Introduction

Our understanding of chronic pancreatitis (CP) etiology remains limited. Despite growing knowledge, it is believed that the known contributing factors to CP may still be underestimated. While most CP have a toxic etiology (TCP), a considerable proportion of CP is classified as idiopathic (ICP). It is plausible to speculate that some ICP cases may have a genetic basis that has not been tested or identified. Distinguishing between TCP, genetic CP (CGP) and ICP based solely on clinical features remains challenging and still the available evidence is still insufficient.

Aims & Methods

This study aimed at analyzing a prospective CP dataset to compare clinical features at diagnosis across etiologies, using principal component analysis (PCA)-based clustering to define distinct groups, with a focus on the idiopathic subtype.
We performed a retrospective analysis of a prospectively maintained database of CP patients seen in a single tertiary center (January 2019 until March 2025). We evaluated the differences in demographics, clinical characteristics, risk factors, and imaging features among patients categorized into six groups based on the TIGAR-O classification with a classical statistical analysis with Bonferroni correction for multiplicity. A PCA was performed to explore the data. To improve factor interpretability, an orthogonal rotation was applied, and the rotated factor pattern was obtained.

Results

A total of 282 patients with CP were included. Median age at diagnosis was 54 (IQR,42-64) years and 66.3% were female. TCP represented 47.2% of cases, ICP 18.8% (with early onset (<35 years) representing 15.1% of ICP cases), GCP 16.7%, autoimmune 5.7%, recurrent 6.4% and obstructive 5.3%. When comparing all etiology groups, patients with TCP were more frequently male (82%), heavy smokers (> 20 packs/year) (84.6%) and alcohol consumers (88%) than other etiologies and associated more with COPD with a statistically significant difference (p<0.0001). The family history of CP was more frequent in GCP (25.5%) compared to others. Incidental diagnosis and painless presentation were more frequent in ICP (49.1% and 62.3% respectively). Calcifications and a definite diagnosis were more frequent in the TCP and less frequent in the AIP compared to other groups (p<0.0001). After PCA analysis, five clusters were identified based on diagnostic characteristics. Focusing on the most common etiologies (TCP, ICP, GCP), a first cluster was linked with TCP and characterized by males aged 40-59, heavy smokers and drinkers, with cardiovascular and pulmonary comorbidities and jaundice among presenting signs. Another cluster was linked to late-onset ICP (>45 years), painless at diagnosis with no other symptoms or only pancreatic exocrine insufficiency (PEI). Finally, early-onset ICP (<45 years) clustered with younger patients and GCP, typically meeting minor Rosemont criteria EUS findings and lower severity according to the MANNHEIM classification.

Conclusion

Idiopathic CP behaves differently according to age of diagnosis. At the time of diagnosis, early-onset ICP clusters with genetic forms (probably due to still unknown genetic factors influencing the CP development) while late-onset ICP constitute a distinct, usually painless subgroup of patients that clusters separately from the most common TCP.

Introduction

Intraductal papillary mucinous neoplasms (IPMNs) are increasingly diagnosed due to rising life expectancy and widespread use of abdominal imaging. Despite the publication of several guidelines to drive the management of IPMNs, a significant proportion of patients still undergo surgical resection for lesions ultimately classified as low-grade dysplasia (LGD), while others managed conservatively may progress to invasive carcinoma (IC). Pancreatic surgery could have high perioperative morbidity and mortality, highlighting the need for improved preoperative stratification. Among the available tools, endoscopic ultrasound with fine-needle aspiration (EUS-FNA) represents a key diagnostic method for assessing the risk of malignancy in IPMN.

Aims & Methods

This study aimed to evaluate the diagnostic accuracy of EUS-FNA in predicting histological dysplasia grade in surgically resected IPMNs. We retrospectively included patients who underwent both EUS-FNA and surgery at San Raffaele Hospital. Surgical diagnoses were classified into LGD, high-grade dysplasia (HGD), or IC, while cytological diagnoses also included “Negative for malignant cells” (NMC). We defined STRICT criteria (SC) as exact cytological-histological concordance (considering NMC as non-concordant), while LARGE (LC) considered NMC equal to LGD. Concordance was assessed using Fleiss’ kappa (κ) and linear weighted κ. Uni- and multivariate logistic regressions were conducted to identify predictors of concordance. Diagnostic performance of EUS cytology in distinguishing LGD and HGD/IC was evaluated through sensitivity, specificity, PPV, NPV, and accuracy. A Random Forest classifier was developed to predict concordance before FNA utilizing three variables: patient age, main pancreatic duct (MPD) dilation, and IPMN subtype. The model was trained on the entire dataset with 100 decision trees and a fixed random state to ensure reproducibility.

Results

Ninety-four patients were included (36% branch duct-, 41% main duct-, 23% mixed type-IPMN). The concordance using SC and LC criteria was moderate (Fleiss’ κ respectively 0.41 and 0.36). The weighted κ was 0.55. When stratified, concordance was κ=0.52 for LGD 0.437 for IC, and 0.109 for HGD. Univariate analysis identified diffuse MPD dilation (p=0.0016 SC, p=0.0002 LC), cyst wall enhancement (p=0.0955 SC), grade of dysplasia (p=0.0809 SC, <0.00001 LC), and IPMN subtype (p=0.0433 LC) as significant. Multivariate analysis confirmed cyst wall enhancement (OR=0.128, p=0.0334) and grade of dysplasia (OR=0.239, p=0.0094) as independent predictors using SC, while the latter one alone (OR=0.354, p=0.0027) when LC were considered. Diagnostic performance of EUS cytology in distinguishing LGD vs HGD/IC showed sensitivity 75%, specificity 89.2%, PPV 93.1%, NPV 64.7%, accuracy 79.8%. The Random Forest model demonstrated high predictive performance, achieving an accuracy of 94.7% and an area under the receiver operating characteristic curve (AUC) of 0.99. It correctly classified 89 out of 94 cases, with 4 false negatives and 1 false positive. Precision and recall were 97.9% and 92.3% for the concordant class.

Conclusion

EUS-FNA shows moderate concordance with final pathology, especially for LGD and IC, while HGD remains challenging. Pre-FNA imaging features are predictive of concordance. A machine learning model demonstrated high accuracy using preprocedural variables only, supporting its clinical value in biopsy guidance. Strengths include the high-volume pancreatic center setting. Limitations include selection bias from a surgical cohort, which is inherent to histology-based studies.

Introduction

The prognosis for patients with advanced pancreatic cancer (PC) remains exceptionally bleak, with a 5-year survival rate estimated at just 4%. This condition is frequently accompanied by pancreatic exocrine insufficiency, which contributes to malnutrition and a significant decline in nutritional status. While conventional laboratory markers such as serum albumin and lymphocyte counts are commonly employed to assess nutritional health, integrative nutritional indices have emerged as meaningful prognostic indicators across various malignancies. Specifically, the hemoglobin, albumin, lymphocytes, and platelets index (HALP) has shown promise in predicting overall survival in cancer cohorts. However, other indices, such as the prognostic immune nutritional index (PINI), have yet to be examined in the context of pancreatic cancer.

Aims & Methods

Aim: This study aims to assess the prognostic value of the HALP and PINI in patients with advanced pancreatic cancer.
A retrospective analysis was conducted utilizing electronic medical records from 158 patients diagnosed with advanced pancreatic cancer who had begun treatment. Conventional parameters were employed to calculate HALP and PINI levels, which were then compared between patients with proximal and distal tumor locations prior to the initiation of chemotherapy. Within a subgroup of 125 patients receiving FOLFIRINOX, baseline HALP and PINI values were analyzed in relation to outcomes categorized into three groups at the 12-week follow-up: mortality (n=21), disease progression (n=51), and disease stabilization (n=53). The log-rank test was utilized to evaluate statistical differences between high and low nutritional index groups. Univariate and multivariable analyses were performed to identify risk factors for mortality within three months of chemotherapy initiation.

Results

Among the 158 patients included in the analysis, those with tumors located in the pancreatic head exhibited significantly lower HALP (32.34 vs. 43.05, p=0.021) and PINI (3.23 vs. 3.48, p=0.003) compared to patients with distal tumors. In the FOLFIRINOX subgroup, HALP levels were significantly lower in individuals who deceased by the first follow-up (25.76 vs. 36.115 and 41.8, p=0.041), while PINI did not demonstrate a similar relationship. Univariate analysis revealed that a HALP value below 26.85 (HR 2.548; 95% CI: 1.021-6.357, p=0.045) and a PINI below 3.26 (HR 3.49; 95% CI: 1.31-9.299, p=0.012) were independent predictors of mortality. In multivariate analysis, the presence of two or more metastatic sites beyond the primary tumor was the sole factor associated with a heightened risk of death at the first follow-up (HR 7.21; 95% CI: 2.02-25.738, p=0.002).

Conclusion

Our findings support the notion that HALP and PINI are closely related to nutritional status and serve as independent risk factors for mortality within three months of initiating chemotherapy in patients with advanced pancreatic cancer.

Introduction

Pancreatic ductal adenocarcinoma carries a dismal prognosis because it is often diagnosed at an advanced stage, with five-year survival rates below 10%. High-grade pancreatic intraepithelial neoplasia (HG-PanIN) represents a stage 0 lesion confined to the ductal epithelium and marks an essential precursor to invasive cancer. Early detection of HG-PanIN makes curative treatment possible. Magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive means of visualizing both ductal and parenchymal pancreatic changes, but its ability to distinguish HG-PanIN from low-grade PanIN (LG-PanIN) has not been fully characterized.

Aims & Methods

This study aimed to identify specific MRCP imaging features that differentiate HG-PanIN from LG-PanIN. To this end, we conducted a multicenter retrospective analysis of 57 surgically confirmed PanIN cases—41 HG-PanIN and 16 LG-PanIN—collected between January 2010 and October 2023 at four Japanese tertiary centers. Two experienced abdominal radiologists independently reviewed MRCP images for main pancreatic duct (MPD) stenosis morphology, the morphology of the transition zone between stenosis and dilation, upstream MPD dilation, perilesional branch pancreatic duct (BPD) dilation, perilesional cysts, and focal pancreatic parenchymal atrophy (PPA). Disagreements were resolved by consensus. Receiver operating characteristic analysis established optimal thresholds for graded variables, which were then converted into binary measures. We assessed interobserver agreement using Cohen’s weighted κ statistics and calculated sensitivity, specificity, and accuracy for each imaging feature.

Results

Perilesional BPD dilation demonstrated substantial agreement (κ = 0.64) and yielded sensitivity of 87.8 %, specificity of 62.5 %, and accuracy of 80.7 %, representing the highest diagnostic performance. MPD stenosis morphology also showed substantial agreement (κ = 0.67) with sensitivity of 48.8 %, specificity of 75.0 %, and accuracy of 56.1 %. Upstream MPD dilation exhibited substantial agreement (κ = 0.76) but produced sensitivity of 65.9 % and specificity of 31.3 %. Focal PPA achieved high sensitivity (85.4 %) despite only fair agreement (κ = 0.23). When BPD dilation was combined with PPA, specificity increased to 93.8 % and overall accuracy reached 77.2 %.

Conclusion

These results highlight perilesional BPD dilation on MRCP as a key noninvasive indicator of HG-PanIN. Integrating ductal and parenchymal imaging markers may refine early diagnostic strategies and guide timely surgical intervention in high-risk patients. Prospective validation in larger cohorts and the development of standardized MRCP protocols are warranted to enhance surveillance of pancreatic precursor lesions and improve patient outcomes.

Introduction

​Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related deaths, with a five-year survival rate under 10% [1]. Its lethality stems from its aggressive progression and strong chemotherapy resistance, both closely linked to epithelial-mesenchymal transition (EMT). EMT enables epithelial cells to gain migratory mesenchymal traits and is regulated by transcription factors such as SNAIL, SLUG, ZEB1/2, and TWIST [2]. Among these, SNAIL plays a major role in metastasis [3], while ZEB1 is associated with poor prognosis [4]. EMT is tightly modulated by networks including ELAVL1, which encodes the RNA-binding protein HuR. HuR stabilizes mRNAs by binding AU-rich elements (AREs) in their 3′ untranslated regions (3′UTRs), promoting their expression [5].

Aims & Methods

This study aimed to identify post-transcriptional interactions between ELAVL1 and EMT-related genes and assess their prognostic value in PDAC. mRNA was extracted from cancerous and adjacent normal tissues (n=65), converted to cDNA, and analyzed by RT-PCR. BxPC-3, MiaPaCa-2, and Su.86.86 cell lines were cultured under standard conditions. Immunoprecipitation was performed on 1–2×10⁷ cells using a mouse monoclonal anti-HuR antibody, with IgG as control. qRT-PCR assessed mRNA enrichment. Binding sites were annotated using CISBP-RNA, considering only RNAdirect-confirmed 3′UTR motifs. Target 3′UTR sequences were retrieved from GENCODE V47. Statistical analysis was performed using GraphPad Prism, applying the Wilcoxon signed-rank test, Kruskal-Wallis test with Dunn’s correction, and Spearman correlation. Data were presented as median ± interquartile range, with p<0.05 considered significant.

Results

​Expression levels of EMT-related genes and ELAVL1 varied according to survival outcomes. In short-term survivors (1–12 months), SNAIL and SLUG were significantly upregulated (2.19- and 1.92-fold), while ZEB2 was downregulated (0.65-fold). Medium-term survivors (13–35 months) showed reduced ZEB1 (0.53), SNAIL (0.30), SLUG (0.35), and TWIST (0.68). Long-term survivors (36–125 months) had the lowest levels of ZEB1 (0.24), ZEB2 (0.50), SLUG (0.24), TWIST (0.35), and ELAVL1 (0.72). ELAVL1 showed strong positive correlations with ZEB1, SNAIL, and SLUG (r = 0.74–0.76), whereas overall survival was weakly negatively correlated with the expression of ZEB1, SNAIL, SLUG, and TWIST (r = -0.25 to -0.32). Although ZEB1, SNAIL, and TWIST did not show significant survival differences individually, low SLUG predicted better early survival (36 vs. 15 months, p = 0.0278). ELAVL1 expression was stratified as high and low. High ELAVL1 corresponded to a 71.65-fold increase in ZEB1, whereas high ZEB1 reduced ELAVL1 by 96.1%. High ELAVL1 also led to a 312.35-fold increase in SNAIL, while low ELAVL1 still supported elevated SNAIL expression (8.45-fold). High SNAIL expression reduced ELAVL1 by 90%, though simultaneous high expression of both resulted in a 3.71-fold ELAVL1 increase. High SLUG reduced ELAVL1 by 93%, whereas low SLUG led to a 198.11-fold increase. Binding site analysis revealed ELAVL1 targets within 3′UTRs: 34 in ZEB1, 1 in SNAIL, and 9 in SLUG.

Conclusion

ELAVL1 (HuR) likely plays a central role in regulating EMT in PDAC through stabilization of key transcription factor mRNAs. High levels of ELAVL1, SNAIL, SLUG, and ZEB1 were associated with worse outcomes, particularly in short-term survivors. Conversely, low expression of SLUG was linked to improved survival. The strong correlations and validated binding sites suggest ELAVL1 as a promising prognostic biomarker and potential therapeutic target in PDAC.

References

1. Nakaoka K, Ohno E, Kawabe N, Kuzuya T, Funasaka K, Nakagawa Y, et al. Current status of the diagnosis of early-stage pancreatic ductal adenocarcinoma. Diagnostics (Basel). 2023;13(2).
2. Kaşıkcı E, Aydemir E, Bayrak ÖF, Şahin F. Inhibition of migration, invasion and drug resistance of pancreatic adenocarcinoma cells - role of Snail, Slug and Twist and small molecule inhibitors. Onco Targets Ther. 2020;13:5763-77.
3. Tang X, Sui X, Weng L, Liu Y. SNAIL1: Linking tumor metastasis to immune evasion. Front Immunol. 2021;12:724200.
4. Liu M, Zhang Y, Yang J, Zhan H, Zhou Z, Jiang Y, et al. Zinc-dependent regulation of ZEB1 and YAP1 coactivation promotes epithelial-mesenchymal transition plasticity and metastasis in pancreatic cancer. Gastroenterology. 2021;160(5):1771-1783.e1.
5. Majumder M, Chakraborty P, Mohan S, Mehrotra S, Palanisamy V. HuR as a molecular target for cancer therapeutics and immune-related disorders. Adv Drug Deliv Rev. 2022;188(114442):114442.

Introduction

Intraductal papillary mucinous neoplasms (IPMNs) are a common type of mucinous pancreatic cystic lesions and represent a precursor of pancreatic cancer. The WHO classification distinguishes three grades of IPMN — low-grade/high-grade intraepithelial neoplasia and IPMN-associated invasive carcinoma—with distinct clinical management. The correct estimation of IPMN biology in clinical practice is often challenging and relies particularly on the assessment of lesion morphology, as histological confirmation is seldom possible. Therefore, improved biomarkers are needed to guide personalized management of IPMN patients.
In our preliminary analysis of public RNA-seq datasets (healthy controls n=7; LGD IPMN n=6; HGD IPMN n=6; invasive IPMN n=3), DLGAP5 expression increased significantly with IPMN grade (ANOVA p=5.48×10⁻⁶). DLGAP5 is a microtubule-associated protein essential for mitosis and vesicular trafficking—processes implicated in pancreatic cancer progression.

Aims & Methods

We aimed to assess the utility of DLGAP5 as a marker of IPMN progression as well as identify potential surrogate cystic-fluid biomarkers. Because of the intracellular localization of DLGAP5, we did not expect it to be present in the cyst fluid. However, given the role of microtubules in protein secretion, we hypothesized that DLGAP5 regulates the secretion of distinct set of proteins, which are highly correlated with its expression.
Protein expression of DLGAP5 was evaluated by immunohistochemistry (Santa Cruz Biotechnology, sc-377044) on retrospective cohort of patients who underwent pancreatic resection for IPMN at our institution (n=45). Functional studies were conducted in vitro by modulating DLGAP5 expression in pancreatic cancer cell lines (PaTu 8902, MiaPaCa2) and IPMN precursor cell line (ASAN-PaCa). Mass spectrometry-based secretome analysis of IPMN precursor cells was performed to identify DLGAP5-associated secreted proteins with potential for clinical testing in cyst fluid.

Results

DLGAP5 staining density and intensity differed significantly among LGD, HGD, and carcinoma (Fisher–Freeman–Halton p<0.0001 for both). Post-hoc Fisher’s exact tests showed LGD vs HGD (density p<0.001; intensity p<0.001) and LGD vs carcinoma (density p<0.001; intensity p<0.001) to be significant; HGD vs carcinoma was not (density p=0.673; intensity p=0.414). Functional assays demonstrated that DLGAP5 knockdown in pancreatic cancer cells decreased proliferation, while its overexpression in IPMN precursor cells increased proliferation. Secretome profiling revealed eight proteins whose secretion was significantly increased in IPMN precursor cells overexpressing DLGAP5 compared to empty vector expressing cells. Among them, PRDX1, PRDX2, FABP5, and SCGB1D2 (p=0.03, 0.038, 0.035 and 0.009 respectively) have previously been identified in cyst fluid or serum of IPMN patients, indicating translational relevance.

Conclusion

In conclusion, we validated DLGAP5 as a marker for IPMN progression and identified several DLGAP5-dependent secreted proteins that may serve as surrogate biomarkers for stratification of the patients with IPMN. Prospective validation in cystic fluid samples is ongoing.

Introduction

The early diagnosis of pancreatic cancer has long been considered a major clinical challenge. Recently in Japan, imaging-based screening strategies focusing on indirect findings have ushered in a new era, enabling the detection of carcinoma in situ and high-grade pancreatic intraepithelial neoplasia (PanIN). This study aimed to elucidate the molecular evolutionary mechanisms of PanIN development and progression.

Aims & Methods

We conducted detailed histopathological analysis and multi-regional genomic sequencing on 33 lesions obtained from a single patient with a family history of pancreatic cancer. The patient initially underwent distal pancreatectomy for a branch duct-type intraductal papillary mucinous neoplasm (IPMN) accompanied by adjacent main pancreatic duct (MPD) stenosis, followed by remnant pancreatectomy four years later due to newly detected ductal irregularities. The analyzed lesions included 15 low-grade PanINs, 14 high-grade PanINs, two low-grade IPMNs, and two concomitant pancreatic ductal adenocarcinoma components. Molecular analyses included KRAS and GNAS mutation detection using droplet digital PCR, targeted sequencing using a pancreatic cancer-related gene panel, and whole-exome sequencing. Tumor phenotypes were assessed by immunohistochemistry.

Results

Among numerous low-grade PanINs harboring various KRAS mutations, four distinct multicentric high-grade PanINs arose in the pancreatic body and tail. These included a laterally spreading high-grade PanIN within the stenotic MPD, characterized by KRAS G12D, TP53 deletion, and GATA6 Y83TfsX54; and three discrete high-grade PanINs located in branch ducts, all harboring KRAS G12V accompanied respectively by TP53 Y107D; TP53 S241F and ARID1A Q386X and S2096X; and TP53 G245S and ARID1A Q1066X. A low-grade gastric-type IPMN harboring KRAS G12R was determined to be clonally independent from the adjacent high-grade PanINs. A low-grade PanIN with KRAS G12D was identified at the pancreatic cut margin, though it showed no evidence of malignancy. In the remnant pancreatic head, a high-grade PanIN harboring KRAS G12D, TP53 deletion, and GATA6 Y83TfsX54—identical to the dominant clone in the pancreatic body—had extended along the MPD from the ductal stump to the ampulla. Two small invasive carcinoma foci were found to be continuous with this high-grade PanIN and shared identical KRAS, TP53, and GATA6 mutations, along with additional copy number variations affecting several genes. Another small high-grade PanIN with KRAS G12D and TP53 C275Y was identified in a neighboring branch duct. Furthermore, a germline CDKN2A H66R variant was detected, suggesting a potential hereditary predisposition to pancreatic tumorigenesis. The patient has remained recurrence-free for four years following the remnant pancreatectomy.

Conclusion

In high-risk individuals with a family history of pancreatic cancer or IPMN, PanINs may develop in large numbers, and multiple carcinomas in situ can arise simultaneously. Among these, clones exhibiting pronounced intraductal proliferation or progression toward invasion—thereby impacting clinical outcomes—may be selectively favored. This study provides novel insights into the clonal selection and molecular progression of multicentric high-grade PanINs. To our knowledge, this is the first report to comprehensively delineate the molecular trajectory of multifocal high-grade PanINs in a high-risk patient.