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

​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

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 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

The rise in obesity rates has triggered a surge in associated health issues, with metabolic syndrome (MS) affecting approximately 25% of populations in Western countries. Severe acute pancreatitis (AP) is associated with mortality rates as high as 50%. Prior research has linked components of MS to heightened complications and mortality in cases of AP.

Aims & Methods

This meta-analysis aims to elucidate potential risk factors and their combined effects on the outcomes of AP. We performed a systematic search of PubMed, Embase, and the Cochrane Library until November 1, 2023, identifying studies based on specified criteria. We investigated the influence of MS and its components (obesity, hypertension, diabetes mellitus, and hypertriglyceridemia) on AP outcomes, calculating pooled odds ratios (OR) with 95% confidence intervals (CIs). The study protocol was registered with PROSPERO under the identifier CRD42023471092.

Results

From an initial 15,904 records, 93 studies were included in the analysis. Overweight and obesity emerged as significant risk factors for complications (local OR: 2.677, 95%CI: 1.421-5.044; systemic OR: 2.404, 95%CI: 1.481-3.901) and the severity of AP (BMI≥30 kg/m², OR: 3.058, 95%CI: 1.369-6.829). Elevated triglyceride levels were linked to ICU admissions (OR: 2.546, 95%CI: 1.529-4.237) and severe AP (OR: 2.372, 95%CI: 1.275-4.413); hypertension correlated with increased mortality (OR: 2.135, 95%CI: 1.870-2.437), while diabetes was associated with higher odds of ICU admission (OR: 1.645, 95%CI: 1.358-1.992) and severe AP (OR: 1.49, 95%CI: 1.09-2.03). Our findings suggest that MS may elevate the likelihood of severe AP (OR=1.398, 95%CI: 0.918-2.129).

Conclusion

The individual components of metabolic syndrome are significant risk factors for complications, severity, and mortality related to acute pancreatitis. It is imperative to prioritize lifestyle counseling, education, and effective management for patients dealing with obesity.

Introduction

Lumen-apposing metal stents (LAMSs) have significantly advanced endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs). However, their impact on clinical outcomes in real-world settings remains incompletely understood.

Aims & Methods

Using the Diagnosis Procedure Combination database—a nationwide inpatient database in Japan where LAMSs were approved in 2018—we identified 5,885 patients who underwent EUS-guided treatment for PFCs at 550 hospitals between 2010 and 2023. We examined the association between treatment period (before vs. after LAMS implementation at each hospital) and clinical outcomes. Multivariable logistic regression analyses were conducted to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for in-hospital mortality, bleeding, length of stay, and total healthcare costs, adjusting for potential confounders.

Results

Compared with patients treated in the pre-LAMS period, those treated in the post-LAMS period had a significantly higher risk of bleeding (adjusted OR, 1.56; 95% CI, 1.35–1.81). Additionally, the post-LAMS period was associated with an increase of approximately $3,300 (USD) in total healthcare costs, with an adjusted OR for being in the highest quartile of total costs of 1.55 (95% CI, 1.34–1.79). There was no significant difference in the risk of in-hospital mortality (adjusted OR, 1.21; 95% CI, 0.95–1.55) or prolonged hospitalisation (adjusted OR for top quartile, 0.98; 95% CI, 0.86–1.12).

Conclusion

The introduction of LAMSs was associated with an increased risk of bleeding and higher healthcare costs, without significant improvements in mortality or hospital stay duration. These findings suggest that routine use of LAMSs for EUS-guided PFC treatment should be reconsidered.

Disclosure

HI declares research funding from Boston Scientific Japan, Fujifilm, and Piolax Medical Devices; honoraria from Boston Scientific Japan, Century Medical, Create Medic, Fujifilm, Gadelius Medical, Hitachi Medical, Japan Lifeline, Kaneka, Kawasumi Laboratories, Olympus Medical, Piolax Medical Devices, Sumitomo Bakelite, UMIDAS, and Zeon Medical; and contributions from Boston Scientific Japan, Gadelius Medical, Japan Lifeline, and Zeon Medical. YN declares research funding from Boston Scientific Japan, Century Medical, Fujifilm, Gadelius Medical, HOYA Pentax Medical, Hitachi Medical, Kaneka, and Medico’s Hirata; and honoraria from Boston Scientific Japan, Fujifilm, Gadelius Medical, Hitachi Medical, J-MIT, Medico’s Hirata, and Olympus Medical. This work was not supported by any of those companies. No other conflicts of interest exist. The other authors declare that they have no conflicts of interest.