: 10.1053/j.gastro.2009.01.071] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Overexpression of cyclooxygenase-2 (COX-2) is implicated in cancer development. This study examined the functional relevance of genetic polymorphisms in the COX-2 promoter and evaluated their associations with susceptibility to pancreatic cancer. METHODS Genotypes and haplotypes of COX-2 -765G/C, -1195G/A, and -1290A/G were analyzed in 393 pancreatic cancer patients and 786 controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed by logistic regression.The function of the -765G-->C polymorphism was examined by a set of biochemical assays. RESULTS The -1195AA or -765GC genotype carriers had a 1.34-fold (95% CI: 1.12-1.60) or 1.63-fold (95% CI: 1.25-2.10) excess risk for developing pancreatic cancer. These 2 variants showed a cooperative effect in context of haplotype, with the ORs for the A(-1195)-C(-765)- containing haplotypes being significantly greater than those for the G(-1195)-G(-765)-containing haplotypes. The -765C allele and smoking displayed a multiplicative joint effect, with an OR of 3.72 (95% CI: 1.70-8.14) for heavy smokers carrying the -765GC genotype. Biochemical assays suggest that the -765G-->C change creates a binding site for nucleophosmin (NPM) and phosphorylated NPM (p-NPM), which acts as a transcriptional inhibitor. Cigarette smoke remarkably increased COX-2 promoter activity, and this effect was more pronounced for the -765C allele compared with the -765G allele. Cigarette smoke reduced nuclear p-NPM levels, which was reversely associated with COX-2 expression. CONCLUSIONS Functional COX-2 polymorphisms are associated with susceptibility to pancreatic cancer and tobacco smoke specifically increases -765C promoter activity, which might be mediated by p-NPM.
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Affiliation(s)
- Dan Zhao
- Department of Etiology and Carcinogenesis, Cancer Hospital and Institute, Chinese Academy of Medical Sciences, Beijing
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Bergmann F, Breinig M, Höpfner M, Rieker RJ, Fischer L, Köhler C, Esposito I, Kleeff J, Herpel E, Ehemann V, Friess H, Schirmacher P, Kern MA. Expression pattern and functional relevance of epidermal growth factor receptor and cyclooxygenase-2: novel chemotherapeutic targets in pancreatic endocrine tumors? Am J Gastroenterol 2009; 104:171-81. [PMID: 19098866 DOI: 10.1038/ajg.2008.33] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatic endocrine tumors represent morphologically and biologically heterogeneous neoplasms. Well-differentiated endocrine tumors (benign or of uncertain behavior) can be distinguished from well-differentiated and poorly differentiated endocrine carcinomas. Although many well-differentiated endocrine carcinomas show rather low rates of tumor growth, more than two-thirds of pancreatic endocrine carcinomas display distant metastases at the time of diagnosis. As the currently applied therapies beyond surgery only achieve partial or complete response rates of approximately 15%, additional chemotherapeutic targets are needed, especially in the therapy of inoperable and progressive pancreatic endocrine carcinomas. METHODS The expression of epidermal growth factor receptor (EGFR) and cyclooxygenase (COX)-2 were investigated in 110 clinically and pathomorphologically well-characterized pancreatic endocrine tumors, using immunohistochemistry and immunoblot analyses. Functional tests were performed using the human pancreas carcinoid cell line BON and the mouse insulinoma cell line beta-TC-3. RESULTS The expression of EGFR correlated significantly with the grade of malignancy, increasing from low rates of expression in benign tumors and tumors of uncertain behavior to high rates of expression in well- and poorly differentiated endocrine carcinomas. The expression of COX-2 was independent of the malignant potential, but was more frequently expressed in primary tumors than in metastases. The treatment of the human pancreas carcinoid cell line BON and the mouse insulinoma cell line beta-TC-3 with EGFR and COX-2 inhibitors (monotherapy and combined therapy) resulted in a significant, dose-dependent reduction of cell viability coupled with increased apoptosis. CONCLUSIONS Our results suggest that EGFR and COX-2 may represent useful additional chemotherapeutic targets in pancreatic endocrine tumors.
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Affiliation(s)
- Frank Bergmann
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
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Strimpakos A, Saif MW, Syrigos KN. Pancreatic cancer: from molecular pathogenesis to targeted therapy. Cancer Metastasis Rev 2008; 27:495-522. [PMID: 18427734 DOI: 10.1007/s10555-008-9134-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreatic cancer is a deadly malignancy with still high mortality and poor survival despite the significant advances in understanding, diagnosis, and access to conventional and novel treatments. Though cytotoxic chemotherapy based on the purine analogue gemcitabine remains the standard approach in adjuvant and palliative setting the need for novel agents aiming at the main pathophysiological abnormalities and molecular pathways involved remains soaring. So far, evidence of clinical benefit, though small, exists only from the addition of the targeted agent erlotinib on the standard gemcitabine chemotherapy. Apart from the popular monoclonal antibodies and small molecules tyrosine kinase inhibitors, other novel compounds being tested in preclinical and clinical studies target mTOR, NF-kappaB, proteasome and histone deacetylase. These new drugs along with gene therapy and immunotherapy, which are also under clinical evaluation, may alter the unfavorable natural course of this disease. In this review we present the main pathophysiological alterations met in pancreatic cancer and the results of the florid preclinical and clinical research with regards to the targeted therapy associated to these abnormalities.
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Expression of COX-2 is associated with accumulation of p53 in pancreatic cancer: analysis of COX-2 and p53 expression in premalignant and malignant ductal pancreatic lesions. Eur J Gastroenterol Hepatol 2008; 20:732-9. [PMID: 18617777 DOI: 10.1097/meg.0b013e3282f945fb] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Cyclooxygenase-2 (COX-2) and tumor suppressor p53 are molecules that are linked to the oncogenesis of pancreatic cancer. COX-2 represents a key modulatory molecule in inflammation and carcinogenesis, and is known to be implicated in the positive regulation of growth and tumorigenesis. Abnormal expression of p53 is common in many human neoplasms including pancreatic cancer. Recent studies demonstrated functional interactions between p53 and COX-2. The p53-dependent upregulation of COX-2 was proposed to be another mechanism by which p53 could abate its own growth-inhibitory and apoptotic effects. METHODS In this study, we immunohistochemically analyzed the expression of COX-2 and p53 in 95 pancreatic resection specimens [adenocarcinomas, 95 lesions; pancreatic intraepithelial neoplasias (PanINs), 155; normal ducts, 70]. RESULTS The expression of COX-2 increased progressively with the grade of ductal lesions (P<0.00001). A statistically significant difference of COX-2 expression between normal ducts and low-grade PanINs was revealed (P=0.0042). COX-2 overexpression was demonstrated in 82 PanINs (52.9%), and in 76 adenocarcinomas (80%). No significant correlation between the grade of adenocarcinoma and COX-2 expression was revealed (P=0.2). The expression of p53 again increased progressively with the grade of lesions (P<0.00001) with a significant increase in high-grade PanINs. A correlation between COX-2 and p53 expression levels in carcinomas was revealed (P=0.0002), and an accumulation of p53 was associated with COX-2 overexpression in premalignant and malignant ductal lesions. CONCLUSION These findings confirmed the generally accepted pancreatic cancer progression model, and supported the concept of the interactive role of COX-2 and p53 in pancreatic cancer carcinogenesis, which offers opportunities for targeted therapy and chemoprevention of pancreatic cancer using COX-2 inhibitors.
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Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are a well-characterized group of intraductal mucin-producing cystic neoplasms of pancreas with clear malignant potential. It has a favorable prognosis and distinct molecular or clicinopathologic features compared with other types of pancreatic tumors. In addition, IPMNs can be divided into several subtypes in accordance with the papillary structure and mucin expression profile. Importantly, as IPMNs are acknowledged as key stages during pancreatic carcinogenesis, it can better reveal the mechanism and biological characteristics of IPMNs through further investigation of the pathologic features and the molecular aberrations harbored in different subtypes of IPMNs. This paper reviewed relevant literatures and elucidated its progression in terms of the molecular and clicinopathologic characteristics, diagnosis, treatment and prognosis of IPMNs.
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Capurso G, Schünemann HJ, Terrenato I, Moretti A, Koch M, Muti P, Capurso L, Delle Fave G. Meta-analysis: the use of non-steroidal anti-inflammatory drugs and pancreatic cancer risk for different exposure categories. Aliment Pharmacol Ther 2007; 26:1089-99. [PMID: 17894651 DOI: 10.1111/j.1365-2036.2007.03495.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND A better understanding of predictors of risk for pancreatic ductal adenocarcinoma (PDAC) could inform preventive efforts against this lethal cancer. While aspirin (ASA) and non-steroidal anti-inflammatory drugs (NSAIDS) might protect against several gastrointestinal cancers, their role in the development of PDAC remains unclear. AIM To conduct a systematic review and meta-analysis on the relation between ASA/NSAIDs exposure and the risk of PDAC. Methods We searched Pubmed, Embase, Scopus, Cochrane database of systematic reviews and reference lists of identified papers and included observational (cohort or case-control) studies and randomized controlled trials examining exposure to ASA and/or NSAIDs and the incidence or mortality of PDAC. We defined three categories (low, intermediate, high), based on exposure duration and dose. RESULTS Eight studies fulfilled our inclusion criteria (four cohort, three case controls, and one randomized controlled trial studies) enrolling 6301 patients between 1971-2004; all but one study took place in the US. The pooled OR were 0.99 (0.83-1.19), 1.11 (0.84-1.47) and 1.09 (0.67-1.75) in the low, intermediate and high exposure groups respectively, with considerable heterogeneity (I(2) ranging 60-86%). Sensitivity analysis by ASA use only, study design or sex did not reveal additional important information. CONCLUSIONS This study did not show an association between ASA/NSAIDs and PDAC. The large baseline exposure in controls in North-America may have obscured an association. There is need for additional studies, especially in Europe, to clarify this issue.
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Affiliation(s)
- G Capurso
- Digestive and Liver Disease Unit, II Medical School, University La Sapienza, Rome, Italy
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Abstract
The genetic paradigm of cancer, focused largely on sequential molecular aberrations and associated biological impact in the neoplastic cell compartment of malignant tumors, has dominated our view of cancer pathogenesis. For the most part, this conceptualization has overlooked the dynamic and complex contributions of the surrounding microenvironment comprised of non-tumor cells (stroma) that may resist, react to, and/or foster tumor development. Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal disease in which a prominent tumor stroma compartment is a defining characteristic. Indeed, the bulk of PDAC tumor volume consists of non-neoplastic fibroblastic, vascular, and inflammatory cells surrounded by immense quantities of extracellular matrix, far exceeding that found in most other tumor types. Remarkably, little is known about the composition and physiology of the PDAC tumor microenvironment, in particular, the role of stroma in tumor initiation and progression. This review attempts to define key challenges, opportunities and state-of-knowledge relating to the PDAC microenvironment research with an emphasis on how inflammatory processes and key cancer pathways may shape the ontogeny of the tumor stroma. Such knowledge may be used to understand the evolution and biology of this lethal cancer and may convert these insights into new points of therapeutic intervention.
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Affiliation(s)
- Gerald C Chu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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31
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Abstract
Despite recent improvements in chemotherapy and radiation therapy in cancer management with the addition of biological agents, novel treatment approaches are needed to further benefit patients. Cyclo-oxygenase (COX)-2 inhibition represents one such possibility. COX-2 is an enzyme induced in pathological states such as inflammatory disorders and cancer, where it mediates production of prostanoids. The enzyme is commonly expressed in both premalignant lesions and malignant tumours of different types. A growing body of evidence suggests an association of COX-2 with tumour development, aggressive biological tumour behaviour, resistance to standard cancer treatment, and adverse patient outcome. COX-2 may be related to cancer development and propagation through multiple mechanisms, including stimulation of growth, migration, invasiveness, resistance to apoptosis, suppression of the immunosurveillance system, and enhancement of angiogenesis. Epidemiological data suggest that NSAIDs and selective COX-2 inhibitors might prevent the development of cancers, including colorectal, oesophageal and lung cancer. Preclinical investigations have demonstrated that inhibition of this enzyme with selective COX-2 inhibitors enhances tumour response to radiation and chemotherapeutic agents. These preclinical findings have been rapidly advanced to clinical oncology. Clinical trials of the combination of selective COX-2 inhibitors with radiotherapy, chemotherapy or both in patients with a number of cancers have been initiated, and preliminary results are encouraging. This review discusses the role of COX-2, its products (prostaglandins) and its inhibitors in tumour growth and treatment.
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Affiliation(s)
- Zhongxing Liao
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Feldmann G, Beaty R, Hruban RH, Maitra A. Molecular genetics of pancreatic intraepithelial neoplasia. ACTA ACUST UNITED AC 2007; 14:224-32. [PMID: 17520196 PMCID: PMC2666331 DOI: 10.1007/s00534-006-1166-5] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Accepted: 04/11/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent evidence suggests that noninvasive precursor lesions, classified as pancreatic intraepithelial neoplasia (PanIN), can progress to invasive pancreatic cancer. This review will discuss the major genetic alterations in PanIN lesions. METHODS A comprehensive review of the literature was performed in order to find studies on the molecular profile of human PanIN lesions. In addition, recent publications on genetically engineered mouse models of preinvasive neoplasia and pancreatic cancers were reviewed. RESULTS PanINs demonstrate abnormalities at the genomic (DNA), transcriptomic (RNA), and proteomic levels, and there is a progressive accumulation of molecular alterations that accompany the histological progression from low-grade PanIN-1A to high-grade PanIN-3 lesions. Molecular changes in PanINs can be classified as "early" (KRAS2 mutations, telomere shortening, p21(WAF1/CIP1) up-regulation, etc.), "intermediate" (cyclin D1 up-regulation, expression of proliferation antigens, etc.), or "late" (BRCA2 and TP53 mutations, DPC4/SMAD4/MADH4 inactivation, etc.). All the genetic changes observed in PanINs are also found in invasive ductal adenocarcinomas, where they usually occur at a higher frequency. Genetically engineered mice expressing mutant Kras in the pancreas, with or without additional genetic alterations, provide a unique in vivo platform to study the pancreatic cancer progression model. CONCLUSIONS Molecular studies have been instrumental in establishing that PanIN lesions are the noninvasive precursors for invasive ductal adenocarcinomas. The availability of molecular date provides the basis for designing rational early detection strategies and therapeutic intervention trials before pancreatic neoplasms invade, with the intention of alleviating the dismal prognosis associated with this disease.
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Affiliation(s)
- Georg Feldmann
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Ross Bldg 632, Johns Hopkins University School of Medicine, 720 Rutland Ave., Baltimore, MD 21205, USA
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Aho U, Zhao X, Löhr M, Andersson R. Molecular mechanisms of pancreatic cancer and potential targets of treatment. Scand J Gastroenterol 2007; 42:279-96. [PMID: 17354106 DOI: 10.1080/00365520601106384] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Ursula Aho
- Department of Surgery, Lund University Hospital, University of Lund, Lund, Sweden
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