Multidisciplinary standards of care and recent progress in pancreatic ductal adenocarcinoma

Gastrointestinal symptoms in the journey of pancreatic cancer patients

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy frequently arising with nonspecific and overlooked gastrointestinal symptoms. Gastroenterologists are typically the first specialists to encounter these patients, positioning them to play a pivotal role not only in early diagnosis, but also in the ongoing management of the disease's complex symptom burden.

AREAS COVERED

This review explored gastrointestinal symptoms in patients with PDAC (ranging from pain and diarrhea to anorexia, jaundice, and nausea) and outlined both tumor- and treatment-related causes. A literature review based on non-systematic PubMed search updated to April 2025 was conducted to summarize current diagnostic strategies, medical, endoscopic therapies, and multidisciplinary management approaches. In addition, we present original data from a single-center cohort, suggesting that the involvement of gastroenterologists leads to more comprehensive management of gastrointestinal symptom control and supportive care.

EXPERT OPINION

Collaboration among specialists is essential for optimizing patient outcomes in the multidisciplinary management of PDAC. Gastroenterologists' 'stewardship' significantly contributes to prompt diagnosis, symptom control, quality of life preservation, and prognosis. Future priorities should focus on strengthening integration within care pathways, fostering interdisciplinary coordination, and implementing shared clinical tools to enhance comprehensive patient care. A well-structured team-based approach is key to advancing holistic PDAC management.

Novel CT radiomics models for the postoperative prediction of early recurrence of resectable pancreatic adenocarcinoma: A single-center retrospective study in China

PURPOSE

To assess the predictive capability of CT radiomics features for early recurrence (ER) of pancreatic ductal adenocarcinoma (PDAC).

METHODS

Postoperative PDAC patients were retrospectively selected, all of whom had undergone preoperative CT imaging and surgery. Both patients with resectable or borderline-resectable pancreatic cancer met the eligibility criteria in this study. However, owing to the differences in treatment strategies and such, this research mainly focused on patients with resectable pancreatic cancer. All patients were subject to follow-up assessments for a minimum of 9 months. A total of 250 cases meeting the inclusion criteria were included. A clinical model, a conventional radiomics model, and a deep-radiomics model were constructed for ER prediction (defined as occurring within 9 months) in the training set. A model based on the TNM staging was utilized as a baseline for comparison. Assessment of the models' performance was based on the area under the receiver operating characteristic curve (AUC). Additionally, precision-recall (PR) analysis and calibration assessments were conducted for model evaluation. Furthermore, the clinical utility of the models was evaluated through decision curve analysis (DCA), net reclassification improvement (NRI), and improvement of reclassification index (IRI).

RESULTS

In the test set, the AUC values for ER prediction were as follows: TNM staging, ROC-AUC = 0.673 (95% CI: 0.550, 0.795), PR-AUC = 0.362 (95% CI: 0.493, 0.710); clinical model, ROC-AUC = 0.640 (95% CI: 0.504, 0.775), PR-AUC = 0.481 (95% CI: 0.520, 0.735); radiomics model, ROC-AUC = 0.722 (95% CI: 0.604, 0.839), PR-AUC = 0.575 (95% CI: 0.466, 0.686); and deep-radiomics model, which exhibited the highest ROC-AUC of 0.895 (95% CI: 0.820, 0.970), PR-AUC = 0.834 (95% CI: 0.767, 0.923). The difference in both ROC-AUC and PR-AUC for the deep-radiomics model was statistically significant when compared to the other scores (all p < 0.05). The DCA curve of the deep-radiomics model outperformed the other models. NRI and IRI analyses demonstrated that the deep-radiomics model significantly enhances risk classification compared to the other prediction methods (all p < 0.05).

CONCLUSION

The predictive performance of deep features based on CT images exhibits favorable outcomes in predicting early recurrence.

Genome-wide analyses of cell-free DNA for therapeutic monitoring of patients with pancreatic cancer

Determining response to therapy for patients with pancreatic cancer can be challenging. We evaluated methods for assessing therapeutic response using cell-free DNA (cfDNA) in plasma from patients with metastatic pancreatic cancer in the CheckPAC trial (NCT02866383). Patients were evaluated before and after initiation of therapy using tumor-informed plasma whole-genome sequencing (WGMAF) and tumor-independent genome-wide cfDNA fragmentation profiles and repeat landscapes (ARTEMIS-DELFI). Using WGMAF, molecular responders had a median overall survival (OS) of 319 days compared to 126 days for nonresponders [hazard ratio (HR) = 0.29, 95% confidence interval (CI) = 0.11-0.79, P = 0.011]. For ARTEMIS-DELFI, patients with low scores after therapy initiation had longer median OS than patients with high scores (233 versus 172 days, HR = 0.12, 95% CI = 0.046-0.31, P < 0.0001). We validated ARTEMIS-DELFI in patients with pancreatic cancer in the PACTO trial (NCT02767557). These analyses suggest that noninvasive mutation and fragmentation-based cfDNA approaches can identify therapeutic response of individuals with pancreatic cancer.

Lactate-associated gene MCU promotes the proliferation, migration, and invasion of pancreatic ductal adenocarcinoma

BACKGROUND

The metabolism of lactate and lactylation of proteins are believed to influence tumor development through their effects on the tumor microenvironment and immune escape mechanisms. Nevertheless, its significance in pancreatic ductal adenocarcinoma (PDAC) has yet to be fully understood. This investigation sought to assess the predictive value and treatment implications of lactate-related genes (LRGs) in PDAC.

METHODS

We analyzed PDAC data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO), identifying LRGs. Using weighted gene co-expression network analysis (WGCNA) and consensus clustering, we delineated lactate subtypes and extracted differentially expressed genes. Functional enrichment and gene set enrichment analysis (GSEA) analyses were conducted to explore pathways. A lactate-linked risk signature was constructed using Lasso-Cox regression, and its prognostic value was validated. In vitro experiments were executed to examine the function of MCU in PDAC cells. In vitro experiments were conducted to detect the malignant potential of MCU in PDAC cells and its effect on lactic acid metabolism.

RESULTS

Two lactate subtypes were identified, with distinct gene expression profiles and clinical outcomes. The risk signature, comprising four LRGs, predicted survival with significant accuracy. In vitro, MCU knockdown reduced cell proliferation, migration, invasion, and stemness, confirming its role in PDAC malignancy. At the same time, it can also inhibit lactate production and glycolysis processes.

CONCLUSION

Our investigation underscores the importance of LRGs in PDAC, providing a novel prognostic signature and therapeutic target.

Genomic instability, DNA damage response and telomere homeostasis in pancreatic cancer

Pancreatic cancer (PC) is becoming one of the most serious health problems at present, but its causes and risk factors are still unclear. One of the drivers in pancreatic carcinogenesis is altered genomic (DNA) integrity with subsequent genomic instability in cancer cells. The latter comprises a) DNA damage response and DNA repair mechanisms, b) DNA replication and mitosis, c) epigenetic regulation, and d) telomere maintenance. In our review we addressed the above aspects in relation to the most abundant and severe form of PC, pancreatic ductal adenocarcinoma (PDAC). In summary, the interactions between the DNA damage response, telomere homeostasis and mitotic regulation are not comprehensively understood at present, including the epigenetic factors entering the trait of genomic stability maintenance. In addition, the complexity of telomere homeostasis in relation to PDAC risk, prognosis and prediction also warrants further investigations.

Enhancing mesothelin CAR T cell therapy for pancreatic cancer with an oncolytic herpes virus boosting CAR target antigen expression

Mesothelin (MSLN) is a prominent target antigen for CAR T cell therapy due to its extensive expression in various solid tumors, including pancreatic cancer. However, the therapeutic efficacy of MSLN-targeted CAR T cell therapy has been limited in clinical trials for pancreatic cancer, often resulting in temporary stable disease as the best response. The heterogeneous expression of MSLN and its loss over time, along with the immunosuppressive tumor microenvironment (TME), are key factors restricting effectiveness. Oncolytic viruses are emerging cancer therapies that replicate in tumor cells and remodel the TME into an immunogenic state. Here, we engineered an oncolytic herpes simplex virus type 1 expressing human MSLN (HSV-MSLN) and evaluated its combination with MSLN-CAR T cells in a murine pancreatic ductal adenocarcinoma model. In vitro, HSV-MSLN effectively induced MSLN expression on murine pancreatic cancer cells, with subsequent cell lysis. In co-culture, HSV-MSLN-infected cancer cells activated MSLN-CAR T cells, which effectively eliminated the infected cells. In vivo, HSV-MSLN delivered MSLN on the tumor cell surface and reprogrammed the TME toward an immunogenic state. The combination therapy significantly enhanced antitumor efficacy, inducing activated, proliferative CD8+ CAR T cells and reducing PD-1+TIM-3+ exhausted endogenous CD8+ T cells and regulatory T cells in tumors. Furthermore, the combination therapy increased migratory XCR1+CD103+ dendritic cells (DCs) in tumors and tumor-draining lymph nodes (TDLNs) while expanding CD44+CD8+ T cells with central and effector memory phenotypes. Taken together, these results demonstrate that HSV-MSLN reprograms immune cells in the TME and TDLNs and synergizes with MSLN-CAR T cells to enhance antitumor responses, leading to a more robust therapeutic effect.

Nociceptor neurons promote PDAC progression and cancer pain by interaction with cancer-associated fibroblasts and suppression of natural killer cells

The emerging field of cancer neuroscience has demonstrated great progress in revealing the crucial role of the nervous system in cancer initiation and progression. Pancreatic ductal adenocarcinoma (PDAC) is characterized by perineural invasion and modulated by autonomic (sympathetic and parasympathetic) and sensory innervations. Here, we further demonstrated that within the tumor microenvironment of PDAC, nociceptor neurons interacted with cancer-associated fibroblasts (CAFs) through calcitonin gene-related peptide (CGRP) and nerve growth factor (NGF). This interaction led to the inhibition of interleukin-15 expression in CAFs, suppressing the infiltration and cytotoxic function of natural killer (NK) cells and thereby promoting PDAC progression and cancer pain. In PDAC patients, nociceptive innervation of tumor tissue is negatively correlated with the infiltration of NK cells while positively correlated with pain intensity. This association serves as an independent prognostic factor for both overall survival and relapse-free survival for PDAC patients. Our findings highlight the crucial regulation of NK cells by nociceptor neurons through interaction with CAFs in the development of PDAC. We also propose that targeting nociceptor neurons or CGRP signaling may offer a promising therapy for PDAC and cancer pain.

Novel mRNA biomarker-based liquid biopsy for the detection of resectable pancreatic cancer

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies and most often diagnosed at an advanced stage. Identification of markers for the early diagnosis of PDAC is crucial. In this study, we aimed to identify novel mRNA biomarkers for diagnosing PDAC, focusing on early-stage tumorigenesis and associated immunological changes.

METHODS

Blood samples and clinical information from 1,963 individuals were obtained from a single tertiary hospital between 2015 and 2021. Candidate mRNA biomarkers were identified through literature review, and their expression levels in buffy coat samples were measured using reverse-transcription quantitative polymerase chain reaction. Machine learning-based feature selection confirmed the final biomarker panel, which was tested using an independent dataset for diagnostic performance.

RESULTS

In total, 1,504 individuals (417 patients with PDAC and 1,087 non-disease controls) were eligible for the study. Among the 55 candidate biomarkers identified, 15 mRNAs (CCL5, CCR5, CLEC7A, CXCL8, CXCR2, CXCR4, FOXP3, IFNA1, IFNL1, PTGES, PTGES2, PTGS2, SLC27A2, TNF, and VEGFA) were selected based on their diagnostic performance in distinguishing PDAC from control groups. The final model, HELP-15 (Human Early Liquid biopsy for PDAC), identified all PDAC stages (area under the curve [AUC] = 0.956) in the test set. For resectable pancreatic cancer (RPC), the AUC was 0.968, compared to 0.910 for carbohydrate antigen 19 - 9 (CA19-9). The combined model of the panel and CA19-9 achieved an AUC of 0.985 in patients with RPC. For all PDAC stages in patients with normal CA19-9 levels, the AUC of the panel was 0.967, whereas CA19-9 alone or in combination with the panel had AUCs of 0.658 and 0.885, respectively.

CONCLUSION

Compared to CA19-9, the mRNA biomarker panel, HELP-15, improved diagnostic performance in patients with RPC, particularly in those with normal CA19-9 levels.

Establishment of a nomogram based on Lasso Cox regression for albumin combined with systemic immune-inflammation index score to predict prognosis in advanced pancreatic carcinoma

Purpose

The study aims to establish a nomogram to predict advanced pancreatic carcinoma patients' overall survival (OS), incorporating albumin combined with systemic immune-inflammation index (A-SII) score and clinical characteristics.

Methods

A retrospective study analyzed the clinical data of 205 advanced pancreatic carcinoma patients without antitumor treatment from the Yancheng No.1 People's Hospital between October 2011 and June 2023, and the study divided patients into the training set and the validation set randomly at the proportion of three to one. The A-SII score was divided into scores of 0, 1, and 2 according to the different levels of albumin and SII. Receiver operating characteristic (ROC) curves and time-dependent area under the curve were used to evaluate the predictive ability of the A-SII score. The nomogram1 and nomogram2 were established by the multivariate Cox regression and Lasso Cox regression respectively. The study evaluated the discriminability of nomogram1 and nomogram2 based on C-index and ROC curves to obtain the optimal model. Subsequently, we plotted decision curve analyses (DCA) and calibration curves to estimate the clinical benefit and accuracy of nomogram2.

Results

Lasso Cox regression showed that A-SII score, number of organ metastases, tumor size, chemotherapy, targeted therapy, Neutrophil-to-albumin ratio, and lactate dehydrogenase were independent prognostic factors for the OS of advanced pancreatic carcinoma patients. The C-index and ROC curve of the nomogram2 are better than the nomogram1. Subsequently, the DCA and calibration curve of the nomogram2 demonstrate excellent performance.

Conclusion

The nomogram based on the A-SII score and other independent prognostic factors determined by Lasso Cox regression can accurately predict the OS of patients suffering from advanced pancreatic carcinoma.

Tongue coating microbiota-based machine learning for diagnosing digestive system tumours

Background

Digestive system tumours (DSTs) often diagnosed late due to nonspecific symptoms. Non-invasive biomarkers are crucial for early detection and improved outcomes.

Patients and Methods

We collected tongue coating samples from 710 patients diagnosed with DST and 489 healthy controls (HC) from April 2023, to December 2023. Microbial composition was analyzed using 16S rRNA sequencing, and five machine learning algorithms were applied to assess the diagnostic potential of tongue coating microbiota.

Results

Alpha diversity analysis showed that the microbial diversity in the tongue coating was significantly increased in DST patients. LEfSe analysis identified DST-enriched genera Alloprevotella and Prevotella, contrasting with HC-dominant taxa Neisseria, Haemophilus, and Porphyromonas (LDA >4). Notably, when comparing each of the four DST subtypes with the HC group, the proportion of Haemophilus in the HC group was significantly higher, and it was identified as an important feature for distinguishing the HC group. Machine learning validation demonstrated superior diagnostic performance of the Extreme Gradient Boosting (XGBoost) model, achieving an AUC of 0.926 (95% CI: 0.893-0.958) in internal validation, outperforming the other four machine learning models.

Conclusion

Tongue coating microbiota shows promise as a non-invasive biomarker for DST diagnosis, supported by robust machine learning models.

The Influence of Area Deprivation Index on Surgical Outcomes in Pancreas Cancer

BACKGROUND

Surgical resection for pancreas ductal adenocarcinoma (PDAC) remains the mainstay of treatment. Regardless of enhanced survival rates, disparities in patient outcomes and experiences driven by the social determinants of health (SDH) persist. The area deprivation index (ADI) comprises 17 indicators related to education, employment, housing-quality, and poverty. We sought to examine the impact of ADI on surgical outcomes of PDAC patients.

METHODS

Patients who underwent pancreatoduodenectomy or distal pancreatectomy for PDAC between January 2011 and December 2022 were identified. ADI was calculated using patient zip codes and categorized into quartiles, with the highest indicating the most marginalized. The primary outcome was loss to follow-up after surgical resection. To account for confounders, a competing risk multivariable regression analysis was used.

RESULTS

A total of 1001 patients had a mean age of 66.6 (±9.64), with 46.3% (n = 463) of patients being female. A majority, 94.6% (n = 947), identified as white, and 64.1% (n = 641) had at least a college degree. The median length of follow-up after surgery was 1.8 years (interquartile range: 0.9-3.5). Multivariable analysis adjusting for competing risk of death, showed that patients who are least marginalized are 1.57 times more likely to have their follow-up than those most marginalized (hazard ratio: 1.57, 95% confidence interval: 1.08-2.29, p = 0.017).

CONCLUSION

SDH impact many aspects of patient's care including a higher risk of loss to follow-up for marginalized patients after surgery for PDAC. Future efforts should seek to identify and lower barriers faced by marginalized patients with system-level changes to ensure equitable access.

Effect of tumor microenvironment in pancreatic cancer on the loss of β-cell mass: implications for type 3c diabetes

BACKGROUND

To explore the complex interactions between the tumor microenvironment (TME) of pancreatic ductal adenocarcinoma (PDAC) and the loss of β-cell mass, further elucidating the mechanisms of type 3c diabetes mellitus (T3cDM) onset.

METHODS

Single-cell RNA sequencing was employed to analyze the PDAC TME, identifying cell interactions and gene expression changes of endocrine cells. Pathological changes and paraneoplastic islets were assessed in the proximal paratumor (PP) and distal paratumor (DP). Fractional β-cell area and islet density were compared among normal pancreas from donors and paraneoplastic tissues from non-diabetes mellitus (NDM) and T3cDM patients. TUNEL staining, RT-qPCR and CCK8 assay were applied to demonstrate the β-cell apoptosis.

RESULTS

Tumor cells, immune cells and fibroblasts could interact with endocrine cells, and apoptotic pathways were activated in endocrine cells of the PP. The PDAC TME was characterized by marked inflammation, sever fibrosis and atrophy. The islets in the PP had lower fractional β-cell area (0.68 ± 0.65% vs. 0.86 ± 1.02%, P = 0.037) and islet density (0.54 ± 0.42 counts/mm2 vs. 0.83 ± 0.90 counts/mm2, P = 0.001) compared to those in the DP. The PDAC TME in T3cDM exerted a more significant impact on the paraneoplastic islets compared to NDM. Moreover, β-cell apoptosis was markedly increased in the PP compared to the DP in PDAC patients without diabetes, particularly in smaller islets. Apoptosis-related genes were highly expressed in INS-1E cells exposed to PANC-1 medium.

CONCLUSION

Our research revealed that the PDAC TME is usually accompanied by some pathological changes, including inflammation, fibrosis, and atrophy. These pathological changes are related to a reduction in β-cell mass and trigger the development of T3cDM.

Integrated analysis of scRNA-seq and bulk RNA-seq data identifies BHLHE40 as a key gene in pancreatic cancer progression and gemcitabine resistance

OBJECTIVE

Pancreatic cancer is characterized by its high mortality rate and short survival periods, and novel therapeutic targets and tailor personalized strategies are urgently needed. In this study, we aim to investigate the molecular mechanisms underlying pancreatic ductal adenocarcinoma (PDAC) progression and chemoresistance, with a focus on identifying novel therapeutic targets.

METHODS

Multiomics approaches were integrated to identify novel actionable targets for PDAC. Public datasets such as TCGA and GEO were utilized to investigate the relationship between gene expression and clinical outcomes. Functional enrichment, cell-cell communication, and metabolic pathway analyses were performed to reveal PDAC heterogeneity and therapeutic resistance mechanisms.

RESULTS

BHLHE40 was identified as a hub gene linked to high-CNV PDAC cells, Gemcitabine resistance, and poor prognosis in PDAC. High BHLHE40 expression is significantly correlated with immunosuppressive tumor microenvironment (TME) features such as reduced CD8+ T infiltration, TCR richness, and lower tumor mutational burden (TMB). ChIP-seq data analysis confirmed BHLHE40 could directly bind to the SAT1 promoter, establishing a transcriptional axis promoting chemoresistance. Single-cell RNA-seq analysis further revealed that the BHLHE40+/SAT1+ subpopulation cells are resistant to Gemcitabine in PDAC.

CONCLUSIONS

BHLHE40 is significantly correlated with PDAC malignancy and chemoresistance via SAT1 regulation and immune evasion. Targeting BHLHE40 may sensitize PDACs to Gemcitabine and facilitate personalized treatment for BHLHE40+ PDAC patients.

Contrast-enhanced MRI-based intratumoral heterogeneity assessment for predicting lymph node metastasis in resectable pancreatic ductal adenocarcinoma

OBJECTIVES

To develop and validate a contrast-enhanced MRI-based intratumoral heterogeneity (ITH) model for predicting lymph node (LN) metastasis in resectable pancreatic ductal adenocarcinoma (PDAC).

METHODS

Lesions were encoded into different habitats based on enhancement ratios at arterial, venous, and delayed phases of contrast-enhanced MRI. Habitat models on enhanced ratio mapping and single sequences, radiomic models, and clinical models were developed for evaluating LN metastasis. The performance of the models was evaluated via different metrics. Additionally, patients were stratified into high-risk and low-risk groups based on an ensembled model to assess prognosis after adjuvant therapy.

RESULTS

We developed an ensembled radiomics-habitat-clinical (RHC) model that integrates radiomics, habitat, and clinical data for precise prediction of LN metastasis in PDAC. The RHC model showed strong predictive performance, with area under the curve (AUC) values of 0.805, 0.779, and 0.615 in the derivation, internal validation, and external validation cohorts, respectively. Using an optimal threshold of 0.46, the model effectively stratified patients, revealing significant differences in recurrence-free survival and overall survival (OS) (p = 0.004 and p < 0.001). Adjuvant therapy improved OS in the high-risk group (p = 0.004), but no significant benefit was observed in the low-risk group (p = 0.069).

CONCLUSION

We developed an MRI-based ITH model that provides reliable estimates of LN metastasis for resectable PDAC and may offer additional value in guiding clinical decision-making.

CRITICAL RELEVANCE STATEMENT

This ensemble RHC model facilitates preoperative prediction of LN metastasis in resectable PDAC using contrast-enhanced MRI. This offers a foundation for enhanced prognostic assessment and supports the management of personalized adjuvant treatment strategies.

KEY POINTS

MRI-based habitat models can predict LN metastasis in PDAC. Both the radiomics model and clinical characteristics were useful for predicting LN metastasis in PDAC. The RHC models have the potential to enhance predictive accuracy and inform personalized therapeutic decisions.

Correlation of MRI characteristics with KRAS mutation status in pancreatic ductal adenocarcinoma

PURPOSE

To investigate MRI features associated with KRAS mutation status in PDAC and their clinical implications.

MATERIALS AND METHODS

In our study, 1474 patients pathologically confirmed PDAC patients between January 2016 and December 2023 were evaluated. Patients with genetic testing (KRAS mutation status) and MRI examination were enrolled and grouped as KRAS-mutated PDAC and non-KRAS-mutated PDAC. Contrast-enhanced MRI features, clinicopathologic findings, and prognosis were compared between two groups.

RESULTS

A total of 308 surgically confirmed PDAC patients (median age, 67 years [IQR, 59, 72]; 183 male and 125 female) with genetic testing data were included, of which 258 had KRAS-mutated PDAC and 50 had non-KRAS-mutated PDAC. KRAS-mutated PDAC demonstrated distinct clinicopathological characteristics, including higher rates of diabetes (OR, 2.450, 95% CI, 1.151-5.212, P = 0.020), pathological peripheral nerve infiltration (OR, 2.296, 95% CI, 1.083-4.867, P = 0.030), and pN stage (OR, 2.006, 95% CI, 1.012-3.976, P = 0.046). The 1-, 3-, 5-year OS rate was worse for KRAS-mutated PDAC (89.9%, 45.4%, 23.2% vs. 95.1%, 60.4% 60.4%, P = 0.045). Rim enhancement (OR = 2.039, 95% CI: 1.053, 3.951, P = 0.035) and larger tumor size (OR = 3.286, 95% CI: 1.523, 7.089, P = 0.002) were identified as distinctive MRI features for KRAS-mutated PDAC.

CONCLUSION

KRAS-mutated PDAC presents unique clinical and pathological features and is associated with poorer prognosis. Rim enhancement and larger tumor size on MRI were identified as features associated with KRAS-mutated PDAC.

Case Report: Medullary carcinoma of the pancreas with MLH1 promoter hypermethylation, induced deficient mismatch repair, successfully treated with an immune checkpoint inhibitor

We report the case of a 75-year-old woman with a pancreatic body mass. Pathological findings from endoscopic ultrasonography-guided fine-needle aspiration revealed medullary carcinoma of the pancreas (MCP). Deficient mismatch repair (dMMR) and high microsatellite instability (MSI-H) were identified through immunohistochemistry and next generation sequencing, respectively. While immunohistochemistry suggested MLH1 abnormality, no MLH1 mutation was; hypermethylation of the MLH1 promoter was later confirmed via bisulfite sequencing. The patient initially received nab-paclitaxel plus gemcitabine, achieving tumor shrinkage. Upon tumor regrowth, she was treated with the anti-programmed cell death-1 immune checkpoint inhibitor (ICI) pembrolizumab, which resulted in significant tumor reduction. This is the first case report of MCP with dMMR/MSI-H due to MLH1 promoter hypermethylation, effectively treated with an ICI.

Prognostic and immunotherapeutic potential of disulfidptosis-associated signature in pancreatic cancer

Disulfidptosis is a newly discovered formation of programmed cell death. However, the significance of disulfidptosis in pancreatic adenocarcinoma remains unclear. Our investigation aims to elucidate the significance of disulfidptosis in pancreatic ductal adenocarcinoma by integrating diverse datasets, including bulk RNA sequencing data, microarray profiles, single-cell transcriptome profiles, spatial transcriptome data, and biospecimens. Utilizing various bioinformatics tools, we screened disulfidptosis-related genes based on single-cell RNA sequencing profiles, subsequently validating them through enrichment analysis. An 8-gene disulfidptosis-related prognostic signature was established by constructing massive LASSO-Cox regression models and validated by multiple external PDAC cohorts. Evaluation methods, such as Kaplan-Meier curves, ROC curves, time-dependent ROC curves, and decision curve analysis, were employed to assess the prognostic signature's reliability. High disulfidptosis-related scores were associated with a poorer prognosis and diminished sensitivity to immune checkpoint blockade. Further investigation uncovered that the potential components of elevated DPS involve malignant tumor hallmarks, extensive interactions between myCAFs and tumor cells, and the exclusion of immune cells. Cell-cell communication analysis highlighted myCAFs' role in signaling, potentially influencing tumor cells towards increased malignancy through collagen, laminin, and FN1 signaling networks. Spatial transcriptome analysis confirmed the crosstalk between myCAFs and tumor cells. Biospecimens including 20 pairs of PDAC samples and adjacent normal tissues further demonstrated the robustness of DPS and its correlation with CAF markers. In conclusion, our study introduces a novel disulfidptosis-related signature with high efficacy in patient risk stratification, which has the ability to predict the sensitivity to immune checkpoint blockade.

Genetics and clinical implications of SPINK1 in the pancreatitis continuum and pancreatic cancer

Serine peptidase inhibitor, Kazal type 1 (SPINK1), a 56-amino-acid protein in its mature form, was among the first pancreatic enzymes to be extensively characterized biochemically and functionally. Synthesized primarily in pancreatic acinar cells and traditionally known as pancreatic secretory trypsin inhibitor, SPINK1 protects the pancreas by inhibiting prematurely activated trypsin. Since 2000, interest in SPINK1 has resurged following the discovery of genetic variants linked to chronic pancreatitis (CP). This review provides a historical overview of SPINK1's discovery, function, and gene structure before examining key genetic findings. We highlight three variants with well-characterized pathogenic mechanisms: c.-4141G > T, a causative enhancer variant linked to the extensively studied p.Asn34Ser (c.101A > G), which disrupts a PTF1L-binding site within an evolutionarily conserved HNF1A-PTF1L cis-regulatory module; c.194 + 2T > C, a canonical 5' splice site GT > GC variant that retains 10% of wild-type transcript production; and an Alu insertion in the 3'-untranslated region, which causes complete loss of function by forming extended double-stranded RNA structures with pre-existing Alu elements in deep intronic regions. We emphasize the integration of a full-length gene splicing assay (FLGSA) with SpliceAI's predictive capabilities, establishing SPINK1 the first disease gene for which the splicing impact of all possible coding variants was prospectively determined. Findings from both mouse models and genetic association studies support the sentinel acute pancreatitis event (SAPE) model, which explains the progression from acute pancreatitis to CP. Additionally, SPINK1 variants may contribute to an increased risk of pancreatic ductal adenocarcinoma (PDAC). Finally, we discuss the therapeutic potential of SPINK1, particularly through adeno-associated virus type 8 (AAV8)-mediated overexpression of SPINK1 as a strategy for treating and preventing pancreatitis, and highlight key areas for future research.

circ-1584 selectively promotes the antitumor activity of the oncolytic virus M1 on pancreatic cancer

Pancreatic cancer is among the most challenging tumors to treat, and due to its immune tolerance characteristics, existing immunotherapy methods are not effective in alleviating the disease. Oncolytic virus therapy, a potential new strategy for treating pancreatic cancer, also faces the limitation of being ineffective when used alone. Elucidating the key host endogenous circular RNAs (circRNAs) involved in M1 virus-mediated killing of pancreatic ductal adenocarcinoma (PDAC) cells may help overcome this limitation. Here, we report that the oncolytic virus M1, a nonpathogenic alphavirus, exhibits different cell viability-inhibitory effects on different pancreatic cancer cells in the clinical stage. Through high-throughput circRNA sequencing, we found that circRNA expression varies among these cells. Further gain-of-function and loss-of-function experiments have shown that circ-1584 can selectively enhance the anti-pancreatic cancer effects of the M1 virus in vitro and in vivo. Additionally, circ-1584 may negatively regulate miR-578 to modulate the anti-pancreatic cancer effects of the M1 virus. Our findings lay the foundation for using circRNA as an adjuvant to enhance the M1 virus efficacy against pancreatic cancer.

Synergic value of 3D CT-derived body composition and triglyceride glucose body mass for survival prognostic modeling in unresectable pancreatic cancer

Background

Personalized and accurate survival risk prognostication remains a significant challenge in advanced pancreatic ductal adenocarcinoma (PDAC), despite extensive research on prognostic and predictive markers. Patients with PDAC are prone to muscle loss, fat consumption, and malnutrition, which is associated with inferior outcomes. This study investigated the use of three-dimensional (3D) anthropometric parameters derived from computed tomography (CT) scans and triglyceride glucose-body mass index (TyG-BMI) in relation to overall survival (OS) outcomes in advanced PDAC patients. Additionally, a predictive model for 1 year OS was developed based on body components and hematological indicators.

Methods

A retrospective analysis was conducted on 303 patients with locally advanced PDAC or synchronous metastases undergoing first-line chemotherapy, all of whom had undergone pretreatment abdomen-pelvis CT scans. Automatic 3D measurements of subcutaneous and visceral fat volume, skeletal muscle volume, and skeletal muscle density (SMD) were assessed at the L3 vertebral level by an artificial intelligence assisted diagnosis system (HY Medical). Various indicators including TyG-BMI, nutritional indicators [geriatric nutritional risk index (GNRI) and prealbumin], and inflammation indicators [(C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR)] were also recorded. All patients underwent follow-up for at least 1 year and a dynamic nomogram for personalized survival prediction was constructed.

Results

We included 211 advanced PDAC patients [mean (standard deviation) age, 63.4 ± 11.2 years; 89 women (42.2) %)]. Factors such as low skeletal muscle index (SMI) (P = 0.011), high visceral to subcutaneous adipose tissue area ratio (VSR) (P < 0.001), high visceral fat index (VFI) (P < 0.001), low TyG-BMI (P = 0.004), and low prealbumin (P = 0.001) were identified as independent risk factors associated with 1 year OS. The area under the curve of the established dynamic nomogram was 0.846 and the calibration curve showed good consistency. High-risk patients (> 211.9 points calculated using the nomogram) had significantly reduced survival rates.

Conclusion

In this study, the proposed nomogram model (with web-based tool) enabled individualized prognostication of OS and could help to guide risk-adapted nutritional treatment for patients with unresectable PDAC or synchronous metastases.

Immunohistochemical Evaluation of the Tumor Immune Microenvironment in Pancreatic Ductal Adenocarcinoma

Background: Pancreatic ductal adenocarcinoma is an aggressive neoplasm with a complex carcinogenesis process that must be understood through the interactions between tumor cells and tumor microenvironment cells. Methods: This study was retrospective with a chronological extension period of 16 years and included 56 cases of pancreatic ductal adenocarcinoma. This study identified, quantified, and correlated the cells of the tumor immune microenvironment in pancreatic ductal adenocarcinoma with major prognostic factors as well as overall survival, using an extensive panel of immunohistochemical markers. Results: Three tumor immunotypes were identified: subtype A (hot immunotype), subtype B (intermediate immunotype), and subtype C (cold immunotype). Patients with immunotype C exhibit considerably higher rates of both pancreatic fistulas and acute pancreatitis. Immunotypes B and C significantly increased the risk of this complication by factors of 3.68 (p = 0.002) and 3.94 (p = 0.001), respectively. The estimated probabilities of fistula formation for each immunotype are as follows: 2.5% for immunotype A, 25% for immunotype B, and 28% for immunotype C. There was a statistically significant difference in median survival times according to tumor immunotype (p < 0.001). Specifically, patients with immunotype C tumors had a median survival time of only 120.5 days, compared to 553.5 days for those with immunotype A and 331.5 for immunotype B tumors. Conclusions: The identification of the immunotype of pancreatic ductal adenocarcinoma can be a predictive factor for the occurrence of complications such as pancreatic fistula as well as for overall survival.

Controlled Inflammation Drives Neutrophil-Mediated Precision Drug Delivery in Heterogeneous Tumors

Tumor heterogeneity remains a formidable obstacle in targeted cancer therapy, often leading to suboptimal treatment outcomes. This study presents an innovative approach that harnesses controlled inflammation to guide neutrophil-mediated drug delivery, effectively overcoming the limitations imposed by tumor heterogeneity. By inducing localized inflammation within tumors using lipopolysaccharide, it significantly amplify the recruitment of drug-laden neutrophils to tumor sites, irrespective of specific tumor markers. This strategy not only enhances targeted drug delivery but also triggers the release of neutrophil extracellular traps, further potentiating the anti-tumor effect. Crucially, this study demonstrates that potential systemic inflammatory responses can be effectively mitigated through neutrophil transfusion, ensuring the safety and clinical viability of this approach. In a murine breast cancer model, the method significantly impedes tumor growth compared to conventional treatments. This work offers a versatile strategy for precise drug delivery across diverse tumor types. The findings pave the way for more effective and broadly applicable cancer treatments, potentially addressing the long-standing challenge of tumor heterogeneity.

Long-term lorazepam use may be associated with worse long-term outcomes among patients with pancreatic adenocarcinoma

BACKGROUND

Lorazepam recently has been reported to alter the tumor microenvironment of pancreatic adenocarcinoma in a murine model. We sought to evaluate whether the use of lorazepam was associated with worse outcomes among patients with pancreatic adenocarcinoma.

METHODS

Medicare beneficiaries diagnosed with stage I-IV pancreatic adenocarcinoma between 2013 and 2019 were identified from the Surveillance, Epidemiology and End Results-Medicare database. The association of lorazepam prescription relative to overall survival and recurrence-free survival was examined.

RESULTS

Among 2,810 patients with stage I-III and 10,181 patients with stage IV pancreatic adenocarcinoma, a total of 133 (4.7%) and 444 individuals (4.4%) had a lorazepam prescription before disease diagnosis, respectively. Although the overall lorazepam group had comparable 5-year overall survival (15.0% vs 14.2%, P = .20) and recurrence-free survival (12.7% vs 10.9%, P = .42) with the no-lorazepam group after pancreatic adenocarcinoma resection, individuals with long-term lorazepam prescription (>30 days) had worse 5-year overall survival (9.0% vs 21.0%, P = .02) and recurrence-free survival (6.4% vs 17.1%, P = .009) compared with short-term lorazepam users (≤30 days). Similarly, among patients with metastatic pancreatic adenocarcinoma, individuals with a long-term lorazepam prescription had worse 1-year overall survival (9.7% vs 15.9%, P = .02) compared with patients who had short-term lorazepam prescriptions. On multivariable analysis, long-term lorazepam prescription was independently associated with overall survival among patients with resectable (hazard ratio, 1.82; 95% confidence interval, 1.22-2.74) and metastatic pancreatic adenocarcinoma (hazard ratio, 1.24; 95% confidence interval, 1.02-1.51).

CONCLUSION

Long-term lorazepam prescription was associated with worse long-term outcomes among patients who underwent resection for pancreatic adenocarcinoma and patients with metastatic pancreatic adenocarcinoma. These data support the need for further large scale studies to confirm a potential harmful effect of lorazepam among patients with pancreatic adenocarcinoma.

Dynamine 3 as a diagnostic and prognostic biomarker in pancreatic cancer: Implications for early detection and targeted therapy

BACKGROUND

Dynamins are defined as a group of molecules with GTPase activity. Among them, DNM3 has gained recognition in oncology for its tumor suppressor role. Based on this, the aim of this study is to investigate the effects of the DNM3 gene in patients diagnosed with pancreatic cancer using bioinformatics databases.

MATERIALS AND METHODS

For differential gene expression analysis, TCGA TARGET GTEx study on the UCSC Xena and GEO datasets were utilized; for the analysis of changes in gene expression according to clinical and pathological characteristics, UALCAN was employed; for Overall Survival (OS) analysis, Kaplan-Meier Plotter was used; for gene alteration analysis, cBioPortal was utilized; for immune cell infiltration analysis, Tumor Immune Estimation Resource (TIMER) and TIMER2.0 were employed; for enrichment analyses Enrichr was used; for Gene Set Correlation Enrichment Analysis Gscore was used on GSE15471; for essentiality of DNM3 gene in pancratic cancer cell lines DepMap was used; and for the detection of miRNAs, miRDB was utilized; ENCORI was used for gene-miRNA correlation and miRNA prognosis analyses.

RESULTS

In the pancreatic adenocarcinoma (PAAD) cohort, DNM3 gene expression was higher in tumor samples, and there was no significant difference in expression among cancer stages. High levels of DNM3 gene expression were associated with longer OS in PAAD. A weak positive correlation was observed between DNM3 gene expression and B-Cell and CD4+ T Cell infiltrations, while a moderate positive correlation was found with CD8+ T Cell, Macrophage, Neutrophil, and Dendritic Cell infiltrations in TIMER. NK cell by QUANTISEQ, CD 4+ T Cell by TIMER, T cell regulatory (Tregs) by CIBERSORT-ABS infiltrations were positively associated with DNM3 gene expression and decreased risk in prognosis. Common lymphoid progenitor by XCELL and MDSC by TIDE infiltrations were negatively associated with DNM3 gene expression and increased risk of prognosis. Macrophage M1 by QUANTISEQ was positively associated with DNM3 gene expression and increased risk in prognosis. DNM3 gene appears to be associated with various pathways related to inflammation and the immune system. Amplification of the DNM3 gene was detected in 5 out of 175 patients. Enrichment was observed in pathways such as bacterial invasion of epithelial cells, endocytosis, endocrine and other factor-regulated calcium reabsorption, synaptic vesicle cycle, and phospholipase D signaling pathway. According to Gscore, DNM3 gene was associated with Fc epsilon RI signaling pathway, HALLMARK MTORC1 SIGNALING, HALLMARK EPITHELIAL MESENCHYMAL TRANSITION gene sets. According to ENCORI, DNM3 gene was negatively correlated with hsa-miR-203a-3p and increased expression of this miRNA was associated with adverse prognosis in PAAD.

CONCLUSIONS

The DNM3 gene may play a tumor suppressor role in pancreatic cancer, similar to its role in other malignancies. The contribution of immune cells may also be significant in this effect. However, in vitro studies are needed to elucidate the mechanisms triggered in pancreatic cancer.

Programmed cell death 1 inhibitor sintilimab plus S-1 and gemcitabine for liver metastatic pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer with poor prognosis. When it metastasizes to the liver, treatment options become particularly limited and challenging. Current treatment options for liver metastatic PDAC are limited, and chemotherapy alone often proves insufficient. Immunotherapy, particularly programmed cell death 1 (PD-1) inhibitors like sintilimab, shows potential efficacy for various cancers but has limited reports on PDAC. This study compares the efficacy and safety of sintilimab plus S-1 and gemcitabine vs S-1 and gemcitabine alone in liver metastatic PDAC.

AIM

To explore the feasibility and effectiveness of combined PD-1 inhibitor sintilimab and S-1 and gemcitabine (combination group) vs S-1 and gemcitabine used alone (chemotherapy group) for treating liver metastatic pancreatic adenocarcinoma.

METHODS

Eligible patients were those with only liver metastatic PDAC, an Eastern Cooperative Oncology Group performance status of 0-1, adequate organ and marrow functions, and no prior anticancer therapy. Participants in the combination group received intravenous sintilimab 200 mg every 3 weeks, oral S-1 40 mg/m² twice daily on days 1-14 of a 21-day cycle, and intravenous gemcitabine 1000 mg/m² on days 1 and 8 of the same cycle for up to eight cycles or until disease progression, death, or unacceptable toxicity. Participants in the chemotherapy group received oral S-1 40 mg/m² twice daily on days 1-14 of a 21-day cycle and intravenous gemcitabine 1000 mg/m² on days 1 and 8 of the same cycle for up to eight cycles. Between June 2020 and December 2021, 66 participants were enrolled, with 32 receiving the combination treatment and 34 receiving chemotherapy alone.

RESULTS

The group receiving the combined therapy exhibited a markedly prolonged median overall survival (18.8 months compared to 10.3 months, P < 0.05) and progression-free survival (9.6 months vs 5.4 months, P < 0.05). compared to the chemotherapy group. The incidence of severe adverse events did not differ significantly between the two groups (P > 0.05).

CONCLUSION

The combination of PD-1 inhibitor sintilimab with S-1 and gemcitabine demonstrated effectiveness and safety for treating liver metastatic PDAC, meriting further investigation.

Trends in the Global Incidence of Pancreatic Cancer and a Brief Review of its Histologic and Molecular Subtypes

The global burden of pancreatic cancer has more than doubled in recent decades. It is now the sixth leading cause of cancer-related death worldwide, with an estimated 510,922 new cases and 467,409 deaths in 2022. The incidence of the disease continues to rise annually, with projections indicating a 95.4% increase in new cases by 2050, potentially reaching a total of 998,663 new cases globally. The overall five-year survival rate for pancreatic cancer is 10% worldwide, showing only a modest improvement compared to the past decade. The rising trends in the incidence rates are likely to continue as the global population ages and access to healthcare improves. The relatively low survival rate is primarily attributed to late-stage diagnoses and the lack of an effective screening method. Currently, population-based screening for asymptomatic individuals is not recommended, highlighting the importance of identifying and monitoring individuals at high risk for pancreatic cancer. Numerous studies have highlighted the differences in the molecular pathology of pancreatic cancer, underscoring the need for continued research to better understand these differences. The silent progression of the disease, poor prognosis, lack of screening options, and the necessity to improve our comprehension of its molecular characteristics emphasize the critical need for ongoing monitoring of disease trends at the population level. This review article analyses trends in the incidence of pancreatic cancer and its histological subtypes and provides an update on its molecular subtypes.

Sociodemographic characteristics associated with pancreatic cancer incidence and mortality among Blacks in the United States: a SEER-based study

Pancreatic cancer (PC) is the third leading cause of all cancer-related fatalities and accounts for approximately 3% of cancer cases in the United States. PC survival rates are lower in Blacks compared to other races, and this has been attributed to socioeconomic and genetic factors. In this study, we evaluated sociodemographic and genetic characteristics associated with PC incidence and mortality among Blacks. Data from the SEER 22 registries (2000-2020) were used to calculate the incidence rates and relative survival. County mortality rates from 2017 to 2021 were analyzed. Incidence rate ratios based on gender, age, primary disease site, stage, level of education, and poverty were calculated. Survival analysis was conducted using the Kaplan-Meier method. Mutant gene expression was obtained from the MSK-CHORD tumor registry. Overall, 48,606 Black patients were diagnosed with malignant PC between 2000 and 2020: females (53.53%) and males (46.47%). Both males and females experienced a slight increase in Annual Percent Change (APC) of PC incidence (0.24, 95% CI, -0.02-0.53) and (0.22, 95% CI, -0.05-0.51), respectively, from 2000 to 2020. Males aged 55 to 75 years were most frequently affected. Overall incidence risk from 2000-2020 by age was higher in Black males IRR > 1 (1.18, 95% CI, 1.16-1.21). The most common primary PC site for Black males and females was the head of the pancreas, 49.06% and 49.88%, respectively. By staging, distant PC had the highest frequency in Blacks. Poverty level was associated with PC incidence among females and PC mortality among both males and females. Stage was associated with survival among males with localized and regional PC. The 5-year relative survival was less than 11% across combined PC stages for both sexes. Black males had a relatively lower 5-year survival than Black females in localized (31.7 vs. 37.2%) and distant PC (2.6% vs. 2.90%). Mutant KRAS expression was higher in Black males. PC incidence and mortality were significantly higher in Black males. Our analysis points to the importance of poverty alleviation programs that target females are likely to reduce PC incidence. Furthermore, receiving recommended screening for PC and early-stage diagnostics is important to lower PC mortality.

Computed Tomography-Based Sarcopenia and Pancreatic Cancer Survival-A Comprehensive Meta-Analysis Exploring the Influence of Definition Criteria, Prevalence, and Treatment Intention

Background: Sarcopenia has been associated with poor outcomes in pancreatic cancer (PC). However, published results are heterogeneous in terms of study design, oncological outcomes, and sarcopenia measurements. This meta-analysis aims to evaluate the impact of computed tomography (CT)-based sarcopenia on overall survival (OS) and progression-free survival (PFS) in patients with PC, considering potential confounders such as the CT-based method and thresholds used to define sarcopenia, as well as treatment intention. Methods: We systematically searched databases for observational studies reporting hazard ratios (HRs) for OS and PFS in PC patients stratified by CT-based sarcopenia status. Random-effects models were used to calculate pooled crude and adjusted HRs (cHRs and aHRs, respectively), with subgroup analyses based on sarcopenia measurement methods, cutoff values, sarcopenia prevalence, and treatment intention. Heterogeneity was assessed using the I2 and τ2 statistics, and publication bias was evaluated using funnel plots and Egger's test. Results: Data from 48 studies were included. Sarcopenia was significantly associated with worse OS (pooled cHR = 1.58, 95% CI: 1.38-1.82; pooled aHR = 1.39, 95% CI: 1.16-1.66) and worse PFS (pooled cHR = 1.55, 95% CI: 1.29-1.86; pooled aHR = 1.31, 95% CI: 1.11-1.55). Subgroup analyses revealed significantly different, stronger associations in studies using stricter sarcopenia cutoffs (<50 cm2/m2 for males) and in patients undergoing curative treatments. Heterogeneity was substantial across analyses (I2 > 67%), but with generally low τ2 values (0.01-0.25). Egger's test indicated potential publication bias for OS (p < 0.001), but no significant bias was observed for PFS (p = 0.576). Conclusions: Sarcopenia determined by CT is an independent predictor of poor OS and PFS in PC, but this association varies depending on the cutoff used for its definition as well as on the treatment intention. Therefore, its routine assessment in clinical practice could provide valuable prognostic information, but future research should focus on standardizing sarcopenia assessment methods.

Skeletal Muscle Index Changes on Locoregional Treatment Application After FOLFIRINOX and Survival in Pancreatic Cancer

BACKGROUND

Patients with borderline resectable (BR) or locally advanced pancreatic cancer (LAPC) require complex management strategies. This study evaluated the prognostic significance of the perichemotherapy skeletal muscle index (SMI) and carbohydrate antigen 19-9 (CA 19-9) in patients with BRPC or LAPC treated with FOLFIRINOX.

METHODS

We retrospectively evaluated 227 patients with BR or LAPC who received at least four cycles of chemotherapy between 2015 and 2020. We analysed chemotherapy response, changes in SMI (ΔSMI, %) on computed tomography (CT) and CA19-9 to determine their impact on progression-free survival (PFS) and overall survival (OS). After the early application of loco-regional treatments (LRT) within 3 months after completing four cycles of chemotherapy, the outcomes were compared between ΔSMI and CA19-9 subgroups.

RESULTS

Among 227 patients (median age, 60 years; 124 [54.6%] male) with 97 BR and 130 LAPC, 50.7% showed partial response (PR) to chemotherapy, 44.5% showed stable disease and 4.8% showed progressive disease (PD). Post-chemotherapy CA19-9 levels were normalized in 41.0% of patients. The high and low ΔSMI groups (based on the gender-specific cut-off of -8.6% for males and -2.9% for females) comprised 114 (50.2%) and 113 (49.8%) patients, respectively. The high ΔSMI group had poorer survival rates than the low ΔSMI group in both PFS (HR = 1.32, p = 0.05) and OS (HR = 1.74, p = 0.001). Multivariable analysis showed that ΔSMI (high vs. low; PFS, HR = 1.39, p = 0.03; OS, HR = 1.82, p < 0.001) and post-chemotherapy response (PD vs. PR/SD; PFS, HR = 18.69, p < 0.001; OS, HR = 6.19, p < 0.001) were independently associated with both PFS and OS. Additionally, the post-chemotherapy CA19-9 (≥ 37 vs. < 37; HR = 1.48, p = 0.01) was an independent predictor for PFS. Early application of LRT after chemotherapy significantly improved PFS and OS in both ΔSMI groups (all p < 0.05). However, it was not beneficial in the group with high ΔSMI and post-chemotherapy CA19-9 ≥ 37 (PFS, p = 0.39 and OS, p = 0.33).

CONCLUSIONS

Progressive sarcopenic deterioration after four cycles of chemotherapy was associated with poor survival outcomes in patients with BR or LAPC after FOLFIRINOX. We also investigated the optimal clinical setting for the early application LRTs using the ΔSMI and post-chemotherapy CA 19-9.

Clinical significance of resection and adjuvant chemotherapy for pancreatic ductal adenocarcinoma with occult para-aortic lymph node metastasis

BACKGROUND

This study aimed to determine the clinical significance of resection of pancreatic ductal adenocarcinoma diagnosed with occult para-aortic lymph node metastasis using intraoperative para-aortic lymph node sampling.

METHODS

Between January 2005 and May 2021, a total of 606 patients who underwent surgery for pancreatic ductal adenocarcinoma with intraoperative para-aortic lymph node sampling were retrospectively investigated and divided into the resected para-aortic lymph node-negative (n = 543), resected para-aortic lymph node-positive (n = 44), and unresected para-aortic lymph node-positive (n = 19) groups. Overall survival, clinicopathologic characteristics, and prognostic factors were analyzed.

RESULTS

The overall survival in the resected para-aortic lymph node-positive group was significantly worse than that in the resected para-aortic lymph node-negative group (3-year overall survival, 29.8% vs 48.4%, P < .001) and significantly better than that in the unresected para-aortic lymph node-positive group (3-year overall survival, 29.8% vs 0.0%, P = .008). In the resected para-aortic lymph node-positive group, adjuvant chemotherapy was an independent prognostic factor (hazard ratio = 2.689, P = .033). The overall survival of patients in the resected para-aortic lymph node-positive group who received adjuvant chemotherapy was comparable to that of patients in the resected para-aortic lymph node-negative group who had 4 or more regional lymph node metastases and received adjuvant chemotherapy (3-year overall survival, 33.9% vs 34.1%, P = .343). A logistic regression analysis showed that neoadjuvant therapy, age <65 years, creatinine clearance >60 mL/min, pancreatic body or tail tumor, and serum albumin level >3.5 g/dL were significant predictive factors for induction of adjuvant chemotherapy in 587 resected patients.

CONCLUSIONS

Resection may be acceptable for patients with para-aortic lymph node-positive pancreatic ductal adenocarcinoma who are likely to tolerate adjuvant chemotherapy.

Comprehensive bioinformatics analysis of the prognostic value and immune infiltration of CAPN2 in pancreatic adenocarcinoma

BACKGROUND

Pancreatic adenocarcinoma (PAAD) is a highly aggressive cancer with a poor prognosis, highlighting an urgent requirement for effective biomarkers for its early diagnosis and prognosis prediction. CAPN2, a calcium-dependent protease, has been implicated in various cancers, but its role in PAAD remains unclear.

METHODS

In this study, we utilized multiple bioinformatics methods, including differential expression, survival, correlation, and enrichment analyses, to investigate the prognostic value of CAPN2 in PAAD using data from the TCGA and GEO databases. Additionally, the correlation between CAPN2 expression and the tumor microenvironment (TME), immunotherapy potential, and drug sensitivity was also explored.

RESULTS

CAPN2 was upregulated in PAAD tissues and was correlated with higher tumor grade. And high expression of CAPN2 was significantly associated with reduced overall survival, establishing it as an independent prognostic biomarker for PAAD. Enrichment analysis implicated that CAPN2 was involved in multiple biological processes and pathways associated with tumor immunity. Furthermore, CAPN2 expression had a negative correlation with immune cell infiltration and a positive association with tumor mutational burden, which may have potential implications for immunotherapy strategies.

CONCLUSIONS

CAPN2 is a promising biomarker for PAAD prognosis and a potential therapeutic target. Its association with the TME and immunotherapy response highlights its importance in PAAD progression and patient outcomes, warranting further investigation into its role and potential clinical applications.

Retinoic acid receptor-β deletion in a model of early pancreatic ductal adenocarcinoma (PDAC) tumorigenesis

Vitamin A (VA, retinol) and its metabolites, including retinoic acid (RA), play a major role in the maintenance of cell populations in the adult pancreas. Pancreatic ductal adenocarcinomas (PDACs) contain lower amounts of VA and express lower levels of retinoic acid receptors (RARs) compared to normal human pancreatic tissues. Our goal was to determine if VA signaling directly impacts molecular events underlying pancreatic carcinogenesis using cell-type specific genetic approaches in mice. We knocked out retinoic acid receptor beta (RAR-β) selectively in pancreatic cells by tamoxifen treatment after crossing these adult RAR-βfl/fl mice with Pdx1/CreER (PCer) and lox-stop-lox KRasG12D transgenic mice. Our data show that the rounds of tamoxifen we used were able to induce the knockout of the RAR-β gene in pancreatic cells in this PCer;KRas;RAR-βfl/fl transgenic model. We detected increases in proteins involved in RA metabolism (CYP26A1, RBP1, and ALDH1A2) in the PCer;RAR-βD/wt pancreata, but the levels of RBP1 and ALDH1A2 were decreased in PCer;RAR-βD (both RAR-β alleles deleted) compared to PCer;KRas;RAR-βD and wild-type pancreata. Ki67 and vimentin proteins exhibited lower levels in the PCer;KRas;RAR-βD and PCer;RAR-βD pancreata compared to wild-type, indicating that deletion of RAR-β reduced cell proliferation in acinar cells. Expression of SOX9, a key protein required for formation and maintenance of PDAC, was higher in PCer;RAR-βD/wt and PCer;RAR-βD pancreata compared to wild-type, indicating that deletion of RAR-β increases SOX9 levels even without the KRas activating mutation. In summary, lack of RAR-β in pancreatic acinar cells reduced cell proliferation and increased SOX9 protein levels in this transgenic model.

Role of volumetric tumor enhancement on CT in predicting overall survival in patients with unresectable pancreatic ductal adenocarcinoma

PURPOSE

To assess the utility of volumetric tumor enhancement on CT to predict tumor treatment response and the overall survival (OS) of patients with PDAC undergoing FOLFIRINOX-based systemic chemotherapy. Additionally, we aim to explore the performance of a novel model that incorporates relevant volumetric CT-derived parameters to the established RECIST 1.1 in predicting both treatment response and OS.

MATERIAL AND METHODS

In this retrospective single-institution study, 127 patients with PDAC who received FOLFIRINOX neoadjuvant chemotherapy between December 2012 and November 2021 were included. Manual volumetric segmentation of the single largest tumor was performed on portal venous phase images. Total and enhancing tumor volumes were calculated. Response by RECIST 1.1 was compared to response by tumor volume and enhancing tumor volume on follow-up CT.

RESULTS

There was no association between overall survival and RECIST 1.1 (p-value = 0.284), volumetric RECIST (p-value = 0.402), and other volumetric CT variables, except for a percentage reduction in enhancing tumor volume (p-value = 0.043). Using univariate survival analysis for categorical thresholds defined by CART, the percentage change in enhancing tumor volume was associated with OS (p-value = 0.018). There was also a significant association between baseline enhancing tumor volume and OS (p-value <0.0001). Using these two categories, we defined a multivariable model associated with OS (p-value <0.0001).

CONCLUSION

Percentage reduction in enhancing tumor volume was related to OS in non-surgical PDAC patients treated with FOLFIRINOX chemotherapy and could potentially be incorporated into patient survival prediction models.

hnRNPLL regulates MYOF alternative splicing and correlates with early metastasis in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a deadly cancer known for its high rate of early metastasis, necessitating the discovery of the underlying mechanisms. Herein, we report that heterogeneous nuclear ribonucleoprotein L-like (hnRNPLL) expression significantly increases at the invasion forefront in PDAC and is associated with early metastasis and poor prognosis. Our findings revealed that hnRNPLL knockdown resulted in extensive exon skipping (ES) events. In particular, we identified myoferlin (MYOF), a member of the ferlin family involved in membrane processes, as a functional splicing target of hnRNPLL. hnRNPLL depletion stimulates MYOF exon 17 retention to reduce the short isoform of MYOF (MYOFb) and inhibit metastasis. In contrast, hnRNPLL or MYOFb overexpression promoted pancreatic cancer cell migration and invasion. These results suggest that hnRNPLL is a critical factor for early PDAC metastasis. hnRNPLL and MYOFb may be potential therapeutic targets for PDAC.

Identification of SMAD4-mutated pancreatic ductal adenocarcinoma using preoperative contrast-enhanced MRI and clinical characteristics

AIM

To assess the value of preoperatively contrast-enhanced MRI and clinical characteristics for identification of SMAD4-mutated pancreatic ductal adenocarcinoma (PDAC) patients.

MATERIALS AND METHODS

This retrospective study included patients with surgically confirmed PDAC from January 2016 to December 2022. Based on immunostaining results indicating the mutation of SMAD4, the enrolled participants were grouped into SMAD4-mutated PDAC and non-SMAD4-mutated PDAC. Contrast-enhanced MRI findings, clinical-pathological characteristics, and prognosis were recorded and reviewed. The pathological findings and clinical prognosis were compared between the two groups. Uni- and multivariable logistic regression analyses were further performed to determine the radiological and clinical predictive factors for the mutation of SMAD4.

RESULTS

In total, 428 PDAC patients were enrolled and analyzed, who were grouped as SMAD4-mutated PDAC (n = 224) and non-SMAD4-mutated PDAC (n = 204). SMAD4-mutated PDAC demonstrated higher frequency of pathological fatty infiltration (83.4% vs. 74.2%, P = 0.016), peripheral nerve infiltration (84.4% vs. 76.5%, P = 0.039). and higher recurrence rates (43.6% vs. 58.9%, P = 0.045) than non-SMAD4-mutated PDAC. The 3-year recurrence-free survival rates were worse for SMAD4-mutated PDAC (28.7% vs. 39.1%). In multivariable logistic regression analyses, CA19-9 > 100 U/mL (odds ratio [OR] = 1.519, P = 0.041), CBD dilation (OR = 1.564, P = 0.036), and rim enhancement (OR = 1.631, P = 0.025) were independent predictive factors.

CONCLUSION

Rim enhancement, CBD dilation on contrast-enhanced MRI and higher CA19-9 level are promising radiological and clinical factors for identifying SMAD4-mutated PDAC.

Different Cytotoxic Effects of Cisplatin on Pancreatic Ductal Adenocarcinoma Cell Lines

This study examined the response to cisplatin in BxPC-3, Mia-Paca-2, PANC-1, and YAPC pancreatic cancer lines with different genotypic and phenotypic characteristics, and the mechanisms associated with their resistance. BxPC-3 and MIA-PaCa-2 cell lines were the most sensitive to cisplatin, while YAPC and PANC-1 were more resistant. Consistently, in cisplatin-treated BxPC-3 cells, the cleavage patterns of pro-caspase-9, -7, -3, and PARP-1 demonstrated that they were more sensitive than YAPC cells. The autophagic pathway, promoting cisplatin resistance, was active in BxPC-3 cells, as demonstrated by the time-dependent conversion of LC3-I to LC3-II, whereas it was not activated in YAPC cells. In cisplatin-treated BxPC-3 cells, Bcl-2 decreased, while Beclin-1, Atg-3, and Atg-5 increased along with JNK1/2 phosphorylation. Basal levels of phosphorylated ERK1/2 in each cell line were positively correlated with cisplatin IC50 values, and cisplatin caused the activation of ERK1/2 in BxPC-3 and YAPC cells. Furthermore, ERK1/2 pharmacological inactivation increased cisplatin lethality in both BxPC-3 and YAPC cells, suggesting that p-ERK1/2 may be related to cisplatin resistance of PDAC cells. Different mechanisms and strategies are generally required to acquire drug resistance. Here, we partially explain the other response to cisplatin of BxPC-3 and YAPC cell lines by relating it to the role of ERK pathway.

Cancer-associated fibroblasts: heterogeneity, tumorigenicity and therapeutic targets

Cancer, characterized by its immune evasion, active metabolism, and heightened proliferation, comprises both stroma and cells. Although the research has always focused on parenchymal cells, the non-parenchymal components must not be overlooked. Targeting cancer parenchymal cells has proven to be a formidable challenge, yielding limited success on a broad scale. The tumor microenvironment(TME), a critical niche for cancer cell survival, presents a novel way for cancer treatment. Cancer-associated fibroblast (CAF), as a main component of TME, is a dynamically evolving, dual-functioning stromal cell. Furthermore, their biological activities span the entire spectrum of tumor development, metastasis, drug resistance, and prognosis. A thorough understanding of CAFs functions and therapeutic advances holds significant clinical implications. In this review, we underscore the heterogeneity of CAFs by elaborating on their origins, types and function. Most importantly, by elucidating the direct or indirect crosstalk between CAFs and immune cells, the extracellular matrix, and cancer cells, we emphasize the tumorigenicity of CAFs in cancer. Finally, we highlight the challenges encountered in the exploration of CAFs and list targeted therapies for CAF, which have implications for clinical treatment.

CircRREB1 Mediates Metabolic Reprogramming and Stemness Maintenance to Facilitate Pancreatic Ductal Adenocarcinoma Progression

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal tumor with limited treatment options and poor patient survival. Circular RNAs (circRNA) play crucial regulatory roles in the occurrence and development of various cancers, including PDAC. In this study, using circRNA sequencing of diverse PDAC samples, we identified circRREB1 as an oncogenic circRNA that is significantly upregulated in PDAC and is correlated with an unfavorable patient prognosis. Functionally, loss of circRREB1 markedly inhibited glycolysis and stemness, whereas elevated circRREB1 elicited the opposite effects. Mechanistically, circRREB1 interacted with PGK1, disrupting the association between PTEN and PGK1 and increasing PGK1 phosphorylation to activate glycolytic flux. Moreover, circRREB1 promoted WNT7B transcription by directly interacting with YBX1 and facilitating its nuclear translocation, consequently activating the Wnt/β-catenin signaling pathway to maintain PDAC stemness. Overall, these results highlight circRREB1 as a key regulator of metabolic and stemness properties of PDAC. Significance: CircRREB1 stimulates PGK1 to induce glycolysis and activates the Wnt/β-catenin signaling pathway to maintain stemness in pancreatic cancer, indicating the potential of circRREB1 as a biomarker and therapeutic target.

TRIM16 and PRC1 Are Involved in Pancreatic Cancer Progression and Targeted by Delphinidin

Pancreatic cancer (PC) is the leading cause of cancer-related death worldwide, and new biomarkers, therapeutic targets, and candidate drugs are needed. In this work, three PC-related microarray datasets (GSE183795, GSE28735, and GSE62452) were analyzed. The differentially expressed genes (DEGs) of PC were obtained with the limma package in R. Weighted gene co-expression network analysis (WGCNA) and machine learning approaches were used to screen the hub genes. Kaplan-Meier plotter and receiver operating characteristic (ROC) curve analysis were utilized to assess the diagnostic efficacy of the hub genes. The binding ability between natural bioactive ingredients and hub proteins was evaluated by molecular docking and molecular dynamics simulation. CCK-8, flow cytometry, transwell, and western blot assays were used to analyze the viability, apoptosis, cell cycle progression, invasion, and pathway change of PC cells. Additionally, a nude mice model was used to evaluate the aggressive properties of PC cells in vivo. In this study, a total of 988 DEGs were identified, which were mainly enriched in cell adhesion and PI3K-Akt signaling pathway, and two core genes TRIM16 and PRC1 were further identified. The overall survival of patients with high expression of TRIM16 and PRC1 was shorter. Delphinidin (Del) had good binding affinity with both TRIM16 and PRC1, and Del could inhibit the viability, invasion, and metastasis of PC cells and induce cell apoptosis and G0/G1 phase arrest. In addition, Del could promote the activation of p53 and inhibit the activation of the PI3K/AKT signaling pathway in PC cells. In summary, TRIM16 and PRC1 are identified as prognostic biomarkers and therapeutic targets for PC, and Del has good binding affinity with them and may be a potential therapeutic agent for PC.

GDF15 and LCN2 for early detection and prognosis of pancreatic cancer

BACKGROUND

The prognosis of pancreatic ductal adenocarcinomas (PDAC) remains very poor, emphasizing the critical importance of early detection, where biomarkers offer unique potential. Although growth differentiation factor 15 (GDF15) and Lipocalin 2 (LCN2) have been linked to PDAC, their precise roles as biomarkers are uncertain.

METHODS

Circulating levels of GDF15 and LCN2 were examined in human PDAC patients, heathy controls, and individuals with benign pancreatic diseases. Circulating levels of IL-6, CA19-9, and neutrophil-to-lymphocyte ratio (NLR) were measured for comparisons. Correlations between PDAC progression and overall survival were assessed. A mouse PDAC model was employed for comprehensive analyses, complementing the human studies by exploring associations with various metabolic and inflammatory parameters. Sensitivity and specificity of the biomarkers were evaluated.

FINDINGS

Our results demonstrated elevated levels of circulating GDF15 and LCN2 in PDAC patients compared to both healthy controls and individuals with benign pancreatic diseases, with higher GDF15 levels associated with disease progression and increased mortality. In PDAC mice, circulating GDF15 and LCN2 progressively increased, correlating with tumor growth, behavioral manifestations, tissue and molecular pathology, and cachexia development. GDF15 exhibited highly sensitive and specific for PDAC patients compared to CA19-9, IL-6, or NLR, while LCN2 showed even greater sensitivity and specificity in PDAC mice. Combining GDF15 and LCN2, or GDF15 and CA19-9, enhanced sensitivity and specificity.

INTERPRETATION

Our findings indicate that GDF15 holds promise as a biomarker for early detection and prognosis of PDAC, while LCN2 could strengthen diagnostic panels.

Thermal Liquid Biopsy: A Promising Tool for the Differential Diagnosis of Pancreatic Cystic Lesions and Malignancy Detection

Pancreatic cystic lesions (PCLs) are a heterogeneous group of lesions with increasing incidence, usually identified incidentally on imaging studies (multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), or endoscopic ultrasound (EUS)) [...].

Correlation of dynamic contrast-enhanced ultrasonography and the Ki-67 labelling index in pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant and aggressive tumor, and high Ki-67 expression indicates poor histological differentiation and prognosis. Therefore, one of the challenges in diagnosing preoperatively patients with PDAC is predicting the degree of malignancy. Dynamic contrast-enhanced ultrasonography (DCE-US) plays a crucial role in abdominal tumor diagnosis, and can adequately show the microvascular composition within the tumors. However, the relationship between DCE-US and the Ki-67 labelling index remains unclear at the present time.

AIM

To predict the correlation between Ki-67 expression and the parameters of DCE-US.

METHODS

Patients with PDAC who underwent DCE-US were retrospectively analyzed. Patients who had received any treatment (radiotherapy or chemotherapy) prior to DCE-US; had incomplete clinical, imaging, or pathologic information; and had poor-quality image analysis were excluded. Correlations between Ki-67 expression and the parameters of DCE-US in patients with PDAC were assessed using Spearman's rank correlation analysis. The diagnostic performances of these parameters in high Ki-67 expression group were evaluated according to receiver operating characteristic curve.

RESULTS

Based on the Ki-67 labelling index, 30 patients were divided into two groups, i.e., the high expression group and the low expression group. Among the relative quantitative parameters between the two groups, relative half-decrease time (rHDT), relative peak enhancement, relative wash-in perfusion index and relative wash-in rate were significantly different between two groups (P = 0.018, P = 0.025, P = 0.028, P = 0.035, respectively). The DCE-US parameter rHDT was moderately correlated with Ki-67 expression, and rHDT ≥ 1.07 was more helpful in accurately diagnosing high Ki-67 expression, exhibiting a sensitivity and specificity of 53.8% and 94.1%, respectively.

CONCLUSION

One parameter of DCE-US, rHDT, correlates with high Ki-67 expression. It demonstrates that parameters obtained noninvasively by DCE-US could better predict Ki-67 expression in PDAC preoperatively.

Establishment and analysis of a prognostic model of pancreatic ductal adenocarcinomas based on nerve-cancer crosstalk-related genes

Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant tumor with a five-year survival rate of 13%, the lowest among all malignant tumors. The work aims to use bioinformatics methods to mine Nerve-cancer crosstalk-related genes (NCCGs) in pancreatic cancer and evaluate their correlation with tumor stage and prognosis, thereby providing a new direction of development and experimental basis for pancreatic cancer treatment. This study included 185 individuals with PDAC from the TCGA database, together with clinical and RNA sequencing data. A review of prior studies revealed the mechanism of neural-cancer crosstalk and identified 42 neural-cancer crosstalk-related genes (NCCGs). Multivariate logistic regression analysis showed that NGFR (OR=39.076, 95% CI; P<0.05), CHRNB2 (OR=41.076, 95% CI; P<0.05), and CHRNA10 (OR=39.038, 95% CI; P<0.05) were identified as independent risk factors for PNI development. Pearson correlation analysis revealed that CHRNA10 was negatively connected with PDAC microsatellite instability, whereas CHRNA10, CHRNB2, and NGFR were negatively correlated with PDAC tumor mutation burden. The GEPIA database revealed that CHRNB2 expression was higher in stage I PDAC. The pancreatic cancer single-cell dataset PAAD_CRA001160 revealed that malignant tumor cells, ductal cells, endothelial cells and fibroblasts accounted for a large proportion in the tumor microenvironment of pancreatic cancer. Furthermore, the NGFR gene was shown to be more significantly expressed in various pancreatic cancer cells. Bioinformatics analysis was used to create a validated prognostic model of pancreatic cancer, which explored the critical mechanisms of neural-tumor interactions and revealed the potential of cancer-neural crosstalk-related genes as prognostic biomarkers and anti-tumor therapy targets.

Comparison of multiple machine learning models for predicting prognosis of pancreatic ductal adenocarcinoma based on contrast-enhanced CT radiomics and clinical features

Objective

The aim of this study was to evaluate the prognostic potential of combining clinical features and radiomics with multiple machine learning (ML) algorithms in pancreatic ductal adenocarcinoma (PDAC).

Methods

A total of 116 patients with PDAC who met the eligibility criteria were randomly assigned to a training or validation cohort. Seven ML algorithms, including Supervised Principal Components, stepwise Cox, Random Survival Forest, CoxBoost, Least absolute shrinkage and selection operation (Lasso), Ridge, and Elastic network, were integrated into 43 algorithm combinations. Forty-three radiomics models were constructed separately using radiomics features extracted from arterial phase (AP), venous phase (VP), and combined arterial and venous phase (AP+VP) images. The concordance index (C-index) of each model was calculated. The model with the highest mean C-index was identified as the best model for calculating the radiomics score (Radscore). Univariate and multivariate Cox analyses were used to identify independent prognostic indicators and create a clinical model for prognosis prediction. The multivariable Cox regression was used to combine Radscore with clinical features to create a combined model. The efficacy of the model was evaluated using the C-index, calibration curves, and decision curve analysis (DCA).

Results

The model based on the Lasso+StepCox[both] algorithm constructed using AP+VP radiomics features showed the best predictive ability among the 114 radiomics models. The C-indices of the model in the training and validation cohorts were 0.742 and 0.722, respectively. Based on the results of the univariate and multivariate Cox regression analyses, sex, Tumor-Node-Metastasis (TNM) stage, and systemic inflammation response index were included to build the clinical model. The combined model, incorporating three clinical factors and AP+VP-Radscore, achieved the highest C-indices of 0.764 and 0.746 in the training and validation cohorts, respectively. In terms of preoperative prognosis prediction for PDAC, the calibration curve and DCA showed that the combined model had a good consistency and greatest net benefit.

Conclusion

A combined model of clinical features and AP+VP-Radscore screened using multiple ML algorithms has an excellent ability to predict the prognosis of PDAC and may provide a noninvasive and effective method for clinical decision-making.

Devimistat (CPI-613) With Modified Fluorouarcil, Oxaliplatin, Irinotecan, and Leucovorin (FFX) Versus FFX for Patients With Metastatic Adenocarcinoma of the Pancreas: The Phase III AVENGER 500 Study

PURPOSE

Metastatic pancreatic adenocarcinoma (mPC) remains a difficult-to-treat disease. Fluorouarcil, oxaliplatin, irinotecan, and leucovorin (FFX) is a standard first-line therapy for mPC for patients with a favorable performance status and good organ function. In a phase I study, devimistat (CPI-613) in combination with modified FFX (mFFX) was deemed safe and exhibited promising efficacy in mPC.

METHODS

The AVENGER 500 trial (ClinicalTrials.gov identifier: NCT03504423) is a global, randomized phase III trial conducted at 74 sites across six countries to investigate the efficacy and safety of devimistat in combination with mFFX (experimental arm) compared with standard-dose FFX (control arm) in treatment-naïve patients with mPC. Treatment, administered in once-every-2-weeks cycles until disease progression or intolerable toxicity, included intravenous devimistat at 500 mg/m2 total per day on days 1 and 3 in the experimental arm. The primary end point of the study was overall survival (OS).

RESULTS

Five hundred and twenty-eight patients were randomly assigned (266 in the experimental arm and 262 in the control arm). The median OS was 11.10 months for devimistat plus mFFX versus 11.73 months for FFX (hazard ratio [HR], 0.95 [95% CI, 0.77 to 1.18]; P = .655) and median progression-free survival was 7.8 months versus 8.0 months, respectively (HR, 0.99 [95% CI, 0.76 to 1.29]; P = .94). Grade ≥3 treatment-emergent adverse events with >10% frequency in the devimistat plus mFFX arm versus the FFX arm were neutropenia (29.0% v 34.5%), diarrhea (11.2% v 19.6%), hypokalemia (13.1% v 14.9%), anemia (13.9% v 13.6%), thrombocytopenia (11.6% v 13.6%), and fatigue (10.8% v 11.5%), respectively.

CONCLUSION

Devimistat in combination with mFFX did not improve long- and short-term mPC patient outcomes compared with standard FFX. There were no new toxicity signals with the addition of devimistat.

Role and functional mechanisms of IL‑17/IL‑17R signaling in pancreatic cancer (Review)

Interleukin‑17 (IL‑17), an inflammatory cytokine primarily secreted by T helper 17 cells, serves a crucial role in numerous inflammatory diseases and malignancies via its receptor, IL‑17R. In addition to stimulating inflammatory responses, IL‑17 exhibits dual functions in tumors, exerting both pro‑ and antitumor effects. Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic malignancy and accounts for >90% of pancreatic cancer cases. PDAC is characterized by a prominent stromal microenvironment with significant heterogeneity, which contributes to treatment resistance. IL‑17/IL‑17R signaling has a notable effect on tumorigenesis, the tumor microenvironment and treatment efficacy in various cancer types, including PDAC. However, the specific mechanisms of IL‑17/IL‑17R signaling in pancreatic cancer remain uncertain. This review presents a brief overview of the current knowledge and recent advances in the role and functional mechanisms of IL‑17/IL‑17R signaling in pancreatic cancer. Furthermore, the potential of IL‑17‑targeted therapeutic strategies for PDAC treatment is also discussed.

Bacterial shift and resistance pattern in pancreatic head resections after selective decontamination of the digestive tract - a propensity score-matched analysis

BACKGROUND

Pancreatic head resection is associated with postoperative morbidity, primarily because of infectious complications. The microbiota in these infections is crucial, and selective decontamination of the digestive tract (SDD) aims to mitigate this risk by targeting pathogenic organisms while preserving beneficial flora. This study aimed to determine the effect of SDD on bacterial shifts and resistance patterns in pancreatic head resection.

METHODS

All patients who underwent pancreatic head resection either between January 2012 and August 2018 (non-SDD group) or between January 2019 and December 2021 (SDD group) were included. Propensity score-matched analysis was performed to compare the bacterial presence and resistance patterns in bile duct smear tests and postoperative complications.

RESULTS

Positive bile duct smear tests were observed more often in the non-SDD group (63.5%) than in the SDD group (51.0%). Moreover, the SDD group exhibited a significant reduction in the median number of bacterial species in the bile ducts compared with the non-SDD group (P = .04). However, a notable increase in gram-negative species was observed in the SDD group. The SDD group experienced higher rates of postoperative complications, including relevant pancreatic fistulas (24.8% in the SDD group vs 11.6% in the non-SDD group; P < .01) and delayed gastric emptying (33.8% in the SDD group vs 21.9% in the non-SDD group; P < .01). No significant difference in antibiotic resistance patterns was observed.

CONCLUSION

SDD in pancreatic head resection reduces bacterial load in the biliary tract, but it is associated with a shift toward more gram-negative species and higher rates of severe postoperative complications. Our findings suggest that SDD may negatively affect postoperative outcomes and should be carefully considered in clinical practice.

The Exon Junction Complex component EIF4A3 plays a splicing-linked oncogenic role in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers, underscoring the urgent need for in-depth biological research. The phenomenon of alternative RNA splicing dysregulation is a common hallmark in cancer, including PDAC, presenting new avenues for understanding and developing diagnostic and therapeutic tools. Our research focuses on EIF4A3, a core component of the Exon Junction Complex intimately linked to RNA splicing, and its role in PDAC. EIF4A3 is overexpressed in PDAC tissue and associated to clinical parameters of malignancy and poorer patient survival. Mechanistically, exploration of PDAC RNA-seq data unveiled the link of EIF4A3 to diverse malignancy processes, consistent with its association to key molecular pathways. EIF4A3 targeting in vitro decreased essential functional tumor features such as proliferation, migration, colony formation and sphere formation, while its in vivo targeting reduced tumor growth. EIF4A3 silencing in PDAC cell lines severely altered its transcriptional and spliceosomic landscapes, as shown by RNA-seq analyses, suggesting a role for EIF4A3 in maintaining RNA homeostasis. Our results indicate that EIF4A3 dysregulation in PDAC has a pleiotropic regulatory role on RNA biology, influencing key cellular functions. This paves the way to explore its potential as novel biomarker and actionable target candidate for this lethal cancer.