Introduction

By 2030, pancreatic ductal adenocarcinoma (PDAC) is predicted to become the second leading cause of cancer-related death. Due to its resistance to conventional therapies and heterogeneous mutational landscape, molecular stratification and the development of targeted therapeutic options are essential for improving survival of PDAC patients. Previous work from our group investigated loss-of-function mouse models for the ATM serine/threonine kinase causing homologous recombination deficiency (HRD) in PDAC. Specifically, ATM loss was reported to accelerate tumorigenesis, support metastatic burden, and coincide with oncogenic programs, including epithelial-mesenchymal transition (EMT). Interestingly, ATM-deficient tumors accumulated EZH2, suggesting that ATM status contributes to rewiring the epigenetic landscape of pancreatic tumors, subsequently supporting oncogenic features.

Aims & Methods

To investigate whether and how EZH2 impacts ATM-deficient PDAC pathogenesis, we generated conditional double ATM and EZH2 knockouts in Kras^G12D/+; Ptf1a^Cre/+ mice. In vitro approaches were conducted using primary cell lines isolated from murine endpoint tumors. Additionally, CRISPR/Cas9 strategy was implemented on ATM-deficient cell lines to decipher the ATM-EZH2 molecular axis.

Results

Double-null mice showed extended mouse survival and decreased undifferentiated malignant cell features. Strikingly, interrogation of publicly available human datasets (TCGA, PanCancer Atlas) revealed a significant extended progression-free survival of ATM^neg EZH2^neg PDAC patients compared to ATM^neg EZH2^pos PDAC cases. Furthermore, we identified the histone-methyltransferase EZH2 as a direct ATM substrate impacting the mesenchymal phenotype of ATM-depleted tumors. Interestingly, RNA-seq analysis of ATM-deficient pancreatic cancer cells revealed upregulation of a transcriptomic program associated with cell differentiation upon EZH2 depletion by CRISPR/Cas9 strategy. In line, EZH2 depletion restored differentiated tumor features ex vivo. Further in vitro investigations revealed that ATM status significantly impacts EZH2 activity via a post-translational regulation axis, leading to a fostered tumor supporting EZH2 activity during pancreatic carcinogenesis. Specifically, the ATM kinase activity results in EZH2 ubiquitination and degradation by promoting Cullin1 E3-ubiquitin ligase recruitment. Finally, we demonstrated that a combinatorial therapy involving a potent EZH2 inhibitor promotes genomic instability and exacerbates the cytotoxic effects of PARP interference in ATM-deficient HRD PDAC.

Conclusion

Overall, we show that ATM deficiency significantly impacts EZH2 epigenetic functions and highlight the molecular stratification according to ATM status prior to pharmacological EZH2 interference in PDAC therapies as a valuable approach to target ATM-deficient HRD tumors.

Introduction

Low Phospholipid-Associated Cholelithiasis (LPAC) syndrome is a rare disorder caused by mutations in the ABCB4 phospholipid transporter, found in biliary canaliculi. These mutations lead to a deficiency in phospholipids and the subsequent precipitation of cholesterol crystals within the small intrahepatic bile ducts. LPAC syndrome can be diagnosed following the emergence of biliary symptoms or through familial screening. The objective of our study is to characterize the epidemiological, clinical, and paraclinical data of patients monitored for LPAC syndrome in our institution and to assess therapeutic responses and outcomes.

Aims & Methods

We collected data from all patients diagnosed with LPAC syndrome at our institution. Diagnosis was established based on the presence of at least two of the following criteria: (1) age at onset of biliary symptoms ≤40 years; (2) presence of hyperechoic intrahepatic foci ("comet tails" or micro-spots); (3) recurrence of biliary symptoms post-cholecystectomy.

Results

10 patients were included. The Average age at diagnosis was 33,6 years, with symptoms typically beginning around age 30. The sex ratio was 2/8 (M/F).a family history of biliary lithiasis and cholecystectomy before the age of 40 were found in 70% of cases . None of the female patients had a history of pregnancy-related cholestasis. 70% of the patients had undergone cholecystectomy prior to their LPAC diagnosis, with recurrence of biliary symptoms before age 40 in all these patients. Clinical presentations upon admission included symptomatic gallstone disease in 5 cases, acute cholangitis due to main bile duct stones in 4 cases, and acute lithiasic pancreatitis in 1 case. Hepatobiliary ultrasound was performed in all patients, revealing comet tail signs in 50% of cases, hyperechoic intrahepatic spots in 20% of cases, and intrahepatic stones in 50% of cases. Biochemical tests showed hyperbilirubinemia in 30% of cases, elevated Gamma-GT and alkaline phosphatase in 80% of cases, and hepatocellular damage in 40% of cases. A mutation in the ABCB4 gene was found in 2-patients.8 patients benefit from An Ursodeoxycholic Acid (UDCA) dosage averaging 11mg/kg, experiencing significant clinical and biological improvements.

Conclusion

LPAC syndrome is a rare pathology in our series, predominantly affecting young, non-overweight women with personal and family history of early biliary stones occurrence . Treatment with Ursodeoxycholic Acid (UDCA) controlled symptoms in the majority of cases.

Clinical Case Summary

A 23-year-old female presented with epigastric pain, jaundice, and elevated liver enzymes. Imaging confirmed a mildly dilated common bile duct (CBD) with multiple filling defects. ERCP revealed a normal ampulla and a half-sphincterotomy was performed with three stones retrieved via balloon trawl. The procedure was uneventful, and she was discharged the same day.
Three days later, she re-presented with dizziness, melaena, and a haemoglobin drop from 127 g/L to 85 g/L. Gastroscopy demonstrated active oozing from the sphincterotomy site, managed successfully with placement of a fully covered metal stent (FCMS). She remained stable and was discharged with outpatient follow-up.
Three weeks later, she re-presented with partial stent blockage and underwent repeat ERCP for stent removal and duct clearance. Within 24 hours, she developed acute left shoulder tip and chest pain. Cardiac investigations were negative. CT imaging demonstrated a large haemoperitoneum and a bulging splenic haematoma without active bleeding, confirmed on a diagnostic laparoscopy .
She was managed conservatively in intensive care and follow up imaging confirmed complete resolution of the haematoma.
This case illustrates splenic haematoma as a rare yet significant complication of ERCP, with only a handful of cases described in the literature. Proposed mechanisms involve shear forces transmitted via the splenogastric ligament, typically in patients with known risk factors such as intra-abdominal adhesions, previous surgery, chronic pancreatitis, or cirrhosis. However, this case highlights its occurrence in a young, healthy patient with no risk factors, suggesting procedural technique or anatomical variation to be a potential trigger for injury. Symptoms such as shoulder or upper quadrant pain following ERCP should prompt consideration of splenic injury. Early recognition is key, as many cases resolve with conservative management but may carry a risk of life-threatening bleeding if unrecognised.

References

MRCP Image Demonstrating CBD Filling Defects
Coronal MRCP showing a mildly dilated common bile duct with multiple signal voids consistent with choledocholithiasis.
ERCP Image Showing Duct Clearance
Fluoroscopic image during ERCP showing balloon trawl and retrieval of multiple CBD stones following half-sphincterotomy.
Blood Results Demonstrating Haemoglobin Drop
Laboratory panel showing haemoglobin decline from 127 g/L to 85 g/L following gastrointestinal bleeding.
Gastroscopy Image Demonstrating Oozing and FCMS Placement
Endoscopic image showing active oozing at the sphincterotomy site and successful placement of a fully covered metal stent.
CT Image of Splenic Haematoma
Axial CT abdomen showing extensive haemoperitoneum and a bulging splenic haematoma in the left upper quadrant.
Follow-up CT Confirming Resolution
Interval CT imaging showing complete resolution of the previously identified splenic haematoma.

Introduction

Autoimmune pancreatitis (AIP) is a rare disease that can be diagnosed, according to the International Consensus Diagnostic Criteria (ICDC). Contrast-enhanced MRI with MRCP has now largely replaced other imaging techniques and ERCP for the assessment of ductal morphology in AIP. A number of MRI-criteria have been proposed, but due to the rarity of the disease the diagnostic imaging criteria have not yet been systematically validated. Aim of the study is to review and optimize the MR-morphologic diagnostic criteria for AIP in terms of specificity and sensitivity in the diagnosis and differential diagnosis of the pancreaticobiliary system.

Aims & Methods

We analyzed retrospectively hundred-fiftysix (n=156) high-quality MRIs: AIP n=56, chronic pancreatitis (CP) n=25, pancreatic cancer (PDAC) n=25, primary sclerosing cholangitis (PSC) n=25, Non-HPB subjects n=25. The MRI reading was conducted in a blinded fashion, using defined criteria by at least two radiological experts. The statistical analysis was performed by means of Proportion test, Chi-square test or Fisher’s exact test, One-way ANOVA and Cohen’s Kappa Statistic of the level of agreement.

Results

The level of agreement between two readers was moderate to substantial agreement (κ 0.23-0.85). Sausage-like enlargment (Reader 1: Sens 30.91%, Spec 98.98%, NPV 71.85%, accuracy 74.51%; Reader 2: Sens 26.79%, Spec 98.00%, NPV 70.50%, accuracy 72.43%), restricted diffusion (Reader 1: Sens 47.83%, Spec 89.29%, NPV 75.76%, accuracy 74.51%; Reader 2: Sens 56.86%, Spec 73.26%, NPV 74.12%, accuracy 72.30%), delayed enhancement in the venous phase (Reader 1: Sens 8.70%, Spec 83.15%, NPV 63.79%, accuracy 74.10%; Reader 2: Sens 32.61%, Spec 79.31%, NPV 69.00%, accuracy 75.19%), the icicle sign (Reader 1: Sens 10.91%, Spec 100%, NPV 66.67%, accuracy 65.30%; Reader 2: Sens 37.50%, Spec 91.00%, NPV 72.22%, accuracy 71.79%) and hyperenhancement of ductal wall (Reader 1: Sens 14.29%, Spec 96.67%, NPV 67.44%, accuracy 71.90%; Reader 2: Sens 8.51%, Spec 95.45%, NPV 66.14%, accuracy 74.10%) show a good accuracy distinguishing AIP from controls. Apparent diffusion coefficient (ADC) was significantly different between AIP, PDAC and CP (ANOVA). The area under the receiver operating characteristic curve (AUROC) was 0.85 (CI 0.73 – 0.97) and 0.68 (CI 0.51 – 0.85) respectively for CP and PDAC.

Conclusion

Our study showed that the Sausage-like enlargment, restricted diffusion, delayed enhancement in the venous phase, the icicle sign and hyperenhancement of ductal wall show a good accuracy distinguishing AIP from controls.

Introduction

MASLD patients is increasing worldwide and the clinical outcomes of different phenotypes had shown varied especially the occurrence of of liver related events (LRE) or major cardiovascular events (MACE)(Eslam M, et al. Hepato Inter 2020, 14:889–919) In addition, the prognostic factors for LRE. or MACE. are not well studied.

Aims & Methods

Aims: We aimed to study the rate of LRE. or MACE and the predictors for LRE. Or MACE. in MASLD patients with liver biopsy proven.
Methods: In a single-tertiary-center prospective cohort, we collected data of MASLD patients with biopsy-proven who were followed up of at least 1 years at King Chulalongkorn Memorial Hospital during 2005-2022. The primary outcome was the presence of LRE. or MACE. which included cirrhotic complications: acute decompensations; EV/GV bleeding, ascites, hepatic encephalopathy or HCC or acute complications requiring liver transplantation or death. MACE was defined by the occurrence of stroke or acute coronary disease or myocardial infarction. Related baseline characteristics, LSM, FIB-4, and liver biopsy were collected.

Results

Among 286 MASLD patients, the MASLD patients with mean age of 50.1 +/- 14.5 years old (range 19-80 yr.) Male and female were 44% and 56 % respectively. MASLD patients were categorized into 3 groups which were type 2 diabetes mellitus (T2DM) in 119 (41.6%), overweight or obese group in 149 (52.1%), and lean MASLD (BMI<23) in 18 (6.3%). Their baseline characteristics were shown in Table 1.
The average BMI was 41.3 kg/m² (range 19.1-88.7). Other metabolic abnormalities were hypertension in 165 (57.7%), and dyslipidemia in 157 (54.9%). There were 6 cirrhotic cases (2.1%) at diagnosis. Presence of advanced liver fibrosis (TE>12KPA) was found in 15 cases (5.2%). After a mean follow-up of 9.5 years (range 1-19); there were 11 cases (3.8%) developed coronary artery disease and 3 cases (1%) developed stroke. LRE. were present in 7 cases (2.4%) which included acute decompensation (3 cases; 1%), HCC (3 cases; 1%), and death (1 cases; 0.3%). The overall complications of LRE. or MACE. were present in 16 cases (5.6%). By using multivariate analysis, the predictors of LRE. or MACE. were in presence of hypertriglyceridemia (aOR 1.01 (1.00-1.01); p =0.002) and older age (aOR 1.06 (1.01-1.11); p =0.023).

Conclusion

The overall complication of LRE. or MACE. was not uncommon (5.6% of this cohort with a mean follow-up of 9.5 years). Older age and hypertriglyceridemia were predictors of LRE. or MACE. occurrence.

References

Eslam M, et al. Hepato Inter 2020, 14:889–919.