Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes

Role of pancreatic juice cytology in diagnosis of high-grade pancreatic intraepithelial neoplasia

High-grade pancreatic intraepithelial neoplasia is a challenging diagnosis and it does not exhibit mass lesions. It is suspected based on changes in the main pancreatic duct in magnetic resonance cholangiopancreatography. Sometimes only an unclear duct shows in magnetic resonance cholangiopancreatography with no focal strictures and upstream dilatation of the main pancreatic duct. Serial pancreatic juice cytology is valuable in diagnosis of those patients.

Liquid biopsies and exosomal ncRNA: Transforming pancreatic cancer diagnostics and therapeutics

Pancreatic cancer is a highly fatal malignancy due to poor early detection rate and resistance to conventional therapies. This review examines the potential for liquid biopsy as a transformative technology to identify diagnostic and therapeutic targets in pancreatic cancer. Specifically, we explore emerging biomarkers such as exosomal non-coding RNAs (ncRNAs), circulating tumor DNA (ctDNA), and circulating tumor cells (CTCs). Tumor-derived exosomes contain nucleic acid and protein that reflect the unique molecular landscape of the malignancy and can serve as an alternative diagnostic approach vs traditional biomarkers like CA19-9. Herein we highlight exosomal miRNAs, lncRNAs, and other ncRNAs alongside ctDNA and CTC-based strategies, evaluating their combined ability to improve early detection, disease monitoring and treatment response. Furthermore, the therapeutic implications of ncRNAs such as lncRNA UCA1 and miR-3960 in chemoresistance and progression are also discussed via suppression of EZH2 and PTEN/AKT pathways. Emerging therapeutic strategies that target the immune response, epithelial-mesenchymal transition (EMT) and drug resistance are explored. This review demonstrates a paradigm shift in pancreatic cancer management toward personalized, less invasive and more effective approaches.

C-reactive protein is a prognostic biomarker in pancreatic ductal adenocarcinoma patients

AIM

The 5-year survival rate of pancreatic ductal adenocarcinoma (PDAC) is approximately 11% and has only improved marginally over the last three decades. For operable PDAC, resection and adjuvant FOLFIRINOX chemotherapy is standard of care. There is growing interest in perioperative regimens to improve outcomes. The non-randomized Phase II study "Gemcitabine and Abraxane for resectable Pancreatic cancer" (GAP) demonstrated the feasibility of perioperative gemcitabine/abraxane. Long-term survival in PDAC requires an effective immune response; hence, we undertook this translational study of the GAP trial cohort to identify immune-oncology biomarkers for clinical use.

METHODS

We combined Nanostring nCounter technology with immunohistochemistry to investigate the correlation between gene expression and overall patient survival. Findings were investigated in samples from the International Cancer Genome Consortium (ICGC, n = 88) and the Australian Pancreatic Genome Initiative (APGI, n = 227).

RESULTS

We confirmed that human equilibrative nucleoside transporter 1 (hENT1) expression was not a prognostic marker in PDAC but patients with high levels of hENT1 were more likely to live longer than 24 months post-surgery. Additionally, CD274 (PD-L1) and two novel biomarkers of survival, cathepsin W (CTSW) and C-reactive protein (CRP), were identified in the GAP cohort (n = 19). CRP expression was confirmed in data from the ICGC. Although PD-L1 and CTSW proteins were not significant across all three cohorts, results show that low CRP mRNA and protein expression are associated with longer overall survival in all three patient groups.

CONCLUSION

PDAC patients with long survival have higher hENT1 expression levels. Furthermore, CRP expression is a biomarker of poor prognosis following perioperative chemotherapy and resection in PDAC patients and thus may be useful for identifying patients who could benefit from more aggressive adjuvant strategies.

Anti-tumor effects of nanosecond pulsed electric fields in a murine model of pancreatic cancer

Nanosecond Pulsed Electric Fields (nsPEFs) treatment has demonstrated anti-tumor effects on various cancer cell lines. However, the use of this treatment in pancreatic cancer is limited. This study demonstrated that nsPEFs treatment effectively suppressed the proliferation and metastasis of pancreatic cancer cells, while also inducing DNA damage. Meanwhile, animal experiments have shown that nsPEFs effectively suppressed the growth of pancreatic cancer, even in cases where the tumor volume exceeded 500-600 mm3 at the initiation of treatment. Notably, a single treatment session was found to significantly inhibit tumor growth, while also showing no adverse effects on the main organs of the mice. RNA sequencing and bioinformatics revealed that seven key genes (CDK1, CENPA, UBE2C, CCNB2, PLK1, CCNA2, and CCNB14) were significantly correlated with the overall survival rate of patients with pancreatic cancer. Through the application of the competing endogenous RNA (ceRNA) hypothesis, two miRNAs (has-let-7b-5p and hsa-miR-193b-3p) and four lncRNAs (MIR4435-2HG, ZNF436-AS1, LINC01089, and MIR4435-2HG) were identified as significantly impacting the overall survival of pancreatic cancer patients. We have effectively developed an mRNA-miRNA-lncRNA network that has the potential to stimulate further investigation into the underlying mechanisms of nsPEFs on pancreatic cancer.

Prognostic impact of inflammatory and nutritional biomarkers in pancreatic cancer

Pancreatic cancer is usually associated with a poor prognosis. Surgery is the main curative treatment but pancreatic operations are aggressive and new tools that help clinicians to predict surgical and prognostic outcomes are necessary. Lu et al recently published a retrospective, single centre cohort study evaluating the impact of seven nutritional and inflammatory markers in pancreatic cancer surgical patients: The albumin-to-globulin ratio, prognostic nutritional index (PNI), systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), nutritional risk index, and the geriatric nutritional risk index. A significant correlation was found between the PNI, SII, NLR, and PLR and a hospital discharge of less than 15 days. In a univariable analysis, PNI, SII, NLR and PLR were significantly related to recurrence-free survival and, in a multivariable analysis PNI was associated with overall survival. Various meta-analyses corroborate the results in terms of prognosis but individual studies are discordant on their usefulness. Besides, the cut-off values for these markers vary significantly between studies and there are no clinical trials comparing them to identify the most relevant ones. These are limitations when implementing nutritional and inflammatory biomarkers into clinical practice and further studies are needed in order to answer these questions.

Oral and Fecal Microbiota as Accurate Non-invasive Tools for Detection of Pancreatic Cancer in the Chinese Population

Pancreatic cancer (PCA), a leading cause of cancer-related deaths, has limited non-invasive diagnostic methods. We aimed to identify oral and fecal microbiome biomarkers and construct diagnostic classifiers. Oral and fecal samples from 97 PCA patients and 90 healthy controls underwent 16S rRNA sequencing. Samples were randomly divided into training and validation cohorts in a 7:3 ratio. Random forest models were constructed using training cohort and validated internally and externally in Chinese, Japanese, and Spanish populations. Results revealed significant dysbiosis of the oral and fecal microbiota of PCA patients. Most of the differential taxa shared between oral and fecal samples showed similar changes. Relative abundances of Streptococcus in oral samples, and of Bifidobacterium, Klebsiella and Akkermansia in fecal samples, were enriched in PCA. The fecal Firmicutes to Bacteroidota ratio was higher in PCA patient samples. Oral and fecal microbiome classifiers based on the top 20 contributing genera were constructed, and internal validation showed that the area under the curve (AUC) values were 0.963 and 0.890, respectively. The fecal microbiome classifier performed well in the external Chinese population, with an AUC of 0.878, but poorly in the Japanese and Spanish populations. Furthermore, fecal microbiomes could predict metastasis status in PCA patients, with an AUC of 0.804. In conclusion, oral and fecal microbiota were dysbiotic in PCA patients. Fecal microbiome classifier provides a feasible, non-invasive, and cost-effective tool with high precision for PCA screening in China; oral microbiome classifier requires further validation in external populations sampled with the same simple and convenient methods.

Real-world effectiveness and safety of second- or third-line pegylated liposomal irinotecan plus 5-fluorouracil and folinic acid in pancreatic ductal adenocarcinoma in Spain

Treatment with pegylated nanoliposomal irinotecan (nal-IRI) plus 5-fluorouracil/leucovorin (folinic acid; 5-FU/LV) has demonstrated remarkable efficacy for metastatic pancreatic ductal adenocarcinoma (PDAC) in clinical trials. However, real-world data on the effectiveness of nal-IRI+5-FU/LV is heterogeneous and is lacking in Spain. To assess the effectiveness and safety of nal-IRI+5-FU/LV in real-life PDAC patients in Spain. A multicenter retrospective study was conducted. Patients aged ⩾18 years who had received at least one cycle of nal-IRI+5-FU/LV as second- or third-line therapy for PDAC were included. The primary endpoint was overall survival (OS) from nal-IRI+5-FU/LV treatment initiation and OS from the diagnosis of metastatic disease (metOS). Overall, 200 evaluable patients were included (⩾3 metastatic sites: 22%; liver/lung metastases: 71.5%/36.9%; and Eastern Cooperative Oncology Group 0-1: 87% at nal-IRI+5FU/LV treatment initiation). Patients received a median of four cycles of nal-IRI+5FU/LV for 2.8 months (range 1.4-7.2), and the treatment was received in the second line by 80% of the patients. The median OS was 7.2 months (6- and 12-month OS rates: 58.1% and 28.9%, respectively), with 27.2% of the patients achieving OS ⩾12 months. The median metOS was 17.5 months, with 30.2% of the patients experiencing metOS ⩾ 24 months. The median progression-free survival (PFS) was 3.7 months (6- and 12-month PFS rate: 37.6% and 15.3%, respectively). The disease control rate was 35.5%. The median CA 19-9 levels decreased by at least 50% in 28.2% of the cases during treatment. Overall, 36% of the patients experienced at least one grade 3-4 adverse event during treatment, the most common being diarrhea (42.6%) and asthenia (30.9%). This real-world study shows that treatment with nal-IRI+5-FU/LV for advanced or metastatic PDAC affords benefit in terms of survival, radiological and CA 19-9 response, and PFS comparable to that reported in the clinical trial setting with a manageable safety profile.

Solid pseudopapillary epithelial neoplasm of the pancreas with liver metastasis

A girl in early adolescence presented with complaints of abdominal pain lasting for 4 months, along with a palpable lump in the epigastric region. A CT scan revealed a large solid-cystic mass lesion measuring 9.5×10.7×12.1 cm, involving the body and tail of the pancreas. Additionally, well-defined hypodense lesions in the liver, localised to segments VIII and IVa, were observed, with the aetiology being indeterminate. An endoscopic ultrasound-guided biopsy of the pancreatic mass confirmed a diagnosis of solid pseudopapillary epithelial neoplasm (SPEN). Ultrasonography (USG) of the liver suggested liver metastasis. Surgical excision of the pancreatic mass and complete excision of the liver metastases were performed with the aid of intraoperative USG. No other sites of metastasis were identified. Liver surface masses, measuring 4×3 cm and 5×3 cm in segments VIII and IVa, respectively, were excised, along with a 13×10×6 cm mass in the pancreatic body and tail. Microscopic examination revealed tumour cells arranged in pseudopapillary and solid patterns. The cells were round to oval with eosinophilic cytoplasm, and areas of necrosis, hyalinisation, cholesterol clefts and calcification were identified, consistent with SPEN. The liver lesions were confirmed as metastases of SPEN. All surgical margins were clear, and the three lymph nodes examined were free of tumour involvement. Immunohistochemistry was negative for synaptophysin and chromogranin, supporting the diagnosis of SPEN. Less than 2% of the tumour cells were positive for Ki-67. A final diagnosis of SPEN of the pancreas with liver metastases was established. The patient is currently on routine follow-up and remains disease-free 4 months postsurgery.

Predictive value of the nutritional risk index for postoperative complications in individuals with pancreatic cancer undergoing pancreaticoduodenectomy

PURPOSE

To explore the predictive value of the geriatric nutritional risk index (GNRI) for postoperative complications and their severity in older adults with pancreatic cancer undergoing pancreaticoduodenectomy (PD).

METHODS

This study conducted a retrospective analysis of 109 older adults with pancreatic cancer undergoing PD at the Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Quzhou Medical University, between May 2019 and May 2022. Statistical analysis of clinical data was performed to assess the predictive value of the GNRI for postoperative complications and their severity in older adults with pancreatic cancer undergoing PD.

RESULTS

Among the 109 individuals in this study, a total of 41 older adults undergoing PD experienced postoperative complications. The outcomes of the regression analysis showed that preoperative GNRI (OR = 0.184, 95 % CI = 0.023-0.457, P < 0.001), albumin levels (OR = 0.897, 95 % CI = 0.812-0.912, P < 0.001) and haemoglobin levels (OR = 1.231, 95 % CI = 1.043-1.451, P = 0.034) significantly influence the incidence of postoperative complications in older adults with pancreatic cancer. The prognostic value of the GNRI in predicting overall postoperative complications boasts a sensitivity of 83.2 %, specificity of 71.2 %, positive predictive value of 81.1 %, negative predictive value of 65.9 %, accuracy rate of 73.1 %, area under the curve (AUC) of 0.756 (P < 0.001) and a discriminative threshold of 97.0. Furthermore, the predictive efficacy of the GNRI in gauging the severity of postoperative complications demonstrates a sensitivity of 85.32 % and specificity of 79.54 %.

CONCLUSION

The GNRI can offer a faster, simpler and more effective method for evaluating nutritional risk in individuals with pancreatic tumours. Moreover, for older adults undergoing PD, it can serve as a convenient and efficient nutritional predictive indicator for postoperative complications and their severity.

Advances in Dendritic Systems and Dendronized Nanoparticles: Paradigm Shifts in Cancer Targeted Therapy and Diagnostics

Cancer has emerged as a global health crisis, claiming millions of lives annually. Dendrimers and dendronized nanoparticles, a novel class of nanoscale molecules with highly branched three-dimensional macromolecular structures, have gained significant attention in cancer treatment and diagnosis due to their unique properties. These dendritic macromolecules offer a precisely controlled branching architecture, enabling functionalization with specific targeting molecules to enhance the selective delivery of therapeutic agents to tumor cells while minimizing systemic toxicity. Through surface modifications and the incorporation of various components, dendrimers demonstrate remarkable adaptability as nanocarriers for biomedical imaging and theranostic applications. Surface functionalization strategies, including PEGylation and ligand attachment (e.g., folic acid, RGD peptide, lactobionic acid), further enhance biocompatibility and facilitate targeted tumor cell imaging. Leveraging their improved biocompatibility and target specificity, dendritic nanosystems offer heightened sensitivity and precision in cancer diagnostics. Notably, the encapsulation of metal nanoparticles within dendrimers, such as gold nanoparticles, has shown promise in enhancing tumor imaging capabilities. Ongoing advancements in nanotechnology are poised to increase the sophistication and complexity of dendrimer-based systems, highlighting their potential as nanocarriers in drug delivery platforms, with a growing number of clinical trials on the horizon. This review provides a comprehensive overview of the potential and future prospects of dendrimers and dendrimer-based nanocarriers in targeted cancer therapy and diagnosis, exploring their ability to enhance biocompatibility, reduce toxicity, and improve therapeutic outcomes across various malignancies.

Restoration of miR-200 expression suppresses proliferation and mobility of pancreatic cancer cell

A number of various human malignancies have been associated with abnormal microRNAs (miRNA) expression. There are evidence that miR-200 operates as both tumor suppressor and an onco-miR in a variety of tumors. In this study, we evaluated the effects of miR-200 on the proliferation and migration of pancreatic cancer cells, as well as the underlying molecular pathways. Clinical tissue samples were used to investigate the expression of miR-200 in pancreatic cancer and normal tissues, and the gene expression omnibus (GEO) database provided bioinformatics confirmation. Using the pCMV vector, miR-200 was transfected into PANC-1 pancreatic cancer cells. After transfection, expression of cancer-related genes (at the mRNA and protein levels) was evaluated. The miR-200-transfected pancreatic cancer cells' survival, invasion, migration, and apoptosis were also investigated. According to the bioinformatics analysis, decreased miR-200 expression was associated with a worse prognosis in pancreatic cancer patients. Moreover, low levels of miR-200 in pancreatic cancer tissues were approved. After transfection, pancreatic cancer cells exhibit a sustained increase in expression of miR-200, which inhibits cell viability, invasion, and migration. Additional investigations revealed that increasing expression of miR-200 increases the proportion of pancreatic cancer cells that endure apoptosis. Changes in the mRNA and protein expression of apoptosis- and metastasis-related genes may account for these findings. Our results indicate that miR-200 functions as a tumor suppressor in pancreatic cancer cells and that upregulating miR-200 levels may be a useful therapeutic strategy for pancreatic cancer patients to halt the progression of the illness.

Synthesis and Biological Evaluation of N-(1H-Indol-6-ylmethyl)benzenesulfonamide Analogs as Metabolic Inhibitors of Mitochondrial ATP Production in Pancreatic Cancer Cells

A library of 26 indolyl sulfonamides and 12 amide and ester analogs based upon the 6-indolyl framework has been synthesized in an effort to target pancreatic cancer. The cytotoxicity of the indolyl sulfonamide compounds has been determined using a traditional (48-h compound exposure) assay against 7 pancreatic cancer cell lines and 1 non-cancerous cell line. The potential role of the compounds as metabolic inhibitors of ATP production was evaluated using a rapid screening (2-h compound exposure) assay developed within our laboratories. The IC50 values of the active compounds were determined using the rapid assay and six compounds displayed an IC50 value <5 μM against one or more pancreatic cancer cell lines. The ester analogs also display activity as potential metabolic inhibitors of ATP production with four of the six compounds displaying an IC50 value <5 μM against one or more pancreatic cancer cell lines.

Longitudinal assessment of disparities in pancreatic cancer care: A retrospective analysis of the National Cancer Database

BACKGROUND

The existence of sociodemographic disparities in pancreatic cancer has been well-studied but how these disparities have changed over time is unclear. The purpose of this study was to longitudinally assess patient management in the context of sociodemographic factors to identify persisting disparities in pancreatic cancer care.

METHODS

Using the National Cancer Database, patients diagnosed with pancreatic ductal adenocarcinoma from 2010 to 2017 were identified. The primary outcomes were surgical resection and/or receipt of chemotherapy. Outcome measures included changes in associations between sociodemographic factors (i.e., sex, age, race, comorbidity index, SES, and insurance type) and treatment-related factors (i.e., clinical stage at diagnosis, surgical resection, and receipt of chemotherapy). For each year, associations were assessed via univariate and multivariate analyses.

RESULTS

Of 75,801 studied patients, the majority were female (51%), White (83%), and had government insurance (65%). Older age (range of OR 2010-2017 [range-OR]:0.19-0.29), Black race (range-OR: 0.61-0.78), lower SES (range-OR: 0.52-0.94), and uninsured status (range-OR: 0.46-0.71) were associated with lower odds of surgical resection (all p < 0.005), with minimal fluctuations over the study period. Older age (range-OR: 0.11-0.84), lower SES (range-OR: 0.41-0.63), and uninsured status (range-OR: 0.38-0.61) were associated with largely stable lower odds of receiving chemotherapy (all p < 0.005).

CONCLUSIONS

Throughout the study period, age, SES, and insurance type were associated with stable lower odds for both surgery and chemotherapy. Black patients exhibited stable lower odds of resection underscoring the continued importance of mitigating racial disparities in surgery. Investigation of mechanisms driving sociodemographic disparities are needed to promote equitable care.