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Kpeglo D, Haddrick M, Knowles MA, Evans SD, Peyman SA. Modelling and breaking down the biophysical barriers to drug delivery in pancreatic cancer. LAB ON A CHIP 2024; 24:854-868. [PMID: 38240720 DOI: 10.1039/d3lc00660c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
The pancreatic ductal adenocarcinoma (PDAC) stroma and its inherent biophysical barriers to drug delivery are central to therapeutic resistance. This makes PDAC the most prevalent pancreatic cancer with poor prognosis. The chemotherapeutic drug gemcitabine is used against various solid tumours, including pancreatic cancer, but with only a modest effect on patient survival. The growing PDAC tumour mass with high densities of cells and extracellular matrix (ECM) proteins, i.e., collagen, results in high interstitial pressure, leading to vasculature collapse and a dense, hypoxic, mechanically stiff stroma with reduced interstitial flow, critical to drug delivery to cells. Despite this, most drug studies are performed on cellular models that neglect these biophysical barriers to drug delivery. Microfluidic technology offers a promising platform to emulate tumour biophysical characteristics with appropriate flow conditions and transport dynamics. We present a microfluidic PDAC culture model, encompassing the disease's biophysical barriers to therapeutics, to evaluate the use of the angiotensin II receptor blocker losartan, which has been found to have matrix-depleting properties, on improving gemcitabine efficacy. PDAC cells were seeded into our 5-channel microfluidic device for a 21-day culture to mimic the rigid, collagenous PDAC stroma with reduced interstitial flow, which is critical to drug delivery to the cancer cells, and for assessment with gemcitabine and losartan treatment. With losartan, our culture matrix was more porous with less collagen, resulting in increased hydraulic conductivity of the culture interstitial space and improved gemcitabine effect. We demonstrate the importance of modelling tumour biophysical barriers to successfully assess new drugs and delivery methods.
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Affiliation(s)
- Delanyo Kpeglo
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK.
| | - Malcolm Haddrick
- Medicines Discovery Catapult, Block 35, Mereside Alderley Park, Alderley Edge, SK10 4TG, UK
| | - Margaret A Knowles
- Leeds Institute of Medical Research at St James's (LIMR), School of Medicine, University of Leeds, LS2 9 JT, UK
| | - Stephen D Evans
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK.
| | - Sally A Peyman
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK.
- Leeds Institute of Medical Research at St James's (LIMR), School of Medicine, University of Leeds, LS2 9 JT, UK
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2
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Pramanik N, Gupta A, Ghanwatkar Y, Mahato RI. Recent advances in drug delivery and targeting for the treatment of pancreatic cancer. J Control Release 2024; 366:231-260. [PMID: 38171473 PMCID: PMC10922996 DOI: 10.1016/j.jconrel.2023.12.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/24/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
Despite significant treatment efforts, pancreatic ductal adenocarcinoma (PDAC), the deadliest solid tumor, is still incurable in the preclinical stages due to multifacet stroma, dense desmoplasia, and immune regression. Additionally, tumor heterogeneity and metabolic changes are linked to low grade clinical translational outcomes, which has prompted the investigation of the mechanisms underlying chemoresistance and the creation of effective treatment approaches by selectively targeting genetic pathways. Since targeting upstream molecules in first-line oncogenic signaling pathways typically has little clinical impact, downstream signaling pathways have instead been targeted in both preclinical and clinical studies. In this review, we discuss how the complexity of various tumor microenvironment (TME) components and the oncogenic signaling pathways that they are connected to actively contribute to the development and spread of PDAC, as well as the ways that recent therapeutic approaches have been targeted to restore it. We also illustrate how many endogenous stimuli-responsive linker-based nanocarriers have recently been developed for the specific targeting of distinct oncogenes and their downstream signaling cascades as well as their ongoing clinical trials. We also discuss the present challenges, prospects, and difficulties in the development of first-line oncogene-targeting medicines for the treatment of pancreatic cancer patients.
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Affiliation(s)
- Nilkamal Pramanik
- Department of Pharmaceutical Sciences, the University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Aditya Gupta
- Department of Pharmaceutical Sciences, the University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Yashwardhan Ghanwatkar
- Department of Pharmaceutical Sciences, the University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Ram I Mahato
- Department of Pharmaceutical Sciences, the University of Nebraska Medical Center, Omaha, NE 68198, USA.
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3
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Sarkar R, Xu Z, Perera CJ, Apte MV. Emerging role of pancreatic stellate cell-derived extracellular vesicles in pancreatic cancer. Semin Cancer Biol 2023; 93:114-122. [PMID: 37225047 DOI: 10.1016/j.semcancer.2023.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/17/2023] [Accepted: 05/19/2023] [Indexed: 05/26/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer that is characterised by a prominent collagenous stromal reaction/desmoplasia surrounding tumour cells. Pancreatic stellate cells (PSCs) are responsible for the production of this stroma and have been shown to facilitate PDAC progression. Recently, extracellular vesicles (EVs), in particular, small extracellular vesicles (exosomes) have been a topic of interest in the field of cancer research for their emerging roles in cancer progression and diagnosis. EVs act as a form of intercellular communication by carrying their molecular cargo from one cell to another, regulating functions of the recipient cells. Although the knowledge of the bi-directional interactions between the PSCs and cancer cells that promote disease progression has advanced significantly over the past decade, studies on PSC-derived EVs in PDAC are currently rather limited. This review provides an overview of PDAC, pancreatic stellate cells and their interactions with cancer cells, as well as the currently known role of extracellular vesicles derived from PSCs in PDAC progression.
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Affiliation(s)
- Rohit Sarkar
- Pancreatic Research Group, South West Sydney Clinical Campuses, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia
| | - Zhihong Xu
- Pancreatic Research Group, South West Sydney Clinical Campuses, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia
| | - Chamini J Perera
- Pancreatic Research Group, South West Sydney Clinical Campuses, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia.
| | - Minoti V Apte
- Pancreatic Research Group, South West Sydney Clinical Campuses, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia
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4
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Hosen SMZ, Uddin MN, Xu Z, Buckley BJ, Perera C, Pang TCY, Mekapogu AR, Moni MA, Notta F, Gallinger S, Pirola R, Wilson J, Ranson M, Goldstein D, Apte M. Metastatic phenotype and immunosuppressive tumour microenvironment in pancreatic ductal adenocarcinoma: Key role of the urokinase plasminogen activator (PLAU). Front Immunol 2022; 13:1060957. [PMID: 36591282 PMCID: PMC9794594 DOI: 10.3389/fimmu.2022.1060957] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/22/2022] [Indexed: 12/15/2022] Open
Abstract
Background Previous studies have revealed the role of dysregulated urokinase plasminogen activator (encoded by PLAU) expression and activity in several pathways associated with cancer progression. However, systematic investigation into the association of PLAU expression with factors that modulate PDAC (pancreatic ductal adenocarcinoma) progression is lacking, such as those affecting stromal (pancreatic stellate cell, PSC)-cancer cell interactions, tumour immunity, PDAC subtypes and clinical outcomes from potential PLAU inhibition. Methods This study used an integrated bioinformatics approach to identify prognostic markers correlated with PLAU expression using different transcriptomics, proteomics, and clinical data sets. We then determined the association of dysregulated PLAU and correlated signatures with oncogenic pathways, metastatic phenotypes, stroma, immunosuppressive tumour microenvironment (TME) and clinical outcome. Finally, using an in vivo orthotopic model of pancreatic cancer, we confirmed the predicted effect of inhibiting PLAU on tumour growth and metastasis. Results Our analyses revealed that PLAU upregulation is not only associated with numerous other prognostic markers but also associated with the activation of various oncogenic signalling pathways, aggressive phenotypes relevant to PDAC growth and metastasis, such as proliferation, epithelial-mesenchymal transition (EMT), stemness, hypoxia, extracellular cell matrix (ECM) degradation, upregulation of stromal signatures, and immune suppression in the tumour microenvironment (TME). Moreover, the upregulation of PLAU was directly connected with signalling pathways known to mediate PSC-cancer cell interactions. Furthermore, PLAU upregulation was associated with the aggressive basal/squamous phenotype of PDAC and significantly reduced overall survival, indicating that this subset of patients may benefit from therapeutic interventions to inhibit PLAU activity. Our studies with a clinically relevant orthotopic pancreatic model showed that even short-term PLAU inhibition is sufficient to significantly halt tumour growth and, importantly, eliminate visible metastasis. Conclusion Elevated PLAU correlates with increased aggressive phenotypes, stromal score, and immune suppression in PDAC. PLAU upregulation is also closely associated with the basal subtype type of PDAC; patients with this subtype are at high risk of mortality from the disease and may benefit from therapeutic targeting of PLAU.
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Affiliation(s)
- S. M. Zahid Hosen
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Md. Nazim Uddin
- Institute of Food Science and Technology, Bangladesh Council of Scientific and Industrial Research (BCSIR), Dhaka, Bangladesh
| | - Zhihong Xu
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Benjamin J. Buckley
- Molecular Horizons and School of Chemistry & Molecular Bioscience, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia,Illawarra Health and Medical Research Institute, Wollongong, NSW, Australia
| | - Chamini Perera
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Tony C. Y. Pang
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia,Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, The University of Sydney, Sydney, NSW, Australia
| | - Alpha Raj Mekapogu
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Mohammad Ali Moni
- School of Health and Rehabilitation Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, St Lucia, QLD, Australia
| | - Faiyaz Notta
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Steven Gallinger
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Ron Pirola
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jeremy Wilson
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - Marie Ranson
- Molecular Horizons and School of Chemistry & Molecular Bioscience, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia,Illawarra Health and Medical Research Institute, Wollongong, NSW, Australia
| | - David Goldstein
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia,Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Minoti Apte
- Pancreatic Research Group, SWS Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia,*Correspondence: Minoti Apte,
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5
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Channon LM, Tyma VM, Xu Z, Greening DW, Wilson JS, Perera CJ, Apte MV. Small extracellular vesicles (exosomes) and their cargo in pancreatic cancer: Key roles in the hallmarks of cancer. Biochim Biophys Acta Rev Cancer 2022; 1877:188728. [PMID: 35385773 DOI: 10.1016/j.bbcan.2022.188728] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 01/18/2023]
Abstract
Pancreatic cancer (PC) is a devastating disease, offering poor mortality rates for patients. The current challenge being faced is the inability to diagnose patients in a timely manner, where potentially curative resection provides the best chance of survival. Recently, small/nanosized extracellular vesicles (sEVs), including exosomes, have gained significant preclinical and clinical attention due to their emerging roles in cancer progression and diagnosis. Extracellular vesicles (EVs) possess endogenous properties that offer stability and facilitate crossing of biological barriers for delivery of molecular cargo to cells, acting as a form of intercellular communication to regulate function and phenotype of recipient cells. This review provides an overview of the role of EVs, their subtypes and their oncogenic cargo (as characterised by targeted studies as well as agnostic '-omics' analyses) in the pathobiology of pancreatic cancer. The discussion covers the progress of 'omics technology' that has enabled elucidation of the molecular mechanisms that mediate the role of EVs and their cargo in pancreatic cancer progression.
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Affiliation(s)
- Lily M Channon
- Pancreatic Research Group, South Western Sydney Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia
| | - Victoria M Tyma
- Pancreatic Research Group, South Western Sydney Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia
| | - Zhihong Xu
- Pancreatic Research Group, South Western Sydney Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia
| | - David W Greening
- Molecular Proteomics, Baker Heart and Diabetes Institute, Victoria 3004, Australia; Baker Department of Cardiovascular Research, Translation and Implementation, La Trobe University, Victoria 3086, Australia; Central Clinical School, Monash University, Australia, Victoria 3800, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Victoria 3000, Australia
| | - Jeremy S Wilson
- Pancreatic Research Group, South Western Sydney Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia
| | - Chamini J Perera
- Pancreatic Research Group, South Western Sydney Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia
| | - Minoti V Apte
- Pancreatic Research Group, South Western Sydney Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; Ingham Institute of Applied Medical Research, Sydney 2170, Australia.
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6
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Kpeglo D, Hughes MD, Dougan L, Haddrick M, Knowles MA, Evans SD, Peyman SA. Modeling the mechanical stiffness of pancreatic ductal adenocarcinoma. Matrix Biol Plus 2022; 14:100109. [PMID: 35399702 PMCID: PMC8990173 DOI: 10.1016/j.mbplus.2022.100109] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/28/2022] [Accepted: 03/15/2022] [Indexed: 01/18/2023] Open
Abstract
The PDAC stroma stiffness underlines its malignant behavior and drug resistance. 3D in vitro cultures must model the PDAC stroma to effectively drug efficacy. PSCs are responsible for the stroma, and its activity is increased with TGF-β. Develop a 3D culture model of PDAC, which includes PSCs and TGF-β. Assess the mechanical stiffness, stain for collagen, and investigate gemcitabine efficacy.
Despite improvements in the understanding of disease biology, pancreatic ductal adenocarcinoma (PDAC) remains the most malignant cancer of the pancreas. PDAC constitutes ∼95% of all pancreatic cancers, and it is highly resistant to therapeutics. The increased tissue rigidity, which stems from the rich fibrotic stroma in the tumor microenvironment, is central to disease development, physiology, and resistance to drug perfusion. Pancreatic stellate cells (PSCs) are responsible for overproduction of extracellular matrix in the fibrotic stroma, and this is exacerbated by the overexpression of transforming growth factor-β (TGF-β). However, there are few in vitro PDAC models, which include both PSCs and TGF-β or mimic in vivo-like tumor stiffness. In this study, we present a three-dimensional in vitro PDAC model, which includes PSCs and TGF-β, and recapitulates PDAC tissue mechanical stiffness. Using oscillatory shear rheology, we show the mechanical stiffness of the model is within range of the PDAC tissue stiffness by day 21 of culture and highlight that the matrix environment is essential to adequately capture PDAC disease. PDAC is a complex, aggressive disease with poor prognosis, and biophysically relevant in vitro PDAC models, which take into account tissue mechanics, will provide improved tumor models for effective therapeutic assessment.
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Affiliation(s)
- Delanyo Kpeglo
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK
| | - Matthew D.G. Hughes
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK
- Astbury Centre for Structural Molecular Biology, University of Leeds, LS2 9JT, UK
| | - Lorna Dougan
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK
- Astbury Centre for Structural Molecular Biology, University of Leeds, LS2 9JT, UK
| | - Malcolm Haddrick
- Medicines Discovery Catapult, Block 35, Mereside Alderley Park, Alderley Edge, SK10 4TG, UK
| | - Margaret A. Knowles
- Leeds Institute of Medical Research at St James’s (LIMR), School of Medicine, University of Leeds, LS2 9 JT, UK
| | - Stephen D. Evans
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK
- Astbury Centre for Structural Molecular Biology, University of Leeds, LS2 9JT, UK
| | - Sally A. Peyman
- Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK
- Leeds Institute of Medical Research at St James’s (LIMR), School of Medicine, University of Leeds, LS2 9 JT, UK
- Corresponding author at: Molecular and Nanoscale Physics Group, School of Physics and Astronomy, University of Leeds, LS2 9 JT, UK.
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7
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Perera CJ, Falasca M, Chari ST, Greenfield JR, Xu Z, Pirola RC, Wilson JS, Apte MV. Role of Pancreatic Stellate Cell-Derived Exosomes in Pancreatic Cancer-Related Diabetes: A Novel Hypothesis. Cancers (Basel) 2021; 13:cancers13205224. [PMID: 34680372 PMCID: PMC8534084 DOI: 10.3390/cancers13205224] [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: 08/25/2021] [Revised: 09/27/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a devastating condition characterised by vague symptomatology and delayed diagnosis. About 30% of PDAC patients report a history of new onset diabetes, usually diagnosed within 3 years prior to the diagnosis of cancer. Thus, new onset diabetes, which is also known as pancreatic cancer-related diabetes (PCRD), could be a harbinger of PDAC. Diabetes is driven by progressive β cell loss/dysfunction and insulin resistance, two key features that are also found in PCRD. Experimental studies suggest that PDAC cell-derived exosomes carry factors that are detrimental to β cell function and insulin sensitivity. However, the role of stromal cells, particularly pancreatic stellate cells (PSCs), in the pathogenesis of PCRD is not known. PSCs are present around the earliest neoplastic lesions and around islets. Given that PSCs interact closely with cancer cells to drive cancer progression, it is possible that exosomal cargo from both cancer cells and PSCs plays a role in modulating β cell function and peripheral insulin resistance. Identification of such mediators may help elucidate the mechanisms of PCRD and aid early detection of PDAC. This paper discusses the concept of a novel role of PSCs in the pathogenesis of PCRD.
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Affiliation(s)
- Chamini J. Perera
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; (C.J.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Ingham Institute for Applied Medical Research, Sydney 2170, Australia
| | - Marco Falasca
- Metabolic Signalling Group, Curtin Health Innovation Research Institute, Curtin Medical School, Curtin University, Perth 6102, Australia;
| | - Suresh T. Chari
- M.D Anderson Cancer Centre, Department of Gastroenterology, Hepatology and Nutrition, University of Texas, Houston, TX 75083, USA;
| | - Jerry R. Greenfield
- St Vincent Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia;
- Healthy Ageing, Garvan Institute of Medical Research, Darlinghurst 2830, Australia
- Department of Diabetes and Endocrinology, St Vincent’s Hospital, Darlinghurst 3065, Australia
| | - Zhihong Xu
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; (C.J.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Ingham Institute for Applied Medical Research, Sydney 2170, Australia
| | - Romano C. Pirola
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; (C.J.P.); (Z.X.); (R.C.P.); (J.S.W.)
| | - Jeremy S. Wilson
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; (C.J.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Ingham Institute for Applied Medical Research, Sydney 2170, Australia
| | - Minoti V. Apte
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia; (C.J.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Ingham Institute for Applied Medical Research, Sydney 2170, Australia
- Correspondence: ; Tel.: +61-2-87389029
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8
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Stellate Cells Aid Growth-Permissive Metabolic Reprogramming and Promote Gemcitabine Chemoresistance in Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13040601. [PMID: 33546284 PMCID: PMC7913350 DOI: 10.3390/cancers13040601] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/04/2021] [Accepted: 01/29/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary The great majority, more than 90%, of patients with pancreatic ductal adenocarcinoma (PDAC) die within less than five years after detection of the disease, despite recent treatment advances. The poor prognosis is related to late diagnosis, aggressive disease progression, and tumor resistance to conventional chemotherapy. PDAC tumor tissue is characterized by dense fibrosis and poor nutrient availability. A large portion of the tumor is made up of stromal fibroblasts, the pancreatic stellate cells (PSCs), which are known to contribute to tumor progression in several ways. PSCs have been shown to act as an alternate energy source, induce drug resistance, and inhibit drug availability in tumor cells, however, the underlying exact molecular mechanisms remain unknown. In this literature review, we discuss recent available knowledge about the contributions of PSCs to the overall progression of PDAC via changes in tumor metabolism and how this is linked to therapy resistance. Abstract Pancreatic ductal adenocarcinoma (PDAC), also known as pancreatic cancer (PC), is characterized by an overall poor prognosis and a five-year survival that is less than 10%. Characteristic features of the tumor are the presence of a prominent desmoplastic stromal response, an altered metabolism, and profound resistance to cancer drugs including gemcitabine, the backbone of PDAC chemotherapy. The pancreatic stellate cells (PSCs) constitute the major cellular component of PDAC stroma. PSCs are essential for extracellular matrix assembly and form a supportive niche for tumor growth. Various cytokines and growth factors induce activation of PSCs through autocrine and paracrine mechanisms, which in turn promote overall tumor growth and metastasis and induce chemoresistance. To maintain growth and survival in the nutrient-poor, hypoxic environment of PDAC, tumor cells fulfill their high energy demands via several unconventional ways, a process generally referred to as metabolic reprogramming. Accumulating evidence indicates that activated PSCs not only contribute to the therapy-resistant phenotype of PDAC but also act as a nutrient supplier for the tumor cells. However, the precise molecular links between metabolic reprogramming and an acquired therapy resistance in PDAC remain elusive. This review highlights recent findings indicating the importance of PSCs in aiding growth-permissive metabolic reprogramming and gemcitabine chemoresistance in PDAC.
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9
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Martinez-Useros J, Martin-Galan M, Garcia-Foncillas J. The Match between Molecular Subtypes, Histology and Microenvironment of Pancreatic Cancer and Its Relevance for Chemoresistance. Cancers (Basel) 2021; 13:322. [PMID: 33477288 PMCID: PMC7829908 DOI: 10.3390/cancers13020322] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/17/2022] Open
Abstract
In the last decade, several studies based on whole transcriptomic and genomic analyses of pancreatic tumors and their stroma have come to light to supplement histopathological stratification of pancreatic cancers with a molecular point-of-view. Three main molecular studies: Collisson et al. 2011, Moffitt et al. 2015 and Bailey et al. 2016 have found specific gene signatures, which identify different molecular subtypes of pancreatic cancer and provide a comprehensive stratification for both a personalized treatment or to identify potential druggable targets. However, the routine clinical management of pancreatic cancer does not consider a broad molecular analysis of each patient, due probably to the lack of target therapies for this tumor. Therefore, the current treatment decision is taken based on patients´ clinicopathological features and performance status. Histopathological evaluation of tumor samples could reveal many other attributes not only from tumor cells but also from their microenvironment specially about the presence of pancreatic stellate cells, regulatory T cells, tumor-associated macrophages, myeloid derived suppressor cells and extracellular matrix structure. In the present article, we revise the four molecular subtypes proposed by Bailey et al. and associate each subtype with other reported molecular subtypes. Moreover, we provide for each subtype a potential description of the tumor microenvironment that may influence treatment response according to the gene expression profile, the mutational landscape and their associated histology.
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10
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Robinson CM, Talty A, Logue SE, Mnich K, Gorman AM, Samali A. An Emerging Role for the Unfolded Protein Response in Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13020261. [PMID: 33445669 PMCID: PMC7828145 DOI: 10.3390/cancers13020261] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 12/17/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most common form of pancreatic cancer and one of the leading causes of cancer-associated deaths in the world. It is characterised by dismal response rates to conventional therapies. A major challenge in treatment strategies for PDAC is the presence of a dense stroma that surrounds the tumour cells, shielding them from treatment. This unique tumour microenvironment is fuelled by paracrine signalling between pancreatic cancer cells and supporting stromal cell types including the pancreatic stellate cells (PSC). While our molecular understanding of PDAC is improving, there remains a vital need to develop effective, targeted treatments. The unfolded protein response (UPR) is an elaborate signalling network that governs the cellular response to perturbed protein homeostasis in the endoplasmic reticulum (ER) lumen. There is growing evidence that the UPR is constitutively active in PDAC and may contribute to the disease progression and the acquisition of resistance to therapy. Given the importance of the tumour microenvironment and cytokine signalling in PDAC, and an emerging role for the UPR in shaping the tumour microenvironment and in the regulation of cytokines in other cancer types, this review explores the importance of the UPR in PDAC biology and its potential as a therapeutic target in this disease.
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Affiliation(s)
- Claire M. Robinson
- Apoptosis Research Centre, School of Natural Sciences, National University of Ireland, H91 W2TY Galway, Ireland; (C.M.R.); (A.T.); (K.M.); (A.M.G.)
| | - Aaron Talty
- Apoptosis Research Centre, School of Natural Sciences, National University of Ireland, H91 W2TY Galway, Ireland; (C.M.R.); (A.T.); (K.M.); (A.M.G.)
| | - Susan E. Logue
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0J9, Canada;
- Research Institute in Oncology and Hematology, Cancer Care Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Katarzyna Mnich
- Apoptosis Research Centre, School of Natural Sciences, National University of Ireland, H91 W2TY Galway, Ireland; (C.M.R.); (A.T.); (K.M.); (A.M.G.)
| | - Adrienne M. Gorman
- Apoptosis Research Centre, School of Natural Sciences, National University of Ireland, H91 W2TY Galway, Ireland; (C.M.R.); (A.T.); (K.M.); (A.M.G.)
| | - Afshin Samali
- Apoptosis Research Centre, School of Natural Sciences, National University of Ireland, H91 W2TY Galway, Ireland; (C.M.R.); (A.T.); (K.M.); (A.M.G.)
- Correspondence:
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11
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Pothula SP, Xu Z, Goldstein D, Pirola RC, Wilson JS, Apte MV. Targeting HGF/c-MET Axis in Pancreatic Cancer. Int J Mol Sci 2020; 21:E9170. [PMID: 33271944 PMCID: PMC7730415 DOI: 10.3390/ijms21239170] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 12/11/2022] Open
Abstract
Pancreatic cancer (pancreatic ductal adenocarcinoma (PDAC/PC)) has been an aggressive disease that is associated with early metastases. It is characterized by dense and collagenous desmoplasia/stroma, predominantly produced by pancreatic stellate cells (PSCs). PSCs interact with cancer cells as well as other stromal cells, facilitating disease progression. A candidate growth factor pathway that may mediate this interaction is the hepatocyte growth factor (HGF)/c-MET pathway. HGF is produced by PSCs and its receptor c-MET is expressed on pancreatic cancer cells and endothelial cells. The current review discusses the role of the MET/HGF axis in tumour progression and dissemination of pancreatic cancer. Therapeutic approaches that were developed targeting either the ligand (HGF) or the receptor (c-MET) have not been shown to translate well into clinical settings. We discuss a two-pronged approach of targeting both the components of this pathway to interrupt the stromal-tumour interactions, which may represent a potential therapeutic strategy to improve outcomes in PC.
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Affiliation(s)
- Srinivasa P. Pothula
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia; (S.P.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia;
| | - Zhihong Xu
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia; (S.P.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia;
| | - David Goldstein
- Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia;
| | - Romano C. Pirola
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia; (S.P.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia;
| | - Jeremy S. Wilson
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia; (S.P.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia;
| | - Minoti V. Apte
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine and Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia; (S.P.P.); (Z.X.); (R.C.P.); (J.S.W.)
- Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia;
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12
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Verloy R, Privat-Maldonado A, Smits E, Bogaerts A. Cold Atmospheric Plasma Treatment for Pancreatic Cancer-The Importance of Pancreatic Stellate Cells. Cancers (Basel) 2020; 12:cancers12102782. [PMID: 32998311 PMCID: PMC7601057 DOI: 10.3390/cancers12102782] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/17/2020] [Accepted: 09/26/2020] [Indexed: 01/18/2023] Open
Abstract
Simple Summary This review aims to highlight the potential of cold plasma, the fourth state of matter, as anti-cancer treatment for pancreatic cancer, and the importance of pancreatic stellate cells in the response to this treatment. Currently, a significant lack of basic research on cold plasma considering both pancreatic cancer and stellate cells exists. However, co-cultures of these populations can be advantageous, as they resemble the cell-to-cell interactions occurring in a tumor in response to therapy. Even more, these studies should be performed prior to clinical trials of cold plasma to avoid unforeseen responses to treatment. This review article provides a framework for future research of cold plasma therapies for pancreatic cancer, considering the critical role of pancreatic stellate cells in the disease and treatment outcome. Abstract Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with low five-year survival rates of 8% by conventional treatment methods, e.g., chemotherapy, radiotherapy, and surgery. PDAC shows high resistance towards chemo- and radiotherapy and only 15–20% of all patients can have surgery. This disease is predicted to become the third global leading cause of cancer death due to its significant rise in incidence. Therefore, the development of an alternative or combinational method is necessary to improve current approaches. Cold atmospheric plasma (CAP) treatments could offer multiple advantages to this emerging situation. The plasma-derived reactive species can induce oxidative damage and a cascade of intracellular signaling pathways, which could lead to cell death. Previous reports have shown that CAP treatment also influences cells in the tumor microenvironment, such as the pancreatic stellate cells (PSCs). These PSCs, when activated, play a crucial role in the propagation, growth and survival of PDAC tumors. However, the effect of CAP on PSCs is not yet fully understood. This review focuses on the application of CAP for PDAC treatment and the importance of PSCs in the response to treatment.
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Affiliation(s)
- Ruben Verloy
- Plasma Lab for Applications in Sustainability and Medicine-ANTwerp, University of Antwerp, 2610 Wilrijk, Belgium;
- Center for Oncological Research, University of Antwerp, 2610 Wilrijk, Belgium;
- Correspondence: (R.V.); (A.P.-M.); Tel.: +32-3265-2343 (R.V. & A.P.-M.)
| | - Angela Privat-Maldonado
- Plasma Lab for Applications in Sustainability and Medicine-ANTwerp, University of Antwerp, 2610 Wilrijk, Belgium;
- Center for Oncological Research, University of Antwerp, 2610 Wilrijk, Belgium;
- Correspondence: (R.V.); (A.P.-M.); Tel.: +32-3265-2343 (R.V. & A.P.-M.)
| | - Evelien Smits
- Center for Oncological Research, University of Antwerp, 2610 Wilrijk, Belgium;
| | - Annemie Bogaerts
- Plasma Lab for Applications in Sustainability and Medicine-ANTwerp, University of Antwerp, 2610 Wilrijk, Belgium;
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13
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Das S, Shapiro B, Vucic EA, Vogt S, Bar-Sagi D. Tumor Cell-Derived IL1β Promotes Desmoplasia and Immune Suppression in Pancreatic Cancer. Cancer Res 2020; 80:1088-1101. [PMID: 31915130 PMCID: PMC7302116 DOI: 10.1158/0008-5472.can-19-2080] [Citation(s) in RCA: 185] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/22/2019] [Accepted: 12/31/2019] [Indexed: 12/20/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is an aggressive malignancy typified by a highly stromal and weakly immunogenic tumor microenvironment that promotes tumor evolution and contributes to therapeutic resistance. Here, we demonstrate that PDA tumor cell-derived proinflammatory cytokine IL1β is essential for the establishment of the protumorigenic PDA microenvironment. Tumor cell-derived IL1β promoted the activation and secretory phenotype of quiescent pancreatic stellate cells and established an immunosuppressive milieu mediated by M2 macrophages, myeloid-derived suppressor cells, CD1dhiCD5+ regulatory B cells, and Th17 cells. Loss of tumor cell-derived IL1 signaling in tumor stroma enabled intratumoral infiltration and activation of CD8+ cytotoxic T cells, attenuated growth of pancreatic neoplasia, and conferred survival advantage to PDA-bearing mice. Accordingly, antibody-mediated neutralization of IL1β significantly enhanced the antitumor activity of α-PD-1 and was accompanied by increased tumor infiltration of CD8+ T cells. Tumor cell expression of IL1β in vivo was driven by microbial-dependent activation of toll-like receptor 4 (TLR4) signaling and subsequent engagement of the NLRP3 inflammasome. Collectively, these findings identify a hitherto unappreciated role for tumor cell-derived IL1β in orchestrating an immune-modulatory program that supports pancreatic tumorigenesis. SIGNIFICANCE: These findings identify a new modality for immune evasion in PDA that depends on IL1β production by tumor cells through TLR4-NLRP3 inflammasome activation. Targeting this axis might provide an effective PDA therapeutic strategy.
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MESH Headings
- Animals
- Antineoplastic Agents, Immunological/pharmacology
- Antineoplastic Agents, Immunological/therapeutic use
- CD8-Positive T-Lymphocytes/drug effects
- CD8-Positive T-Lymphocytes/immunology
- Carcinogenesis/immunology
- Carcinoma, Pancreatic Ductal/drug therapy
- Carcinoma, Pancreatic Ductal/immunology
- Carcinoma, Pancreatic Ductal/pathology
- Cell Line, Tumor/transplantation
- Disease Models, Animal
- Drug Synergism
- Epithelial Cells
- Female
- Humans
- Inflammasomes/immunology
- Inflammasomes/metabolism
- Interleukin-1beta/antagonists & inhibitors
- Interleukin-1beta/immunology
- Interleukin-1beta/metabolism
- Lymphocytes, Tumor-Infiltrating/drug effects
- Lymphocytes, Tumor-Infiltrating/immunology
- Mice
- Mice, Transgenic
- NLR Family, Pyrin Domain-Containing 3 Protein/metabolism
- Pancreatic Ducts/cytology
- Pancreatic Neoplasms/drug therapy
- Pancreatic Neoplasms/immunology
- Pancreatic Neoplasms/pathology
- Primary Cell Culture
- Programmed Cell Death 1 Receptor/antagonists & inhibitors
- Programmed Cell Death 1 Receptor/immunology
- Signal Transduction/immunology
- Toll-Like Receptor 4/metabolism
- Tumor Escape/drug effects
- Tumor Escape/immunology
- Tumor Microenvironment/drug effects
- Tumor Microenvironment/immunology
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Affiliation(s)
- Shipra Das
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, New York
| | - Beny Shapiro
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, New York
| | - Emily A Vucic
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, New York
| | - Sandra Vogt
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, New York
| | - Dafna Bar-Sagi
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, New York.
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14
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Bazzichetto C, Conciatori F, Luchini C, Simionato F, Santoro R, Vaccaro V, Corbo V, Falcone I, Ferretti G, Cognetti F, Melisi D, Scarpa A, Ciuffreda L, Milella M. From Genetic Alterations to Tumor Microenvironment: The Ariadne's String in Pancreatic Cancer. Cells 2020; 9:cells9020309. [PMID: 32012917 PMCID: PMC7072496 DOI: 10.3390/cells9020309] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/18/2020] [Accepted: 01/23/2020] [Indexed: 02/06/2023] Open
Abstract
The threatening notoriety of pancreatic cancer mainly arises from its negligible early diagnosis, highly aggressive progression, failure of conventional therapeutic options and consequent very poor prognosis. The most important driver genes of pancreatic cancer are the oncogene KRAS and the tumor suppressors TP53, CDKN2A, and SMAD4. Although the presence of few drivers, several signaling pathways are involved in the oncogenesis of this cancer type, some of them with promising targets for precision oncology. Pancreatic cancer is recognized as one of immunosuppressive phenotype cancer: it is characterized by a fibrotic-desmoplastic stroma, in which there is an intensive cross-talk between several cellular (e.g., fibroblasts, myeloid cells, lymphocytes, endothelial, and myeloid cells) and acellular (collagen, fibronectin, and soluble factors) components. In this review; we aim to describe the current knowledge of the genetic/biological landscape of pancreatic cancer and the composition of its tumor microenvironment; in order to better direct in the intrinsic labyrinth of this complex tumor type. Indeed; disentangling the genetic and molecular characteristics of cancer cells and the environment in which they evolve may represent the crucial step towards more effective therapeutic strategies
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Affiliation(s)
- Chiara Bazzichetto
- Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (C.B.); (V.V.); (I.F.); (G.F.); (F.C.)
| | - Fabiana Conciatori
- Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (C.B.); (V.V.); (I.F.); (G.F.); (F.C.)
- Correspondence: ; Tel.: +39-06-52665185
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134 Verona, Italy;
| | - Francesca Simionato
- Division of Oncology, University of Verona, 37126 Verona, Italy; (F.S.); (M.M.)
| | - Raffaela Santoro
- Medicine-Digestive Molecular Clinical Oncology Research Unit, University of Verona, 37126 Verona, Italy; (R.S.); (D.M.)
| | - Vanja Vaccaro
- Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (C.B.); (V.V.); (I.F.); (G.F.); (F.C.)
| | - Vincenzo Corbo
- ARC-Net Research Centre, University and Hospital Trust of Verona, 37126 Verona, Italy; (V.C.); (A.S.)
| | - Italia Falcone
- Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (C.B.); (V.V.); (I.F.); (G.F.); (F.C.)
| | - Gianluigi Ferretti
- Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (C.B.); (V.V.); (I.F.); (G.F.); (F.C.)
| | - Francesco Cognetti
- Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (C.B.); (V.V.); (I.F.); (G.F.); (F.C.)
| | - Davide Melisi
- Medicine-Digestive Molecular Clinical Oncology Research Unit, University of Verona, 37126 Verona, Italy; (R.S.); (D.M.)
| | - Aldo Scarpa
- ARC-Net Research Centre, University and Hospital Trust of Verona, 37126 Verona, Italy; (V.C.); (A.S.)
| | - Ludovica Ciuffreda
- SAFU, Department of Research, Advanced Diagnostics, and Technological Innovation, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | - Michele Milella
- Division of Oncology, University of Verona, 37126 Verona, Italy; (F.S.); (M.M.)
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