Introduction

Acute pancreatitis is the most common and serious complication of endoscopic retrograde cholangiopancreatography (ERCP). Risk factors for PEP are classified as patient-related and endoscopist- or technique- related factors. However, patient-related factors focused on the pancreatic volume and intrapancreatic fat content have not been investigated previously. In this study, we used 3- dimensional (3D) volumetry, and histogram investigated the potential association of pancreatic head volume and fat content with the incidence of PEP.

Aims & Methods

We retrospectively analyzed 157 patients who underwent ERCP for diagnostic or therapeutic purposes.Pancreatic volume was measured by using contrast-enhanced images obtained by continuous 5.0-mm, 320-, 64-row detector CT before ERCP. Computed tomography scan images of precontrast and venous phase were used for evaluation. Pancreatic volume was determined by using 3D analysis software. The pancreas was divided into the head and body/tail using the left edge of the superior mesenteric-portal vein confluence, and the volume of each part was calculated separately. Hounsfield unit histogram analysis (HUHA) was performed by using precontrast images. The percentage of HUHA ≤0 Hounsfield unit (HU) in pancreatic parenchyma represented the fat content. Multivariate analysis was performed to identify risk factors for PEP.

Results

PEP occurred in 35 patients (PEP group) and the incident rate was 22.3%. The mean volume of the whole pancreas was significantly larger in the PEP group (p<0.001). The mean volume of the pancreatic head was significantly larger in the PEP group (p<0.0001), but there were no significant differences in those of the pancreatic body and tail. Fat content of the pancreatic head was significantly higher in the PEP group (p<0.01), but there were no significant differences in fat content of the pancreatic body and tail. Multivariate analysis revealed that the pancreatic guidewire placement (hazard ratio [HR], 4.7; p < 0.01), the pancreatic head volume (HR, 7.1; p < 0.01), and fat content of the pancreatic head (HR, 5.1; p < 0.01) were independent risk factors for PEP.

Conclusion

The volume and fat content of the pancreatic head were independent predicting factors for PEP. Quantitative assessment of the pancreas using multislice CT imaging may contribute to the prediction of the onset of PEP.

Introduction

Besides stage, age and CA19-9 there is limited knowledge on “patient-related factors” associated with chemotherapy response for Pancreatic Ductal Adenocarcinoma (PDAC) patients. Smoking worsens chemotherapy response in other tumours and seems to promote tumor progression in PDAC preclinical models, but data in human PDAC are scanty.

Aims & Methods

PDAC patients were prospectively enrolled at diagnosis with exposome and clinical data registered, and tumors sampled for research purpose during Endoscopic Ultrasound (EUS). Patients were then followed-up to register chemotherapy treatment [whether Folfirinox (F), Abraxane-gemcitabine (AG) or a combination of cisplatin, abraxane, capecitabine and gemcitabine (PAXG)] and evaluate disease control rate (DCR) at 6-months (DCR-6), Progression-Free-Survival (PFS) and Overall-Survival (OS). We also explored transcriptomic signatures associated with smoking on a subset of EUS-acquired PDAC samples undergoing RNA-sequencing, with differential gene expression (DGE) analysis and pathways analysis performed. Furthermore, in vitro analyses with PDAC cell lines CAPAN-1 were treated with Folfirinox or gemcitabine with/without the nicotine compound 4-(Methylnitrosoamino)-1-(3-pyridinyl)-1-butanone to evaluate in vitro effects.

Results

326 patients treated with chemotherapy of interest were analyzed. Median age was 65, with 51.5% being males. Disease’s resectability at diagnosis was 10.4% resectable, 37.7% borderline-resectable, 26.9.% locally-advanced, 24.8% metastatic. AG was used in 42.3% of patients, PAXG in 25.7%, Folfirinox in 31.9%. DCR-6 was 57.9% in current smokers vs 70.4% in never-/ex-smokers (p=0.05). Current smoking was associated with a lack of DCR-6 at adjusted multivariable analysis (OR=1.99; 95%CI:1.1-3.5; p=0.01). At subgroup analysis, this was confirmed only for Folfirinox patients, with DCR-6 being 46.2% for current smokers vs 75.6% for non-current smokers(p=0.007). Current smokers had a significantly shorter PFS (5 vs 13 months; HR:1.79; 95%CI:1.13-3.21; p=0.01) and OS (24 vs 34; HR 1.93; 95%CI: 1-3.67; p=0.04) compared to non-smokers at adjusted multivariable analysis.
At transcriptomic analysis on a subset of 84 patients, current smokers were more prevalent in patients developing the more aggressive basal-like subtype (50% vs 15%; p=0.03), had lower expression of the classical marker GATA6 (3.27 vs 3.92; p=0.03) as also different activated pathways such as activated MAPK signalling, Axon guidance, Hypoxia and epithelial-mesenchymal-transition signalling among the others.
At in vitro experiments, for cell survival analysis, CAPAN-1 PDAC cells showed a significant reduced response to Folfirinox treatment when treated in combination with nicotin compounds, which was not observed for gemcitabine alone or in combination.

Conclusion

Collectively, our results consistently point towards a deleterious effect of smoking on response to Folfirinox regimen. Clinical data show that current smoking is a predictive factor for lower DCR-6, shorter PFS and OS; transcriptomic analyses show different gene expressions between smokers and non-smokers, with a transition toward reduced expression of classical phenotype and activation of inflammatory and pro-mesenchimal pathways. In vitro experiments support the negative effect of smoking on the response to Folfirinox. Smoking should be considered as a covariate to be investigated when choosing chemotherapy regimens in patients with PDAC, and patients should be discouraged to continue smoking.

Introduction

Surgery is the traditional treatment of traumatic pseudocysts, but with considerable morbidity and mortality. A minimally invasive management of these collections has been increasingly used. Objective: To analyze the outcome following endoscopic treatment of pancreatic pseudocysts caused by abdominal trauma and to study the integrity of the main pancreatic duct (MPD).

Aims & Methods

Patients with pancreatic fluid collections due to abdominal trauma and who underwent endoscopic therapy were studied. All were symptomatic with a persistent collection for more than 6 weeks. Opacification of the MPD allowed characterization according to Takishima Classification (I, II and III) which guided therapy. Endoscopic drainage was divided into: transpapillary (Takishima II and III without bulging), transmural (type I) or combined (type II or III with bulging).

Results

From January 2020 January 2025 51 patients (36 men, mean age of 35.2 years, range - 13.9 years) were identified who developed pancreatic collections after blunt or penetrating abdominal trauma., The average size of the collection was 14.3  5.2 cm. ERP was obtained in 47/51 (90%). Drainage was transmural in 13 (all type I), combined in 24 (type IIa (4), IIb (7) and III (13) and transpapillary in 10 (all type III without bulging). The remaining 4 were drained transmurally. The success of endoscopic treatment was 94% with a recurrence rate of 8%. Stent occlusion occurred in 6%. There were 9 complications, but no procedural-related deaths. Patients with penetrating trauma had more recurrences than those with blunt trauma (p = 0.01). Penetrating trauma conferred a relative risk for development of infection 0.25; (95% 0.07 - 0.88; p = 0.045).

Conclusion

Endoscopic treatment of pancreatic fluid collections that develop after pancreatic trauma is safe and effective and can be considered a first-choice alternative to surgical and/or percutaneous treatment. Pancreatography is useful in determining the best endoscopic approach.

Disclosure

​NO CONFLICT OF INTEREST

Introduction

Advanced pancreatic cancer (PC) continues to be associated with a poor prognosis, where the occurrence of pancreatic exocrine insufficiency frequently leads to malnutrition and deteriorating nutritional status. Traditional laboratory markers, such as lymphocyte count and serum albumin levels, are commonly employed to assess nutritional status; however, integrated nutritional indices like the Prognostic Nutritional Index (PNI) have emerged as significant prognostic indicators in various malignancies. Notably, a low PNI has been identified as a predictor of postoperative complications following the Whipple procedure in pancreatic cancer patients and significantly correlates with overall survival among individuals with advanced PC. While the Nutritional Risk Index (NRI) has been evaluated in other cancer types, its application in advanced pancreatic cancer remains underexplored.

Aims & Methods

This study aims to evaluate the prognostic value of PNI and NRI in patients with advanced pancreatic cancer.
A retrospective analysis was conducted on electronic medical records of 158 patients diagnosed with advanced pancreatic cancer who were initiating chemotherapy. PNI and NRI were computed using standard parameters, and baseline levels were compared between patients with proximal and distal tumor locations. Among 125 patients commencing FOLFIRINOX chemotherapy, baseline PNI and NRI were analyzed in relation to outcomes at the 12-week follow-up, categorizing patients into groups based on mortality (n=21), disease progression (n=51), and disease stabilization (n=53). Statistical differences between high and low nutritional index groups were assessed using the log-rank test, and both univariate and multivariable analyses were conducted to identify risk factors associated with mortality within three months post-chemotherapy initiation.

Results

The analysis revealed that patients with tumors located in the pancreatic head exhibited significantly lower PNI (40.11 vs. 42.01, p=0.002) and NRI (104.30 vs. 110.06, p=0.004) compared to those with distal tumors. In the FOLFIRINOX subgroup, a significant decrease in PNI (39.51 vs. 41.51 and 41.82, p=0.044) was observed among those who deceased by the first follow-up, while NRI did not show similar significance. Univariate analysis identified a PNI cut-off of 40.25 (HR 2.514; 95% CI: 1.025-6.169, p=0.044) and an NRI threshold below 105.6 (HR 2.75; 95% CI: 1.039-7.277, p=0.042) as independent prognostic factors. However, in multivariable analysis, the presence of two or more metastatic sites beyond the primary tumor was the only factor significantly related to mortality risk by the follow-up (HR 7.21; 95% CI: 2.02-25.738, p=0.002).

Conclusion

Our findings underscore the relationship between PNI and NRI with nutritional status, asserting their utility as predictive tools for survival in patients with advanced pancreatic cancer initiating chemotherapy.

Introduction

Pancreatic ductal adenocarcinoma (PDAC) is characterized by very poor 5-year survival of only 8-12% due to a late diagnosis and a highly desmoplastic environment, limiting therapeutic options [1]. Current treatment options for PDAC patients are mostly restricted to chemotherapy followed by surgery or palliative care [2]. These treatments have limited efficacy and are accompanied by severe side effects, strongly affecting the quality of life of these patients. Recent advances in nanotechnology have optimized targeted drug delivery in tumors with high stromal density by improving intratumoral drug retention, enhancing local drug concentrations, and thereby boosting treatment efficacy and potentially reducing side effects [3-6]. This would enable an efficient endoscopic delivery of a local depot of concentrated chemotherapy.

Aims & Methods

Here we investigated the preclinical efficacy and tolerability of a novel thermosensitive hydrogel, ChemoGell (CG), loaded with gemcitabine in preclinical human and mouse PDAC models. To evaluate the efficacy of CG, in vitro experiments using patient-derived organoids and PDAC explants were performed. This was further explored in vivo by using a human patient-derived xenograft (PDX) and the syngeneic KPC3 mouse model. Two intratumoral injections with saline, CG and gemcitabine-loaded CG (CG-Gem) were performed in both PDX and KPC3 models and compared to systemic gemcitabine administration. To evaluate potential off-target effect, other vital organs and haematological toxicity related to gemcitabine were evaluated.

Results

Both CG and CG-Gem were safe and well-tolerated in vivo. Upon CG-Gem, both in vitro and in vivo models showed strongly increased cytotoxicity compared to unloaded CG and control groups. Remarkably, we were able to inject a much higher dose (~125x) intratumorally compared to systemic gemcitabine dose. By increasing gemcitabine cytotoxicity, locally treated mice showed a significant improved survival. In a human PDX model, complete survival of mice (100%) was observed compared to control groups in which all reached humane endpoint. Given the enhanced treatment efficacy, we are currently investigating the role of the tumor microenvironment, particularly looking at stromal and immune cell dynamics. Interestingly, preliminary data shows that CG-Gem depots are surrounded and/or infiltrated with fibroblasts, macrophages, and other immune cells. To reveal the mechanism behind, further experiments looking at the different cell subtypes are undergoing.

Conclusion

Our findings represent a potential strategy for integrating localized (endoscopic) and systemic treatment modalities, addressing critical challenges in hard-to-treat PDAC management, and improving patient prognosis through more effective and targeted therapeutic strategies.

References

1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024; 74(3): 229-263.
2. Conroy T, Pfeiffer P, Vilgrain V, Lamarca A, Seufferlein T, O’Reilly EM, et al. Pancreatic cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Annals of Oncology. 2023/11/01;34(11).
3. Ramazani F, Nostrum CFv, Storm G, Kiessling F, Lammers T, Hennink WE, et al. Locoregional cancer therapy using polymer-based drug depots. Drug Discovery Today. 2016/04/01;21(4).
4. Luo W, Zhang T. The new era of pancreatic cancer treatment: Application of nanotechnology breaking through bottlenecks. Cancer Letters. 2024/07/10;594.
5. Jiang Z, Fu Y, Shen H. Development of Intratumoral Drug Delivery Based Strategies for Antitumor Therapy. Drug Design, Development and Therapy. 2024 Dec 31:2189-202.
6. Rossi SM, Ryan BK, Kelly HM. Evaluation of the activity of a chemo-ablative, thermoresponsive hydrogel in a murine xenograft model of lung cancer. British Journal of Cancer 2020 123:3. 2020-05-27;123(3).

Disclosure

Helena Kelly is a named inventor on granted patent US20230126053 ‘Thermo-responsive hydrogel for intratumoral administration as a treatment in solid tumor cancers’ and is also co-founder and CSO of OncoLize LLC. Mike de Leeuw is co-founder and CEO of OncoLize LLC. Tushar Tomar is drug development director of OncoLize LLC. This work was supported by a research grant from OncoLize to LH.

Introduction

Intraductal papillary mucinous neoplasms (IPMN) are the most common type of cystic pancreatic lesions, and are established precancerous lesions. Among them, side-branch IPMN (SB-IPMN) are the most prevalent, and exhibit a low risk of malignant transformation. The Kyoto guidelines, last revised in 2024, define criteria for management and surveillance of IPMN, based on high-risk stigmata and worrisome features. Surveillance intervals for non-resected IPMN, either by MRI/MRCP or EUS, are based on the size of the largest cyst or cyst progression. However, there is considerable variability in clinical practice across physicians and institutions.

Aims & Methods

This study aimed to use an AIgo-based decision-support tool to compare real-life clinical practice at Tel Aviv Sourasky Medical Center with guideline-based management according to the Kyoto criteria, and to evaluate its cost-effectiveness.
​SB-IPMN cases were collected retrospectively. A Sher-AI¹ Algo-based tool based on the Kyoto guidelines², was used as a decision-supporting tool to determine the updated recommended management strategy. Initial MRI/MRCP findings, clinical presentation, and laboratory data were integrated into the platform for each case, and the recommendations were compared with the primary management strategy selected at the time of presentation. Long-term radiological and clinical follow-up data were collected for eventual development of pancreatic ductal adenocarcinoma (PDAC).

Results

Two hundred patients (66% male, 34% female) with a mean age of 66.8±10.6 years were followed up radiologically and clinically for median durations of 55.3±29.5 and 63.5±28.4 months, respectively. Average leading cyst size at presentation was 11±6.9 mm. Following index MRI/MRCP, only 37 patients (18.5%) were managed in accordance with the Kyoto guidelines. The rest were mostly subjected to more rigorous follow-up (n=115, 57.5%), while 48 patients (24%) underwent less intensive monitoring. Most of the patients in the latter group were older (mean age 71.9±9.5 years) and had more comorbidities. Over-rigorous follow-up resulted in an average excess of 0.33 MRI/MRCPS per patient-year. During follow-up, PDAC developed in only one patient from the conservatively managed group, with the latter occurring after five years of cyst stability.

Conclusion

Fewer than 20% of patients with SB-IPMN were managed in alignment with the Kyoto guidelines. Most patients underwent more intensive surveillance, which did not appear to reduce PDAC incidence, inflicting stress on patients and unnecessary use of public health resources. This raises questions about the cost-effectiveness of such an approach and highlights the potential value of Algo-based decision-support tools in standardizing clinical practice.

References

1. sher-ai.com
2. International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas
Takao Ohtsuka et al., Pancreatology, 2024.