Patients with normal-range CA19-9 levels represent a distinct subgroup of pancreatic cancer patients

Tumor Size Reduction and Serum Carbohydrate Antigen 19-9 Kinetics After Neoadjuvant FOLFIRINOX in Patients With Pancreatic Ductal Adenocarcinoma

BACKGROUND

Changes in tumor size and serum carbohydrate antigen 19-9 are commonly reported markers used to assess response to neoadjuvant therapy in pancreatic ductal adenocarcinoma. We evaluated the impact of the percentual tumor size reduction and carbohydrate antigen 19-9 kinetics on resectability and response to neoadjuvant FOLFIRINOX.

METHODS

This was an institutional analysis of patients with non-metastatic (upfront resectable, borderline resectable, and locally advanced) pancreatic ductal adenocarcinoma who underwent neoadjuvant FOLFIRINOX. Resectability, pathologic response, disease recurrence, and overall survival were evaluated.

RESULTS

Among 193 patients who completed FOLFIRINOX, 60% underwent resection, and 91% were R0. Pathologically, complete, and near-complete responses were achieved in 4% and 40% of patients, respectively. Tumor size reduction (odds ratio 1.02 per 1%, P = .024) and normalization of carbohydrate antigen 19-9 (odds ratio 2.61, P = .035) were associated with increased odds of resectability. Concerning pathologic response, tumor size reduction (odds ratio 1.03 per 1%, P = .018) was associated with increased odds of a complete and near-complete response. Lastly, in resected patients, a postoperative increase in carbohydrate antigen 19-9 after prior normalization after neoadjuvant therapy were at an increased risk of recurrence (hazard ratio 9.58, P < .001) and worse survival (hazard ratio 10.4, P < .001) compared to patients who maintained normalization.

CONCLUSION

In patients with non-metastatic pancreatic ductal adenocarcinoma who underwent neoadjuvant therapy, tumor size reduction was a significant predictor of resectability and pathologic response, including complete and near complete responses, whereas serum carbohydrate antigen 19-9 normalization predicted resectability, disease recurrence, and survival. Patients with a postoperative carbohydrate antigen 19-9 rise after prior normalization after administration of neoadjuvant therapy were at an increased risk of recurrence and worse overall survival.

Molecular pathology and protein markers for pancreatic cancer: relevance in staging, in adjuvant therapy, in determination of minimal residual disease, and follow-up

The diagnosis and monitoring of disease through the detection of circulating protein biomarkers is a growing field in the practice of oncology. The search for more effective protein biomarkers to aid in the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma (PDAC) remains a valuable area of study, given the aggressive and often occult nature of this malignancy. Liquid biopsies are attractive, as they offer a minimally invasive and cost-effective approach when compared to traditional biopsy methods and imaging modalities used for diagnosis and surveillance. Carbohydrate antigen (CA) 19-9 is currently the most commonly used serum protein biomarker for the diagnosis and monitoring of patients with PDAC, but due to its sensitivity and specificity, its utility remains limited. In this review, we examine how circulating protein biomarkers are used in the diagnosis, prognostication, and surveillance of PDAC. We also highlight protein biomarkers that are currently under investigation that have the potential to enhance our ability to detect early-stage malignancies, predict response to therapy, and monitor for recurrence, but these markers require larger prospective validation studies before they can be widely implemented. Continued efforts to identify and validate novel biomarkers will be crucial for improving the management and outcomes of patients with this challenging disease.

CA19-9 Response to First-Line Neoadjuvant FOLFIRINOX and Second-Line Gemcitabine/Nab-Paclitaxel for Patients with Operable Pancreatic Cancer

BACKGROUND

Response to second-line (2L) neoadjuvant therapy for operable pancreatic cancer (PC) is understudied. This study examined carbohydrate antigen 19-9 (CA19-9) response to first-line (1L) and 2L chemotherapy.

METHODS

The study identified patients with operable PC and elevated CA19-9 (≥ 35 U/mL with total bilirubin < 2 mg/dL) who received 1L FOLFIRINOX (FFX). The patients were restaged after 2 months and based on response, received additional FFX or gemcitabine/nab-paclitaxel (GnP) as part of total neoadjuvant therapy. Response was defined as a decrease in tumor size on computed tomography (CT) imaging or a decline in CA19-9 of 50% or more and preserved performance status.

RESULTS

For operable PC with an elevated CA19-9, 108 patients received 1L FFX. After 2 months of chemotherapy, the decision was made to continue FFX (FFX ≥ FFX) for 76 (70%) of the 108 patients and switch to GnP (FFX ≥ GnP)) for 32 (30%) of the patients. Of the 32 FFX ≥ GnP patients, 27 had no evidence of radiographic or biochemical (CA19-9) response to 1L FFX. Of these 27 patients, 26 (96%) demonstrated a response to 2L GnP. After 4 months of chemotherapy, 62 (82%) of the 76 FFX ≥ FFX patients had a CA19-9 response compared with 31 (97%) of the 32 FFX ≥ GnP patients (p = 0.04).

CONCLUSIONS

Lack of biochemical response to 2 months of 1L FFX may identify a subgroup of patients with a very high rate of response to 2L GnP, emphasizing the importance of assessing treatment response at 2-month intervals.

Low Carbohydrate Antigen 19-9 (CA 19-9) Levels in a Patient Highly Suspected of Having Caput Pancreas Tumor

Pancreatic cancer is the seventh leading cause of cancer-related mortality worldwide and the eleventh most common cause of cancer-related death in Indonesia. In pancreatic cancer, rapid and early diagnosis is crucial. Carbohydrate antigen 19-9 (CA 19-9), the most sensitive and specific tumor marker for pancreatic cancer, may help in diagnosing and determining prognosis; however, some populations do not express CA 19-9. Cases of low CA 19-9 may occur in populations with Lewis^⍺-β- genotype. These populations are not able to express Lewis antigen and CA 19-9; therefore, CA 19-9 investigation cannot be used for diagnostic and therapeutic measures. In patients highly suspicious of pancreatic cancer where CA 19-9 levels are low, alternative tumor markers such as CA 125 and carcinoembryonic antigen or a combination of various tumor markers can be used to increase sensitivity and specificity in diagnosing pancreatic cancer. A 70-year-old man presented with a complaint of worsening abdominal pain for the last two days. The patient had dark-yellow urine and pale stool. Abdominal ultrasonography and computed tomography scan showed a mass on the head of the pancreas, which was highly suspicious of pancreatic cancer.

Massive ovarian edema with paraovarian cyst torsion treated with laparoscopic surgery: A case report

Massive ovarian edema is a rare gynecological entity resembling a solid ovarian tumor due to the accumulation of edematous fluid within the ovarian stroma. This condition can be easily mistaken for a neoplasm, resulting in overtreatment by removal of the whole affected ovary. The present study describes the case of a 28-year-old woman who experienced massive ovarian edema with paraovarian cyst torsion treated with laparoscopic surgery. The patient experienced lower abdominal pain lasting for 1 week and visited a local clinic. The ultrasonographic examination revealed two loculated ovarian masses and the patient was then referred to the hospital. Transvaginal ultrasonographic examination revealed a 77.9-mm cystic lesion and a 57.7-mm solid lesion in the left adnexa. A magnetic resonance imaging examination revealed a 55-mm lesion with multiple peripheral ovarian follicles, which was isointense on T1-weighted images and hyperintense on T2-weighted images, and a 75-mm cystic lesion, without a solid component, which was hypointense on T1-weighted images and hyperintense on T2-weighted images in the left adnexa. There were no observed abnormalities of the right adnexa or uterus. Laparoscopic surgery was performed, based on a clinical suspicion of massive ovarian edema with paraovarian cyst torsion. Intraoperatively, a paraovarian cyst was identified in the left adnexa that was twisted 360˚. The size of the enlarged left ovary was reduced to almost normal following the detorsion of the left adnexa. The final diagnosis was that of a massive ovarian edema, which was treated by resecting the paraovarian cyst, while preserving the whole left ovary. The pathological examination of the resected paraovarian cyst revealed a serous cystadenoma. Therefore, the present study suggests that the presence of massive ovarian edema should be taken into consideration when encountering a complex solid ovarian mass with multiple peripheral ovarian follicles, particularly in cases with a history of recurrent abdominal pain.

Roles of CA19-9 in pancreatic cancer: Biomarker, predictor and promoter

Carbohydrate antigen 19-9 (CA19-9) is the best validated biomarker and an indicator of aberrant glycosylation in pancreatic cancer. CA19-9 functions as a biomarker, predictor, and promoter in pancreatic cancer. As a biomarker, the sensitivity is approximately 80%, and the major challenges involve false positives in conditions of inflammation and nonpancreatic cancers and false negatives in Lewis-negative Individuals. Lewis antigen status should be determined when using CA19-9 as a biomarker. CA19-9 has screening potential when combined with symptoms and/or risk factors. As a predictor, CA19-9 could be used to assess stage, prognosis, resectability, recurrence, and therapeutic efficacy. Normal baseline levels of CA19-9 are associated with long-term survival. As a promoter, CA19-9 could be used to evaluate the biology of pancreatic cancer. CA19-9 can accelerate pancreatic cancer progression by glycosylating proteins, binding to E-selectin, strengthening angiogenesis, and mediating the immunological response. CA19-9 is an attractive therapeutic target for cancer, and strategies include therapeutic antibodies and vaccines, CA19-9-guided nanoparticles, and inhibition of CA19-9 biosynthesis.

Recent Discoveries of Diagnostic, Prognostic and Predictive Biomarkers for Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease with a dismal prognosis that is frequently diagnosed at an advanced stage. Although less common than other malignant diseases, it currently ranks as the fourth most common cause of cancer-related death in the European Union with a five-year survival rate of below 9%. Surgical resection, followed by adjuvant chemotherapy, remains the only potentially curative treatment but only a minority of patients is diagnosed with locally resectable, non-metastatic disease. Patients with advanced disease are treated with chemotherapy but high rates of treatment resistance and unfavorable side-effect profiles of some of the used regimens remain major challenges. Biomarkers reflect pathophysiological or physiological processes linked to a disease and can be used as diagnostic, prognostic and predictive tools. Thus, accurate biomarkers can allow for better patient stratification and guide therapy choices. Currently, the only broadly used biomarker for PDAC, CA 19-9, has multiple limitations and the need for novel biomarkers is urgent. In this review, we highlight the current situation, recent discoveries and developments in the field of biomarkers of PDAC and their potential clinical applications.

Isolation of exosomes from whole blood by a new microfluidic device: proof of concept application in the diagnosis and monitoring of pancreatic cancer

Background

Exosomes are endocytic-extracellular vesicles with a diameter around 100 nm that play an essential role on the communication between cells. In fact, they have been proposed as candidates for the diagnosis and the monitoring of different pathologies (such as Parkinson, Alzheimer, diabetes, cardiac damage, infection diseases or cancer).

Results

In this study, magnetic nanoparticles (Fe₃O₄NPs) were successfully functionalized with an exosome-binding antibody (anti-CD9) to mediate the magnetic capture in a microdevice. This was carried out under flow in a 1.6 mm (outer diameter) microchannel whose wall was in contact with a set of NdFeB permanent magnets, giving a high magnetic field across the channel diameter that allowed exosome separation with a high yield. To show the usefulness of the method, the direct capture of exosomes from whole blood of patients with pancreatic cancer (PC) was performed, as a proof of concept. The captured exosomes were then subjected to analysis of CA19-9, a protein often used to monitor PC patients.

Conclusions

Here, we describe a new microfluidic device and the procedure for the isolation of exosomes from whole blood, without any need of previous isolation steps, thereby facilitating translation to the clinic. The results show that, for the cases analyzed, the evaluation of CA19-9 in exosomes was highly sensitive, compared to serum samples.

Preoperative CA19-9 levels predict disease-free survival and overall survival in pancreatic adenocarcinoma patients after resection

Background

This study investigates the association between the preoperative serum CA19-9 and the effects of adjuvant chemotherapy (CT), and its impact on survival in patients undergoing curative resection for pancreatic adenocarcinoma (PAC).

Methods

From January 01, 2015 to June 30, 2017, we retrospectively reviewed 421 PAC patients who underwent radical resection. The association between preoperative CA19-9 and disease-free survival (DFS), and overall survival (OS) was analyzed using Kaplan-Meier method and Cox proportional hazards model.

Results

A total of 354 patients eligible for this study were classified into three groups according to preoperative CA19-9: G1 (≤87 U/mL), G2 (87–322 U/mL) and G3 (>322 U/mL), in tertiles. Multivariable analysis showed preoperative CA19-9 and adjuvant CT were both independent predictors of DFS and OS. Subgroup analyses showed the multivariable-adjusted hazard ratios (HR) of DFS for patients treated with adjuvant CT were 0.54 (95% CI, 0.33–0.86), 0.63 (95% CI, 0.40–0.97) and 0.32 (95% CI, 0.21–0.49) in G1, G2 and G3, respectively. A trend of decreasing HR of recurrence risk was observed in the higher preoperative CA 19-9 group treated with CT.

Conclusions

High preoperative CA19-9 is an emerging biomarker that identifies a more aggressive PAC subgroup, which might benefit more from postoperative CT.