Postoperative course and prognostic value of circulating angiogenic cytokines after pancreatic cancer resection

Evaluations of the combined use of blood- and tissue-based protein biomarkers for pancreatic cancer

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy with a low 5-year survival rate. Biomarkers may be of value for the early diagnosis of pancreatic cancer. This study assessed blood- and tumour tissue-based biomarkers associated with pancreatic cancer.

METHODS

We studied 61 patients who underwent pancreatic resection. Of these 61 patients, 46 patients had PDAC, and 15 patients had inflammatory tumours. Blood and tumour tissue levels of VEGF, hypoxia-inducible factor 1α (HIF-1α) and glucose transporter 1 (GLUT1) were measured.

RESULTS

Blood concentrations of VEGF (p < 0.000001) and HIF-1α (p = 0.000002) were significantly higher in the PDAC group than in the inflammatory tumour group. Tumour tissue concentrations of VEGF (p < 0.000001), HIF-1α (p = 0.000005) and GLUT1 (0.000002) were also significantly higher in the PDAC group. Univariate analyses revealed that age, BMI, and blood levels of CA19-9, VEGF, and HIF-1α were potential predictors of PDAC. Potential predictors of PDAC in tumour tissue were VEGF, HIF-1α and GLUT1. Multivariate analyses found that VEGF was the most powerful independent predictor of PDAC in blood (OR = 1.016; 95% CI: 1.007-1.025; 0.001) and tumour tissue (OR = 1.02; 95% CI: 1.008-1.032, p = 0.001). The cut-off point for blood VEGF was 134.56 pg/ml, with a sensitivity of 97.8%, specificity of 86.7%, PPV of 95.7%, and NPV of 92.9%. The cut-off point for tissue tumour VEGF in PDAC was 208.59 pg/mg, with a sensitivity, specificity, PPV and NPV of 97.7%, 92.9%, 97.7%, and 92.9%, respectively.

CONCLUSIONS

There are significant differences in blood-based biomarkers for differentiating between PDAC and inflammatory tumours of the pancreas. VEGF was an independent predictor of PDAC independent of its addition to the routinely used tumour marker CA19-9 antigen.

Identifying Effective Biomarkers for Accurate Pancreatic Cancer Prognosis Using Statistical Machine Learning

Pancreatic cancer (PC) has one of the lowest survival rates among all major types of cancer. Consequently, it is one of the leading causes of mortality worldwide. Serum biomarkers historically correlate well with the early prognosis of post-surgical complications of PC. However, attempts to identify an effective biomarker panel for the successful prognosis of PC were almost non-existent in the current literature. The current study investigated the roles of various serum biomarkers including carbohydrate antigen 19-9 (CA19-9), chemokine (C-X-C motif) ligand 8 (CXCL-8), procalcitonin (PCT), and other relevant clinical data for identifying PC progression, classified into sepsis, recurrence, and other post-surgical complications, among PC patients. The most relevant biochemical and clinical markers for PC prognosis were identified using a random-forest-powered feature elimination method. Using this informative biomarker panel, the selected machine-learning (ML) classification models demonstrated highly accurate results for classifying PC patients into three complication groups on independent test data. The superiority of the combined biomarker panel (Max AUC-ROC = 100%) was further established over using CA19-9 features exclusively (Max AUC-ROC = 75%) for the task of classifying PC progression. This novel study demonstrates the effectiveness of the combined biomarker panel in successfully diagnosing PC progression and other relevant complications among Egyptian PC survivors.

Energy Metabolism, Metabolite, and Inflammatory Profiles in Human Ex Vivo Adipose Tissue Are Influenced by Obesity Status, Metabolic Dysfunction, and Treatment Regimes in Patients with Oesophageal Adenocarcinoma

Oesophageal adenocarcinoma (OAC) is a poor prognosis cancer with limited response rates to current treatment modalities and has a strong link to obesity. To better elucidate the role of visceral adiposity in this disease state, a full metabolic profile combined with analysis of secreted pro-inflammatory cytokines, metabolites, and lipid profiles were assessed in human ex vivo adipose tissue explants from obese and non-obese OAC patients. These data were then related to extensive clinical data including obesity status, metabolic dysfunction, previous treatment exposure, and tumour regression grades. Real-time energy metabolism profiles were assessed using the seahorse technology. Adipose explant conditioned media was screened using multiplex ELISA to assess secreted levels of 54 pro-inflammatory mediators. Targeted secreted metabolite and lipid profiles were analysed using Ultra-High-Performance Liquid Chromatography coupled with Mass Spectrometry. Adipose tissue explants and matched clinical data were collected from OAC patients (n = 32). Compared to visceral fat from non-obese patients (n = 16), visceral fat explants from obese OAC patients (n = 16) had significantly elevated oxidative phosphorylation metabolism profiles and an increase in Eotaxin-3, IL-17A, IL-17D, IL-3, MCP-1, and MDC and altered secretions of glutamine associated metabolites. Adipose explants from patients with metabolic dysfunction correlated with increased oxidative phosphorylation metabolism, and increases in IL-5, IL-7, SAA, VEGF-C, triacylglycerides, and metabolites compared with metabolically healthy patients. Adipose explants generated from patients who had previously received neo-adjuvant chemotherapy (n = 14) showed elevated secretions of pro-inflammatory mediators, IL-12p40, IL-1α, IL-22, and TNF-β and a decreased expression of triacylglycerides. Furthermore, decreased secreted levels of triacylglycerides were also observed in the adipose secretome of patients who received the chemotherapy-only regimen FLOT compared with patients who received no neo-adjuvant treatment or chemo-radiotherapy regimen CROSS. For those patients who showed the poorest response to currently available treatments, their adipose tissue was associated with higher glycolytic metabolism compared to patients who had good treatment responses. This study demonstrates that the adipose secretome in OAC patients is enriched with mediators that could prime the tumour microenvironment to aid tumour progression and attenuate responses to conventional cancer treatments, an effect which appears to be augmented by obesity and metabolic dysfunction and exposure to different treatment regimes.

Blood-based protein biomarkers and red blood cell aggregation in pancreatic cancer

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is highly malignant with a low 5-year survival rate. Blood biomarkers may be of value for the noninvasive diagnosis of pancreatic cancer.

OBJECTIVE

This study assessed blood-based biomarkers and disturbances in red blood cell aggregation associated with pancreatic cancer.

METHODS

We studied 61 patients who underwent pancreatic resection. Of these 61 patients, 46 patients had PDAC, and 15 patients had inflammatory tumours. Serum VEGF, hypoxia-inducible factor (HIF-1α), elastin-derived peptides (EDPs), total sialic acid (TSA) and resistin levels were measured. Red blood cell aggregation was assessed by a laser-assisted optical rotational cell analyser.

RESULTS

VEGF (p < 0.000001), HIF-1α (p = 0.000002), resistin (p = 0.000349), EDP (p = 0.000089) and TSA (p = 0.000013) levels were significantly higher in the PDAC group than in the inflammatory tumour group. The aggregation index (AI), syllectogram amplitude (AMP) and threshold shear rate (γthr) were significantly higher in the PDAC group, whereas the aggregation half-time (t1/2) was lower than in the inflammatory tumour group. Multivariate analyses revealed that VEGF, TSA and EDP levels were variables that predicted PDAC. VEGF levels were the most powerful predictor of PDAC independent of CA 19-9 levels. The cut-off points for VEGF, TSA and EDP levels were 134.56 pg/ml, 109.11 mg/dl and 36.4 ng/ml, respectively, with sensitivities of 97.8%, 87% and 69.6%, respectively, and specificities of 86.7%, 86.7% and 93.3%, respectively.

CONCLUSION

This study indicated that there are significant differences in blood-based biomarkers for differentiating between PDAC and inflammatory tumours of the pancreas. We also confirmed that PDAC is associated with the excessive aggregation of RBCs.

Biomarkers in Liquid Biopsies for Prediction of Early Liver Metastases in Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive solid malignancies with poor survival rates. Only 20% of the patients are eligible for R0-surgical resection, presenting with early relapses, mainly in the liver. PDAC patients with hepatic metastases have a worse outcome compared to patients with metastases at other sites. Early detection of hepatic spread bears the potential to improve patient outcomes. Thus, this study sought for serum-based perioperative biomarkers allowing discrimination of early (EHMS ≤ 12 months) and late hepatic metastatic spread (LHMS > 12 months). Serum samples from 83 resectable PDAC patients were divided into EHMS and LHMS and analyzed for levels of inflammatory mediators by LEGENDplexTM, which was validated and extended by Olink® analysis. CA19-9 serum levels served as control. Results were correlated with clinicopathological data. While serum CA19-9 levels were comparable, Olink® analysis confirmed distinct differences between both groups. It revealed significantly elevated levels of factors involved in chemotaxis and migration of immune cells, immune activity, and cell growth in serum of LHMS-patients. Overall, Olink® analysis identified a comprehensive biomarker panel in serum of PDAC patients that could provide the basis for predicting LHMS. However, further studies with larger cohorts are required for its clinical translation.

Impact of intraoperative margin clearance on survival following pancreatoduodenectomy for pancreatic cancer: a systematic review and meta-analysis

The use of intraoperative margin revision to achieve margin clearance in patients undergoing pancreatoduodenectomy for pancreatic cancer is controversial. We performed a systematic review and meta-analysis to summarize the evidence of intraoperative margin revisions of the pancreatic neck and its impact on overall survival (OS). Nine studies with 4501 patients were included. Patient cohort was stratified in an R0R0-group (negative margin on frozen and permanent section), R1R0-group (revised positive margin on frozen section which turned negative on permanent section), and R1R1-group (positive margin on frozen and permanent section despite margin revision). OS was higher in the R1R0-group (HR 0.83, 95% CI 0.72-0.96, P = 0.01) compared to the R1R1-group but lower compared to the R0R0-group (HR 1.20; 95% CI 1.05-1.37, P = 0.008), respectively. Subgroup analyses on the use of different margin clearance definitions confirmed an OS benefit in the R1R0-group compared to the R1R1-group (HR 0.81; 95% CI 0.65-0.99, P = 0.04). In conclusion, intraoperative margin clearance of the pancreatic neck margin is associated with improved OS while residual tumor indicates aggressive tumor biology. Consensus definitions on margin terminologies, clearance, and surgical techniques are required.

Predictive value of EGF and uPAR for chemoradiotherapy response and survival in patients with esophageal squamous cell carcinoma

Background

Chemoradiotherapy (CRT) plays a central role in the treatment of esophageal squamous cell carcinoma (ESCC). However, no effective biomarkers have been identified for predict CRT sensitivity and prognosis of patients with ESCC. The aim of this study was to investigate cytokine profiles of epidermal growth factor (EGF) and urokinase plasminogen activator receptor (uPAR) in 68 ESCC patients, and to evaluate the clinical utility of these markers.

Methods

This pilot study enrolled 68 patients who received neoadjuvant CRT followed by radical surgery or definitive CRT between 2015 and 2017. Serum specimen was obtained from each patient before treatment and at the time of administration of total doses of 40 Gy. Cytokines expression analyses were performed in pre- and post-treatment serum using human cytokine antibody arrays which contained 120 known tumor-related cytokines.

Results

Seven differentially expressed cytokines identified by cytokine antibody arrays in pre- and post-treatment serum from 4 patients with CRT sensitivity and 4 patients with CRT resistance. Of these, up-regulation of EGF and uPAR in serum at the doses of 40 Gy were associated with adverse clinical outcomes. The predictive value of EGF and uPAR were further assessed in a second set of 60 ESCCs. A total of 68 patients enrolled in this study. The median follow-up duration of these patients was 15.87 months (range, 6.21–23.85 months). Cox multivariate survival analyses revealed that high uPAR ratio after CRT independently predicted progression-free survival (PFS) (HR =3.999, 95% CI: 1.503–10.639, P=0.006) and patients with elevated levels of EGF after CRT exhibited significantly worse overall survival (OS) (HR =2.574, 95% CI: 1.046–6.335, P=0.040). Of note, uPAR expression was significantly positive correlation with EGF expression in pre- and post-treatment serum (P=0.0001, P=0.0038). Patients with both high EGF and uPAR ratios had an inferior PFS and OS, compared to patients with a high EGF ratio only or uPAR ratio only or neither (1-year PFS rate 44.2% vs. 61.4%, 1-year OS rate 64.2% vs. 83.4%, P=0.033 and 0.029, respectively).

Conclusions

The levels of EGF and uPAR in serum are reliable and predictive biomarkers for survival in ESCC patients. Further prospective validation in larger independent cohorts is necessary to fully assess its predictive power. We present the following article in accordance with the REMARK reporting checklist.

A Potential Mechanism of Tumor Progression during Systemic Infections Via the Hepatocyte Growth Factor (HGF)/c-Met Signaling Pathway

Background: Increasing evidence has demonstrated that postoperative infectious complications (PICs) after digestive surgery are significantly associated with negative long-term outcomes; however, precise mechanisms of how PICs affect the poor long-term survival remain unclear. Here, we focused on the hepatocyte growth factor (HGF)/c-Met signaling pathway as one of those mechanisms. Methods: In the clinical setting, serum HGF levels were measured in the patients with sepsis and those with PICs after undergoing esophagectomy. Using a liver metastasis mouse model with cecal ligation and puncture (CLP), expressions of HGF and the roles of the HGF/c-Met pathway in the progression of tumor cells were examined. Results: Serum HGF levels were very high in the patients with intra-abdominal infection on postoperative days (PODs) 1, 3, and 5; similarly, compared to the patients without PICs, those with PICs had significantly higher serum HGF levels on 1, 3, and 5 days after esophagectomy. The patients with PICs showed poorer overall survival than those without PICs, and the patients with high serum HGF levels on POD 3 showed poorer prognosis than those with low HGF levels. Similarly, at 24 and 72 h after operation, serum levels of HGF in CLP mice were significantly higher than those in sham-operated mice. Intraperitoneal injection of mouse recombinant HGF significantly promoted liver metastases in sham-operated mice on 14 days after surgery. Knocking down c-Met expression on NL17 tumor cells by RNAi technology significantly inhibited the promotion of CLP-induced liver metastases. Conclusions: Infections after surgery increased serum HGF levels in the clinical as well as experimental settings. Induction of high serum HGF levels by CLP promoted liver metastases in a murine liver metastasis model, suggesting the involvement of the HGF/c-Met signaling pathway in tumor promotion mechanisms. Thus, targeting the HGF/c-Met signaling pathway may be a promising approach for malignant tumors, particularly in the patients with PICs.

The Hepatic Microenvironment and TRAIL-R2 Impact Outgrowth of Liver Metastases in Pancreatic Cancer after Surgical Resection

Most patients with pancreatic ductal adenocarcinoma (PDAC) undergoing curative resection relapse within months, often with liver metastases. The hepatic microenvironment determines induction and reversal of dormancy during metastasis. Both tumor growth and metastasis depend on the Tumor necrosis factor (TNF)-related apoptosis-inducing ligand-receptor 2 (TRAIL-R2). This study investigated the interplay of TRAIL-R2 and the hepatic microenvironment in liver metastases formation and the impact of surgical resection. Although TRAIL-R2-knockdown (PancTu-I shTR2) decreased local relapses and number of macroscopic liver metastases after primary tumor resection in an orthotopic PDAC model, the number of micrometastases was increased. Moreover, abdominal surgery induced liver inflammation involving activation of hepatic stellate cells (HSCs) into hepatic myofibroblasts (HMFs). In coculture with HSCs, proliferation of PancTu-I shTR2 cells was significantly lower compared to PancTu-I shCtrl cells, an effect still observed after switching coculture from HSC to HMF, mimicking surgery-mediated liver inflammation and enhancing cell proliferation. CXCL-8/IL-8 blockade diminished HSC-mediated growth inhibition in PancTu-I shTR2 cells, while Vascular Endothelial Growth Factor (VEGF) neutralization decreased HMF-mediated proliferation. Overall, this study points to an important role of TRAIL-R2 in PDAC cells in the interplay with the hepatic microenvironment during metastasis. Resection of primary PDAC seems to induce liver inflammation, which might contribute to outgrowth of liver metastases.