Introduction

Intraductal papillary mucinous neoplasms (IPMN) is one of the main pancreatic ductal adenocarcinoma precursors, characterized by a remarkable morphological and spatial heterogeneity. This phenotypical heterogeneity is reflected in IPMN prognosis, with gastric phenotype IPMNs being more often branch-duct and low-grade lesions. There is no biomarker to predict which lesion will progress, complexifying the clinical surveillance scheme. Infiltration of immune cells and fibroblasts in tumor microenvironment (TME) may play a role in this phenotypic heterogeneity.

Aims & Methods

The aim of the present study was to describe the molecular heterogeneity of IPMN lesions at a transcriptional level and their TME. All histological slides from 135 paraffin embedded (FFPE) surgical pancreatic resections for IPMN (2013-2023) were reviewed for selection of regions of morphological interest (ROI) depending on IPMN phenotype and dysplasia. A total of 420 morphologically homogeneous ROI were microdissected for RNA sequencing and 22 from mixed phenotype for DNA sequencing. Additionally, 127 regions adjacent to IPMN lesions were annotated for immunochemistry to quantify immune cell and fibroblast infiltration. Proliferation index was quantified for all microdissections by Ki67 immunostaining.

Results

Among the 135 resections, 49 (36%) were pure gastric, 54 (40%) pure intestinal, 6 (4%) pure pancreatobiliary (PB) and 26 (19%) displayed a mixed phenotype (2 or 3 different phenotypes within the same specimen). Out of the 420 microdissections, 181 were gastric (22% high grade), 195 intestinal (40% high grade) and 44 PB (all high grade). Unsupervised analysis showed an important overlap of gastric and PB phenotype in contrast with intestinal IPMNs. Samples from mixed phenotypes tended to cluster independently and 8 out of 22 showed a common clonal origin. In non-intestinal samples, HG lesions clustered in 2 groups, one purely composed of gastric phenotype and a distinct one composed of gastric and PB. In intestinal samples, HG samples poorly clustered suggesting a biological continuum. Indeed, genes overexpressed in intestinal samples were enriched for cell division and proliferation pathways and the ki67 was significantly higher in intestinal (mean 24% ± 16) compared to gastric samples (mean 6% ± 6.4, p<0.0001). Overexpressed genes in gastric samples were highly enriched in immune response pathways. In fact, TME CD4 and CD8 T cell infiltration was significantly higher in gastric and PB compared to intestinal samples and this, independently of grade of dysplasia. Yet, PB samples displayed a significantly higher TME infiltration of active fibroblasts, regulatory T cells, M2 macrophages and neutrophils compared to gastric and intestinal phenotypes.

Conclusion

Our findings highlight the transcriptomic and microenvironmental heterogeneity of IPMN phenotypes, with distinct molecular programs and immune landscapes associated with each subtype. While intestinal IPMN are characterized by a proliferative, immune-cold profile irrespective of dysplasia grade, gastric and PB lesions show marked immune infiltration, with PB lesions enriched in immunosuppressive cell populations. These results suggest that TME composition may contribute to the differential progression potential of IPMN subtypes and provide a rationale for phenotype-specific biomarkers and interception strategies.

Introduction

Pancreatic ductal adenocarcinoma (PDAC) is the most common neoplastic disease of the pancreas with a high mortality rate due to late diagnosis at an advanced stage for its asymptomatic progression. Chronic pancreatitis, one of the risk factors for the development of PDAC, complicates the diagnostic process as both conditions sometimes share overlapping clinical and pathological features. Identifying individuals at higher risk of developing the disease and detecting pancreatic cancer at an early, curable stage is critical to improving overall patient outcomes. This study investigates the potential of relative telomere length (RTL) in peripheral blood and microbiome composition as biomarkers for PDAC. These biomarkers could support a minimally invasive liquid biopsy approach for early diagnosis of PDAC, differentiation from chronic pancreatitis, and screening of high-risk individuals.

Aims & Methods

A total of 239 participants were enrolled in the study and were divided into four groups: patients with PDAC (n = 36), chronic pancreatitis (n = 60), type II diabetes mellitus (n = 91) and cancer-free individuals (n = 52). Peripheral blood samples were collected to estimate relative telomere length using the multiplex monochrome qPCR method. Stool samples from a subset comprising chronic pancreatitis patients (n = 13), PDAC patients (n = 12), and healthy controls (n = 7) were analysed using 16S rRNA sequencing for metataxonomic analysis of the gut microbiome.

Results

Microbiome analysis revealed dysbiosis in a subset of patients, with an overrepresentation of bacterial species such as Prevotella copri and Akkermansia muciniphila in chronic pancreatitis and PDAC patients. A trend towards reduced microbial diversity was observed in PDAC patients, with changes in bacterial composition already detectable in chronic pancreatitis patients. No significant differences were found in RTL between the PDAC and cancer-free patient groups, and the only risk factors associated with changes were age, gender and smoking.

Conclusion

The pilot findings suggest a general trend towards reduced microbial diversity in PDAC patients, with alterations in bacterial proportions already observed in individuals diagnosed with chronic pancreatitis. These data ptovide a basis for the development of non-invasive diagnostic strategies to improve early detection and clinical outcomes for patients with PDAC. However, relative telomere length has not been shown to be a reliable biomarker.

References

Wu H, Zou WB, Zhou DZ, Gu YT, Liao Z, Li ZS. Longer Leukocyte Telomere Length is Associated With an Increased Risk of Chronic Pancreatitis. Pancreas. 2017;46(8):e65-e66. doi:10.1097/MPA.0000000000000887
Riquelme E, Zhang Y, Zhang L, et al. Tumor Microbiome Diversity and Composition Influence Pancreatic Cancer Outcomes. Cell. 2019;178(4):795-806.e12. doi:10.1016/j.cell.2019.07.008
Antwi SO, Petersen GM. Leukocyte Telomere Length and Pancreatic Cancer Risk: Updated Epidemiologic Review. Pancreas. 2018;47(3):265-271. doi:10.1097/MPA.0000000000000995
Campa D, Felici A, Corradi C, et al. Long or short? Telomere length and pancreatic cancer and its precursor lesions, a narrative review. Mutagenesis. 2025;40(1):39-47. doi:10.1093/mutage/gead034
Sexton RE, Uddin MH, Bannoura S, et al. Connecting the Human Microbiome and Pancreatic Cancer [published correction appears in Cancer Metastasis Rev. 2022 Jun;41(2):333. doi: 10.1007/s10555-022-10037-3.]. Cancer Metastasis Rev. 2022;41(2):317-331. doi:10.1007/s10555-022-10022-w

Introduction

Pancreatic fibrosis (PF) is a prominent histological feature of chronic pancreatitis and influences on vast majority of pancreatic disorders. So, PF early diagnosis gives a great opportunity to be a part of the strategy for preventing pancreatic diseases progression. It makes non-invasive PF assessment especially via biomarkers level measurement research perspective.

Aims & Methods

Aim was to evaluate the possibility of biomarkers levels measurement in PF grade assessment.
Methods. We measured interleukin-10 (IL-10) and interleukin-36 (IL-36), matrix metalloproteinase-1 (MMP-1) and matrix metalloproteinase-9 (MMP-9), fibronectin (FN) and hyaluronic acid (HA) plasma levels from 165 patient who underwent surgery from April 2022 to February 2024 due to pancreatic tumors and advanced chronic pancreatitis. We included 69 (41.8%) male and 96 (58.2%) female patients, mean age was 57.91±13.5 (25-89). Serum levels of specified biomarkers were determined by enzyme immunoassay using commercial kits; data registration performed was carried out on a semi-automatic analyzer. PF morphological grade was assessed according to Klöppel & Maillet’s scoring system [1] and scaled into three grades: mild, moderate and severe PF.
This study was conducted within the healthcare research project “Assessment of pancreatic fibrosis as a prognostic factor for its diseases course” funded by Autonomous non-profit organization "Moscow Center for Innovative Technologies in Healthcare" administered by the Moscow Healthcare Department.

Results

Plasma FN (pFN) level was significantly (p=0.029) higher in patients with mild PF (pFN=110.7±72.7 μg/mL), than in patients with severe PF (pFN=74.9±32.8 μg/mL). The median pFN levels were significantly varied in groups with different grades of intralobular PF (p<0.05), but not in groups divided by perilobular PF grade (p>0.05). Moreover, pFN level significantly negatively correlated with PF integrative grade (Spearmen’s rho = -0.21, p=0.007). Regarding IL-10, IL36, MMP-1, MMP-9 and HA levels, there were no significant differences either in patients with different PF integrative grade, or in groups divided by perilobular and intralobular PF (p>0.05). We revealed no significant correlations between specified biomarkers levels and PF grade (p>0.05).

Conclusion

The FN serum level significantly decreased in patients with severe PF in contrast to patients with mild PF who had comparatively higher serum FN level. Oppositely, IL-10, IL36, MMP-1, MMP-9 and HA had shown no effect in PF grade assessment. It could be useful for noninvasive pancreatic fibrosis diagnosis and even for patients’ selection for advanced diagnostics.

References

1 Esposito I, Hruban RH, Verbeke C, et al. Guidelines on the histopathology of chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and the European Pancreatic Club. Pancreatology. 2020;20(4):586-593. doi:10.1016/j.pan.2020.04.009

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

Pancreatic pseudocyst (PPC) is a well defined local complication of pancreatitis. It has been reported in 8-41% of patients with history of pancreatitis in children¹. In past, surgical technique was treatment of choice for PPC drainage², however with advancements in endoscopic interventions, endoscopic ultrasound (EUS) guided PPC drainage is preferred in present era. Limited literature is available for EUS guided PPC drainage in pediatrics, owing to structure of echo-endoscope due to its rigid tip³, need of anesthesia and endoscopic skills. This study is one of the largest retrospective data⁴ in which we have shared experience of last 10 years for EUS guided PPC drainage from a tertiary care center of Pakistan.

Aims & Methods

This study aimed to evaluate the safety of EUS-guided PPC drainage in a large paediatric cohort (≤18 years) in Karachi, Pakistan, and assess technical and clinical success.
We retrospectively reviewed the charts of patients ≤18 years who underwent EUS-guided PPC drainage from 2015 to 2024 at the Sindh Institute of Advanced Gastroenterology, a tertiary care centre in Karachi, Pakistan. Data collected include patient demographics, aetiology of pancreatitis, PPC characteristics, procedural details, and outcomes. Technical success was defined as successful stent placement across the cyst gastrostomy. Clinical success included PPC resolution and symptom improvement.

Results

28 patients were referred for EUS-guided PPC drainage, 7 patients had no symptoms when presented, so 21 patients underwent EUS-guided PPC drainage. All patients were given general anesthesia by a pediatric anesthetist, and the airway was secured by endotracheal intubation to avoid the risk of aspiration. out of 21 patients,11 were male, with ages ranging from 6 to 18 years (Mean age 14.00± 3.25 years). 11 patients underwent EUS-guided complete aspiration of pseudocyst, with average pseudocyst size of 4.27 X3.93 cm, ranged from 2X1.2cm to 6.7 x5.6 cm. 10 patients underwent EUS-guided pseudocyst drainage via stent placement. The average size of PPC in this group was 8.39 X 8.02 cm, ranged from 6 X5 cm to 14X10cm. 8 pseudocysts were located along the pancreatic body region, 8 were located along the head and neck, and 5 were located near the tail region. Two Double pig tail plastic stents (DPPS) of 7fr 4cm were placed in 9 patients and 7fr 6cm in one patient transmurally into the cyst-gastrostomy tract, whereas LAMS hot axios 10x20 mm was placed in one patient only. One of the patients had a recurrence of pseudocyst with symptoms after 3 months, hence needing repeat pseudocyst drainage. One patient had displacement of DPPS. None of the patients developed major complications.

Conclusion

Endoscopy guided pancreatic pseudocyst drainage is safe and effective in pediatric population, however this procedure should be done by trained and experienced endoscopists under general anesthesia by pediatric anesthetist and EUS guided technique should be preferred over conventional technique of PPC drainage.

References

1.Park, A., Latif, S.U., Shah, A.U., Tian, J., Werlin, S., Hsiao, A., Pashankar, D., Bhandari, V., Nagar, A. and Husain, S.Z. (2009), Changing Referral Trends of Acute Pancreatitis in Children: A 12-year Single-center Analysis. Journal of Pediatric Gastroenterology and Nutrition, 49: 316-322. https://doi.org/10.1097/MPG.0b013e31818d7db3
2.Szakó L, Mátrai P, Hegyi P, Pécsi D, Gyöngyi Z, Csupor D, Bajor J, Erőss B, Mikó A, Szakács Z, Dobszai D. Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous drainage: Meta-analysis. Pancreatology. 2020 Jan 1;20(1):132-41
3.Thomson M, Tringali A, Dumonceau JM, Tavares M, Tabbers MM, Furlano R, Spaander M, Hassan C, Tzvinikos C, Ijsselstijn H, Viala J. Paediatric gastrointestinal endoscopy: European society for paediatric gastroenterology hepatology and nutrition and European society of gastrointestinal endoscopy guidelines. Journal of pediatric gastroenterology and nutrition. 2017 Jan 1;64(1):133-53
4.Nabi Z, Talukdar R, Lakhtakia S, Reddy DN. Outcomes of Endoscopic Drainage in Children with Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis. Pediatr Gastroenterol Hepatol Nutr. 2022 May;25(3):251-262. doi: 10.5223/pghn.2022.25.3.251. Epub 2022 May 9. PMID: 35611379; PMCID: PMC9110851.