Stage Pancreatic Ductal Adenocarcinoma Research Articles

Pancreatic Cancer Surveillance and Survival of High-Risk Individuals

Pancreatic ductal adenocarcinoma (PDAC) is a deadly disease with increasing incidence. The majority of PDACs are incurable at presentation, but population-based screening is not recommended. Surveillance of high-risk individuals for PDAC may lead to early detection, but the survival benefit is unproven. To compare the survival of patients with surveillance-detected PDAC with US national data. This comparative cohort study was conducted in multiple US academic medical centers participating in the Cancer of the Pancreas Screening program, which screens high-risk individuals with a familial or genetic predisposition for PDAC. The comparison cohort comprised patients with PDAC matched for age, sex, and year of diagnosis from the Surveillance, Epidemiology, and End Results (SEER) program. The Cancer of the Pancreas Screening program originated in 1998, and data collection was done through 2021. The data analysis was performed from April 29, 2022, through April 10, 2023. Endoscopic ultrasonography or magnetic resonance imaging performed annually and standard-of-care surgical and/or oncologic treatment. Stage of PDAC at diagnosis, overall survival (OS), and PDAC mortality were compared using descriptive statistics and conditional logistic regression, Cox proportional hazards regression, and competing risk regression models. Sensitivity analyses and adjustment for lead-time bias were also conducted. A total of 26 high-risk individuals (mean [SD] age at diagnosis, 65.8 [9.5] years; 15 female [57.7%]) with PDAC were compared with 1504 SEER control patients with PDAC (mean [SD] age at diagnosis, 66.8 [7.9] years; 771 female [51.3%]). The median primary tumor diameter of the 26 high-risk individuals was smaller than in the control patients (2.5 [range, 0.6-5.0] vs 3.6 [range, 0.2-8.0] cm, respectively; P < .001). The high-risk individuals were more likely to be diagnosed with a lower stage (stage I, 10 [38.5%]; stage II, 8 [30.8%]) than matched control patients (stage I, 155 [10.3%]; stage II, 377 [25.1%]; P < .001). The PDAC mortality rate at 5 years was lower for high-risk individuals than control patients (43% vs 86%; hazard ratio, 3.58; 95% CI, 2.01-6.39; P < .001), and high-risk individuals lived longer than matched control patients (median OS, 61.7 [range, 1.9-147.3] vs 8.0 [range, 1.0-131.0] months; 5-year OS rate, 50% [95% CI, 32%-80%] vs 9% [95% CI, 7%-11%]). These findings suggest that surveillance of high-risk individuals may lead to detection of smaller, lower-stage PDACs and improved survival.

Large Language Models for Automated Synoptic Reports and Resectability Categorization in Pancreatic Cancer.

Background Structured radiology reports for pancreatic ductal adenocarcinoma (PDAC) improve surgical decision-making over free-text reports, but radiologist adoption is variable. Resectability criteria are applied inconsistently. Purpose To evaluate the performance of large language models (LLMs) in automatically creating PDAC synoptic reports from original reports and to explore performance in categorizing tumor resectability. Materials and Methods In this institutional review board-approved retrospective study, 180 consecutive PDAC staging CT reports on patients referred to the authors' European Society for Medical Oncology-designated cancer center from January to December 2018 were included. Reports were reviewed by two radiologists to establish the reference standard for 14 key findings and National Comprehensive Cancer Network (NCCN) resectability category. GPT-3.5 and GPT-4 (accessed September 18-29, 2023) were prompted to create synoptic reports from original reports with the same 14 features, and their performance was evaluated (recall, precision, F1 score). To categorize resectability, three prompting strategies (default knowledge, in-context knowledge, chain-of-thought) were used for both LLMs. Hepatopancreaticobiliary surgeons reviewed original and artificial intelligence (AI)-generated reports to determine resectability, with accuracy and review time compared. The McNemar test, t test, Wilcoxon signed-rank test, and mixed effects logistic regression models were used where appropriate. Results GPT-4 outperformed GPT-3.5 in the creation of synoptic reports (F1 score: 0.997 vs 0.967, respectively). Compared with GPT-3.5, GPT-4 achieved equal or higher F1 scores for all 14 extracted features. GPT-4 had higher precision than GPT-3.5 for extracting superior mesenteric artery involvement (100% vs 88.8%, respectively). For categorizing resectability, GPT-4 outperformed GPT-3.5 for each prompting strategy. For GPT-4, chain-of-thought prompting was most accurate, outperforming in-context knowledge prompting (92% vs 83%, respectively; P = .002), which outperformed the default knowledge strategy (83% vs 67%, P < .001). Surgeons were more accurate in categorizing resectability using AI-generated reports than original reports (83% vs 76%, respectively; P = .03), while spending less time on each report (58%; 95% CI: 0.53, 0.62). Conclusion GPT-4 created near-perfect PDAC synoptic reports from original reports. GPT-4 with chain-of-thought achieved high accuracy in categorizing resectability. Surgeons were more accurate and efficient using AI-generated reports. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Chang in this issue.

New Liquid Biopsy Detects Early Stages of Pancreatic Ductal Adenocarcinoma

New Liquid Biopsy Detects Early Stages of Pancreatic Ductal Adenocarcinoma

The Potential of Fecal and Urinary Biomarkers for Early Detection of Pancreatic Ductal Adenocarcinoma: A Systematic Review.

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal cancer often diagnosed at advanced stages, highlighting the urgent need for early detection strategies. This systematic review explores the potential of fecal and urinary biomarkers for early PDAC detection. A comprehensive search identified eight relevant studies investigating various biomarkers, including proteins, metabolites, microbial profiles, DNA mutations, and non-coding RNAs. Promising findings suggest that urinary biomarkers related to metabolic alterations, inflammatory processes, fecal microbiome profiles, and fecal miRNAs hold diagnostic potential even at early stages of PDAC. Combining biomarkers into panels may enhance diagnostic accuracy. Challenges such as validation in larger cohorts, standardization of protocols, and regulatory approval must be addressed for clinical translation. Despite these hurdles, non-invasive urinary and fecal biomarkers represent a promising avenue for improving PDAC outcomes through early detection.

Computed tomography-based radiomics diagnostic approach for differential diagnosis between early- and late-stage pancreatic ductal adenocarcinoma.

One of the primary reasons for the dismal survival rates in pancreatic ductal adenocarcinoma (PDAC) is that most patients are usually diagnosed at late stages. There is an urgent unmet clinical need to identify and develop diagnostic methods that could precisely detect PDAC at its earliest stages. To evaluate the potential value of radiomics analysis in the differentiation of early-stage PDAC from late-stage PDAC. A total of 71 patients with pathologically proved PDAC based on surgical resection who underwent contrast-enhanced computed tomography (CT) within 30 d prior to surgery were included in the study. Tumor staging was performed in accordance with the 8th edition of the American Joint Committee on Cancer staging system. Radiomics features were extracted from the region of interest (ROI) for each patient using Analysis Kit software. The most important and predictive radiomics features were selected using Mann-Whitney U test, univariate logistic regression analysis, and minimum redundancy maximum relevance (MRMR) method. Random forest (RF) method was used to construct the radiomics model, and 10-times leave group out cross-validation (LGOCV) method was used to validate the robustness and reproducibility of the model. A total of 792 radiomics features (396 from late arterial phase and 396 from portal venous phase) were extracted from the ROI for each patient using Analysis Kit software. Nine most important and predictive features were selected using Mann-Whitney U test, univariate logistic regression analysis, and MRMR method. RF method was used to construct the radiomics model with the nine most predictive radiomics features, which showed a high discriminative ability with 97.7% accuracy, 97.6% sensitivity, 97.8% specificity, 98.4% positive predictive value, and 96.8% negative predictive value. The radiomics model was proved to be robust and reproducible using 10-times LGOCV method with an average area under the curve of 0.75 by the average performance of the 10 newly built models. The radiomics model based on CT could serve as a promising non-invasive method in differential diagnosis between early and late stage PDAC.

Targeted Therapy for Highly Desmoplastic and Immunosuppressive Tumor Microenvironment of Pancreatic Ductal Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal malignancy with a very poor prognosis. Despite advancements in treatment strategies, PDAC remains recalcitrant to therapies because patients are often diagnosed at an advanced stage. The advanced stage of PDAC is characterized by metastasis, which typically renders it unresectable by surgery or untreatable by chemotherapy. The tumor microenvironment (TME) of PDAC comprises highly proliferative myofibroblast-like cells and hosts the intense deposition of a extracellular matrix component that forms dense fibrous connective tissue, a process called the desmoplastic reaction. In desmoplastic TMEs, the incessant aberration of signaling pathways contributes to immunosuppression by suppressing antitumor immunity. This feature offers a protective barrier that impedes the targeted delivery of drugs. In addition, the efficacy of immunotherapy is compromised because of the immune cold TME of PDAC. Targeted therapy approaches towards stromal and immunosuppressive TMEs are challenging. In this review, we discuss cellular and non-cellular TME components that contain actionable targets for drug development. We also highlight findings from preclinical studies and provide updates about the efficacies of new investigational drugs in clinical trials.

Abstract LB316: Endocrine pancreas alteration in pancreatic ductal adenocarcinoma

Abstract Background: The pancreas is central to energy homeostasis, playing essential roles in digestion and regulation of blood glucose. Exocrine pancreas contains large amounts of of hydrolytic enzyme which is responsible for the digestion. Acinar cells, as well as ductal cells, represent the prime components of exocrine pancreas. They are both supposed to be the origin of pancreatic ductal adenocarcinoma(PDAC) and the researches focused on these exocrine cells, as well as other components in pancreatic cancer, are numerous. Islet cells are crucial for glucose homeostasis and their identity are proved to be altered significantly during diabetes by single-cell RNA-sequencing(scRNA-seq). However, the presence or extent of variation of islet cells in PDAC is not established yet. Moreover, due to the low proportion of endocrine cells in pancreas, it is hard to analyze the data of endocrine cells by using published scRNA-seq data of PDAC. As a consequence of this underrepresentation, the function of endocrine cells in PDAC remains unclear. Methods: We used scRNA-seq, multiplex immunohistochemistry (mIHC), high-throughput spatial transcriptomic sequencing (Stereo-seq) to detect the alteration of endocrine pancreas in PDAC of human and mouse model. KPC mice (KrasLSL-G12Dp53LoxPPdx1-CreER) and pancreatic orthotopic transplantation mice were applied to verify the islet cell alteration in multiple stages of PDAC. We also performed islet isolation and purification to enhance the proportion of endocrine cells when preparing single-cell suspension. Cell co-culture experiments were used to determine the interaction between exocrine-endocrine compartments. Results: Through mIHC of islet cells in PDAC tissues and normal pancreas tissues of mice (KPC vs. C57BL/6J) as well as human (PDAC patients vs. healthy donors), we found the decreased proportions of inulin positive (INS+) cells and increased proportions of glucagon positive (GCG+) cells in PDAC tissues. Furthermore, the proportion of pancreatic polypeptide positive (PPY+) cells was significantly elevated in PDAC tissue in both human and murine. Then, we quantified the double-positive cells and found the proportions of INS+GCG+, INS+PPY+ and GCG+PPY+ were markedly increased in PDAC tissue. Additionally, through the experiments in mouse model, we found the islet cells altered gradually within the multiple stage of PDAC(normal-PanIN-PDAC). Finally, it was found that PDAC cells could induce the transdifferentiation of pancreatic α and β cells into GCG+PPY+ and INS+PPY+ double-positive cells, which further promoted PDAC proliferation in a paracrine-dependent manner and formed a reciprocal interaction. Conclusions: Our study systematically maps the alteration of pancreatic endocrine cells in PDAC and elucidates the potential interaction mechanisms between endocrine and exocrine cells during PDAC carcinogenesis. Meanwhile, it is suggested that pancreatic endocrine cells should be considered as an important component of the PDAC microenvironment. Citation Format: Yuan Chen, Xinpeng Yin, Ruiyuan Xu, Rexiati Ruze, Jianlu Song, Chenglin Hu, Chengcheng Wang, Yupei Zhao. Endocrine pancreas alteration in pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB316.

Abstract 7291: Detection of a truncated form of multidrug resistance protein 1 (MRP1) in plasma sEVs derived from cancer patients

Abstract Multidrug resistance protein 1 (MRP1/ABCC1) is an ATP dependent transmembrane efflux pump that confers to drug resistance. Overexpression of MRP1 has been observed in both pancreatic ductal adenocarcinoma (PDAC) and breast cancer tissues. Numerous proteomics studies have revealed the presence of MRP1 in small extracellular vesicles (sEVs) released from cancer cells. Cancer-derived sEVs are known to be released into the circulation, thus becoming attractive candidates for non-invasive biomarker development. However, whether the MRP1 level in plasma sEVs is indicative of human cancer has not been evaluated. This study examined the MRP1 expression in plasma sEVs derived from patients with PDAC, breast and colon cancer, and age- and gender-matched healthy subjects. The patient plasma samples were obtained primarily from the NCI-sponsored Cooperative Human Tissue Network and Stephenson Cancer Center. Healthy plasma samples were provided by the Oklahoma Blood institute. Human pancreatic cancer cell lines PANC-1, MIA PaCa-2 and BxPC-3, and the pancreatic ductal cell line hTERT-HPNE were tested for MRP1 expression prior to examination of plasma samples. Cellular and plasma sEVs were isolated using the double filtration followed by polymer precipitation method. Western blot was performed to assess the expression level of MRP1 and proteomics was applied to confirm the detection of a truncated form of MRP1 in plasma sEVs. MRP1 expression was detected in the sEVs derived from all three pancreatic cancer cell lines but absent in the sEVs from the HPNE line. Overexpression of a truncated MRP1 protein was detected in plasma sEVs derived from patients with early stage (stage I-IIA) and late stage (III-IV) PDAC, compared with that from matched healthy subjects (n=17 for each group). Similar findings were evident in plasma sEVs from patients with breast cancer (n=7), while the results remained inconclusive in plasma sEVs from patients with colon cancer (n=7). Protein structure analysis indicated that the truncated form of MRP1 likely consists of the regions between the QCRL-1 motif and the C-terminus of the protein. Proteomic analysis detected the peptides derived from the C-terminus region, consistent with the structural analysis. Furthermore, the truncated form of MRP1 can only be detected using antibodies against the epitopes in the C-terminus and QCRL-1 region of MRP1 protein. In summary, we have detected a truncated form of MRP1 protein in plasma sEVs derived from cancer patients, and the level of its expression is significantly elevated in patients with PDAC and breast cancer. Citation Format: Kritisha Bhandari, Jeng Shi Kong, Chao Xu, Ajay Jain, Wei-Qun Ding. Detection of a truncated form of multidrug resistance protein 1 (MRP1) in plasma sEVs derived from cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7291.

Abstract 3784: Methylated DNA markers for detection of peritoneal metastasis in pancreatic cancer

Abstract Introduction: Laparoscopy with peritoneal lavage enhances staging accuracy in patients with pancreatic ductal adenocarcinoma (PDAC). Occult intra-abdominal metastases are identified by staging laparoscopy in approximately 20% of patients with radiologically localized PDAC. Peritoneal fluid cytology has limited sensitivity in detecting occult intra-abdominal metastasis. Methylated DNA markers (MDMs) can accurately detect PDAC from tumor tissue, blood, and pancreatic secretions. This study aims to assess the feasibility of assaying MDMs in peritoneal lavage fluid obtained at the time of staging laparoscopy for patients with PDAC. Methods: Peritoneal lavage fluid (25-60 mL) obtained from patients with PDAC at the time of staging laparoscopy was centrifuged for 10 minutes at 1200 × g. The pellet was resuspended and aliquoted into 200µL tubes and frozen at -80°C. DNA extracted from one aliquot was assayed for mutant KRAS (G12A and G13D) and then bisulfite converted to measure 13 MDMs (GRIN2D, CD1D, ZNF781, FER1L4, RYR2, CLEC11A, AK055957, LRRC4, MAX.CHR5.4295, HOXA1, PRKCB, SHISA9, NTRK3) and a normalizing reference gene (B3GALT6) using quantitative methylation specific PCR. The association of KRAS and the average signal from the 13 MDMs (MDMscore) with intra-abdominal metastasis (Y/N) was assessed with the area under the receiver operator characteristic curve (AUC). Results: Among 48 PDAC patients, staging laparoscopy revealed intra-abdominal metastasis in 15 (31%). Of the 15 intra-abdominal metastases, 6 were found to have biopsy-confirmed intra-abdominal metastasis and positive peritoneal cytology, 4 were positive on peritoneal cytology alone, and 5 had biopsy-confirmed intra-abdominal metastasis alone. The sensitivity of the MDMscore for intra-abdominal metastasis was 87% (CI: 60-98%) at 90% (CI: 76-98%) specificity whereas the sensitivity for KRAS was 40% (CI: 16-68%) at 85% (CI: 68-95) specificity. The AUC for the MDMscore was 0.98 (CI: 0.94-1.00) compared to 0.62 (CI: 0.48-0.77) for that of KRAS (p&amp;lt;0.0001). Conclusion: MDMs assayed from peritoneal lavage fluid collected during staging laparoscopy is a novel tool for accurate molecular staging of PDAC. These early results warrant further study in a larger cohort to assess impact on peritoneal staging and its clinical utility in the neoadjuvant treatment paradigm of PDAC. Citation Format: Kalika Maheshwari, Calise K. Berger, William R. Taylor, Douglas W. Mahoney, Kelli N. Burger, Adriana M. Delgado, Karen A. Doering, Heather M. Streich, Patrick H. Foote, Sean P. Cleary, Travis E. Grotz, Micheal L. Kendrick, Rory L. Smoot, Patrick P. Starlinger, Cornelius A. Thiels, Mark J. Truty, Susanne G. Warner, John B. Kisiel, Shounak Majumder. Methylated DNA markers for detection of peritoneal metastasis in pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3784.

Abstract 3794: Clinical impact of high-quality liquid biopsy for peritoneal lavage cytology in resectable pancreatic cancer

Abstract Despite the general trends towards increased cancer survival, pancreatic ductal adenocarcinoma (PDAC) still has a dismal prognosis. Peritoneal recurrence is a major recurrence pattern after pancreatectomy. Peritoneal lavage cytology (CY) is employed widely in the diagnosis and staging of PDAC to rule out patients with occult peritoneal metastasis. However, the importance of CY status both as a sign of irresectability and as a prognostic factor for PDAC remains controversial. The purposes of this study were to determine whether CY+ status precludes radical resection and to propose novel liquid biopsy using peritoneal lavage fluid to detect viable peritoneal tumor cells (v-PTCs). We conducted this study to evaluate use of a new genetically modified telomerase-specific replication-selective adenovirus, expressing GFP (TelomeScan F35) in rapid detection of v-PTC dissemination (Telo-CY). We assessed the clinical utility of high-quality testing of Telo-CY in PDAC patients in comparison with the findings of conventional CY (Conv-CY). This study was approved by the IRB in our Hospital. Patients with resectable cytologically or histologically proven PDAC were enrolled. 100 ml of saline as peritoneal lavage fluid was harvested just after a laparotomy. Half of the fluid was examined by conv-CY, based on Papanicolaou staining and MOC-31 immunostaining, and the remaining half was analyzed to detect v-PTCs by Telo-CY. To distinguish between leucocyte and cells with epithelial origin, cells were stained with anti-CD45 mAb. To further distinguish cells with primary tumor origin, cells were labeled with anti-CEA, anti-CA19-9 and Ep-CAM mAbs. GFP(+) and CD45(-), and either CEA-, CA19-9- or Ep-CAM-(+) cells were counted as v-PTCs. Patients were followed to evaluate its clinical significance. Among 53 patients aged 53-87 years (30 males, 23 females), 5 were conv-CY(+), other 12 were Telo-CY(+). All 53 patients underwent surgical resection (PD/DP/TP=32/14/7). 2 patients were double-CY-(+) [conv-CY(+) and Telo-CY(+)], and peritoneal recurrence occurred at 7-9 months after surgery, despite adjuvant chemotherapy. 3 were conv-CY(+) alone, but Telo-CY(-), and no peritoneal recurrences were observed (0%). Conversely, 10 were Telo-CY(+) alone, but conv-CY(-), and 6 out of 10 patients were relapsed with peritoneal dissemination (60%). Remaining 38 patients were double-CY-negative (conv-CY- and Telo-CY-, conv-CY±), peritoneal recurrence was observed in 3 patients (8.3%). Although CY-positive status predicts poor prognosis and a higher risk of peritoneal dissemination after resection, it is not sufficient to preclude pancreatectomy by conv-CY alone. Combined CY examination with conv-CY and Telo-CY may open the window of opportunity for leading true results, accurately predicting peritoneal recurrence in PDAC patients. The CY status should be confirmed by staging laparoscopy prior to resection. Citation Format: Masahiro Tanemura, Kenta Furukawa, Tadafumi Asaoka, Daiki Marukawa, Hironao Yasuoka, Yasuo Urata, Daisaku Yamada, Shogo Kobayashi, Hidetoshi Eguchi. Clinical impact of high-quality liquid biopsy for peritoneal lavage cytology in resectable pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3794.

Concurrent inhibition of pBADS99 synergistically improves MEK inhibitor efficacy in KRASG12D-mutant pancreatic ductal adenocarcinoma

Therapeutic targeting of KRAS-mutant pancreatic ductal adenocarcinoma (PDAC) has remained a significant challenge in clinical oncology. Direct targeting of KRAS has proven difficult, and inhibition of the KRAS effectors have shown limited success due to compensatory activation of survival pathways. Being a core downstream effector of the KRAS-driven p44/42 MAPK and PI3K/AKT pathways governing intrinsic apoptosis, BAD phosphorylation emerges as a promising therapeutic target. Herein, a positive association of the pBADS99/BAD ratio with higher disease stage and worse overall survival of PDAC was observed. Homology-directed repair of BAD to BADS99A or small molecule inhibition of BADS99 phosphorylation by NCK significantly reduced PDAC cell viability by promoting cell cycle arrest and apoptosis. NCK also abrogated the growth of preformed colonies of PDAC cells in 3D culture. Furthermore, high-throughput screening with an oncology drug library to identify potential combinations revealed a strong synergistic effect between NCK and MEK inhibitors in PDAC cells harboring either wild-type or mutant-KRAS. Mechanistically, both mutant-KRAS and MEK inhibition increased the phosphorylation of BADS99 in PDAC cells, an effect abrogated by NCK. Combined pBADS99-MEK inhibition demonstrated strong synergy in reducing cell viability, enhancing apoptosis, and achieving xenograft stasis in KRAS-mutant PDAC. In conclusion, the inhibition of BADS99 phosphorylation enhances the efficacy of MEK inhibition, and their combined inhibition represents a mechanistically based and potentially effective therapeutic strategy for the treatment of KRAS-mutant PDAC.

The Value of Biological and Conditional Factors for Staging of Patients with Resectable Pancreatic Cancer Undergoing Upfront Resection: A Nationwide Analysis

BackgroundNovel definitions suggest that resectability status for pancreatic ductal adenocarcinoma (PDAC) should be assessed beyond anatomical criteria, considering both biological and conditional factors. This has, however, yet to be validated on a nationwide scale. This study evaluated the prognostic value of biological and conditional factors for staging of patients with resectable PDAC.Patients and MethodsA nationwide observational cohort study was performed, including all consecutive patients who underwent upfront resection of National Comprehensive Cancer Network resectable PDAC in the Netherlands (2014–2019) with complete information on preoperative carbohydrate antigen (CA) 19-9 and Eastern Cooperative Oncology Group (ECOG) performance status. PDAC was considered biologically unfavorable (RB+) if CA19-9 ≥ 500 U/mL and favorable (RB−) otherwise. ECOG ≥ 2 was considered conditionally unfavorable (RC+) and favorable otherwise (RC−). Overall survival (OS) was assessed using Kaplan–Meier and Cox-proportional hazard analysis, presented as hazard ratios (HRs) with 95% confidence interval (CI).ResultsOverall, 688 patients were analyzed with a median overall survival (OS) of 20 months (95% CI 19–23). OS was 14 months (95% CI 10 months—median not reached) in 20 RB+C+ patients (3%; HR 1.61, 95% CI 0.86–2.70), 13 months (95% CI 11–15) in 156 RB+C− patients (23%; HR 1.86, 95% CI 1.50–2.31), and 21 months (95% CI 12–41) in 47 RB−C+ patients (7%; HR 1.14, 95% CI 0.80–1.62) compared with 24 months (95% CI 22–27) in 465 patients with RB−C− PDAC (68%; reference).ConclusionsSurvival after upfront resection of anatomically resectable PDAC is worse in patients with CA19-9 ≥ 500 U/mL, while performance status had no impact. This supports consideration of CA19-9 in preoperative staging of resectable PDAC.

Artificial intelligence to predict T4 stage of pancreatic ductal adenocarcinoma using CT imaging

BackgroundThe accurate assessment of T4 stage of pancreatic ductal adenocarcinoma (PDAC) has consistently presented a considerable difficulty for radiologists. This study aimed to develop and validate an automated artificial intelligence (AI) pipeline for the prediction of T4 stage of PDAC using contrast-enhanced CT imaging. MethodsThe data were obtained retrospectively from consecutive patients with surgically resected and pathologically proved PDAC at two institutions between July 2017 and June 2022. Initially, a deep learning (DL) model was developed to segment PDAC. Subsequently, radiomics features were extracted from the automatically segmented region of interest (ROI), which encompassed both the tumor region and a 3 mm surrounding area, to construct a predictive model for determining T4 stage of PDAC. The assessment of the models' performance involved the calculation of the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. ResultsThe study encompassed a cohort of 509 PDAC patients, with a median age of 62 years (interquartile range: 55–67). The proportion of patients in T4 stage within the model was 16.9%. The model achieved an AUC of 0.849 (95% CI: 0.753–0.940), a sensitivity of 0.875, and a specificity of 0.728 in predicting T4 stage of PDAC. The performance of the model was determined to be comparable to that of two experienced abdominal radiologists (AUCs: 0.849 vs. 0.834 and 0.857). ConclusionThe automated AI pipeline utilizing tumor and peritumor-related radiomics features demonstrated comparable performance to that of senior abdominal radiologists in predicting T4 stage of PDAC.

Reprogramming Pancreatic Ductal Adenocarcinoma to Pluripotency.

The generation of induced pluripotent stem cells (iPSCs) using transcription factors has been achieved from almost any differentiated cell type and has proved highly valuable for research and clinical applications. Interestingly, iPSC reprogramming of cancer cells, such as pancreatic ductal adenocarcinoma (PDAC), has been shown to revert the invasive PDAC phenotype and override the cancer epigenome. The differentiation of PDAC-derived iPSCs can recapitulate PDAC progression from its early pancreatic intraepithelial neoplasia (PanIN) precursor, revealing the molecular and cellular changes that occur early during PDAC progression. Therefore, PDAC-derived iPSCs can be used to model the earliest stages of PDAC for the discovery of early-detection diagnostic markers. This is particularly important for PDAC patients, who are typically diagnosed at the late metastatic stages due to a lack of reliable biomarkers for the earlier PanIN stages. However, reprogramming cancer cell lines, including PDAC, into pluripotency remains challenging, labor-intensive, and highly variable between different lines. Here, we describe a more consistent protocol for generating iPSCs from various human PDAC cell lines using bicistronic lentiviral vectors. The resulting iPSC lines are stable, showing no dependence on the exogenous expression of reprogramming factors or inducible drugs. Overall, this protocol facilitates the generation of a wide range of PDAC-derived iPSCs, which is essential for discovering early biomarkers that are more specific and representative of PDAC cases.

Inhibition of the Alternative Complement Pathway May Cause Secretion of Factor B, Enabling an Early Detection of Pancreatic Cancer.

This study aims to elucidate the cellular mechanisms behind the secretion of complement factor B (CFB), known for its dual roles as an early biomarker for pancreatic ductal adenocarcinoma (PDAC) and as the initial substrate for the alternative complement pathway (ACP). Using parallel reaction monitoring analysis, we confirmed a consistent ∼2-fold increase in CFB expression in PDAC patients compared with that in both healthy donors (HD) and chronic pancreatitis (CP) patients. Elevated ACP activity was observed in CP and other benign conditions compared with that in HD and PDAC patients, suggesting a functional link between ACP and PDAC. Protein-protein interaction analyses involving key complement proteins and their regulatory factors were conducted using blood samples from PDAC patients and cultured cell lines. Our findings revealed a complex control system governing the ACP and its regulatory factors, including Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation, adrenomedullin (AM), and complement factor H (CFH). Particularly, AM emerged as a crucial player in CFB secretion, activating CFH and promoting its predominant binding to C3b over CFB. Mechanistically, our data suggest that the KRAS mutation stimulates AM expression, enhancing CFH activity in the fluid phase through binding. This heightened AM-CFH interaction conferred greater affinity for C3b over CFB, potentially suppressing the ACP cascade. This sequence of events likely culminated in the preferential release of ductal CFB into plasma during the early stages of PDAC. (Data set ID PXD047043.).

Assessment of resectability of pancreatic cancer using novel immersive high-performance virtual reality rendering of abdominal computed tomography and magnetic resonance imaging.

Virtual reality (VR) allows for an immersive and interactive analysis of imaging data such as computed tomography (CT) and magnetic resonance imaging (MRI). The aim of this study is to assess the comprehensibility of VR anatomy and its value in assessing resectability of pancreatic ductal adenocarcinoma (PDAC). This study assesses exposure to VR anatomy and evaluates the potential role of VR in assessing resectability of PDAC. Firstly, volumetric abdominal CT and MRI data were displayed in an immersive VR environment. Volunteering physicians were asked to identify anatomical landmarks in VR. In the second stage, experienced clinicians were asked to identify vascular involvement in a total of 12 CT and MRI scans displaying PDAC (2 resectable, 2 borderline resectable, and 2 locally advanced tumours per modality). Results were compared to 2D standard PACS viewing. In VR visualisation of CT and MRI, the abdominal anatomical landmarks were recognised by all participants except the pancreas (30/34) in VR CT and the splenic (31/34) and common hepatic artery (18/34) in VR MRI, respectively. In VR CT, resectable, borderline resectable, and locally advanced PDAC were correctly identified in 22/24, 20/24 and 19/24 scans, respectively. Whereas, in VR MRI, resectable, borderline resectable, and locally advanced PDAC were correctly identified in 19/24, 19/24 and 21/24 scans, respectively. Interobserver agreement as measured by Fleiss κ was 0.7 for CT and 0.4 for MRI, respectively (p < 0.001). Scans were significantly assessed more accurately in VR CT than standard 2D PACS CT, with a median of 5.5 (IQR 4.75-6) and a median of 3 (IQR 2-3) correctly assessed out of 6 scans (p < 0.001). VR enhanced visualisation of abdominal CT and MRI scan data provides intuitive handling and understanding of anatomy and might allow for more accurate staging of PDAC and could thus become a valuable adjunct in PDAC resectability assessment in the future.

Abstract A057: Decreased plasma linoleic acid and increased oleic acid associated with obesity in pancreatic cancer

Abstract Background: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that interferes with absorption of nutrients including fats. Obesity is a key risk factor for PDAC and confers metabolic dysfunction associated with changes in fatty acid (FA) metabolism, including FAs in the linoleic acid and palmitic acid pathways. In turn, FAs can influence the molecular signaling in pancreatic cells. Changes in blood FA abundance induced by PDAC could be amplified by obesity and influence PDAC-associated outcomes. Therefore, we investigated plasma FA abundance in patients with treatment-naïve PDAC compared with control participants and explored how obesity status affects the linoleic acid and palmitic acid pathways in cancer. Methods: Blood and clinical characteristics were collected from participants with resectable tumors (rPDAC, n=52) or metastatic disease (mPDAC, r=55) that were treatment-naïve and 22 controls. Plasma samples were analyzed for relative FA abundance using gas chromatography and levels were compared between controls, rPDAC and mPDAC. Changes in FA abundance due to obesity (body mass index ≥30 kg/m2) were assessed in all groups. All FA abundance changes were analyzed using a two-way ANOVA with the appropriate parametric or non-parametric test, and p-values were adjusted using the Bonferroni correction. Results: Compared with controls, both rPDAC and mPDAC were associated with increased FA abundance of palmitic acid and decreased abundance of linoleic acid, γ-linolenic acid, and dihomo-γ-linolenic acid, regardless of obesity status (p&amp;lt;0.05). Plasma FA abundance of linoleic acid was increased in mPDAC versus rPDAC, regardless of obesity status (p&amp;lt;0.05). Decreased abundance of linoleic acid was noted in rPDAC and mPDAC participants with obesity versus participants without obesity, while there was an increased abundance of oleic acid observed in mPDAC among participants with obesity versus participants without obesity (p&amp;lt;0.05). Conclusions: Plasma FA levels are dysregulated in all PDAC stages versus controls. The results suggest that obesity-associated metabolic dysregulation influences linoleic acid and oleic acid abundances of participants with treatment-naïve PDAC. By improving our understanding of how obesity influences FA abundance in PDAC, we can identify novel mechanistic targets for treatment specific to PDAC stage and obesity status. Citation Format: Kaylin M. Chasser, Martha A. Belury, Jordan M. Cloyd, Rachel M. Cole, Stacey Culp, Mary E. Dillhoff, Aslam Ejaz, Kristyn Gumpper-Fedus, Phil A. Hart, Lauren Kanzaki, Andrei V. Manilchuk, Anne M. Noonan, Timothy M. Pawlik, Mitchell Ramsey, Zobeida Cruz-Monserrate. Decreased plasma linoleic acid and increased oleic acid associated with obesity in pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr A057.

Abstract C100: Novel functions of ATF4 in early stages of pancreatic cancer tumorigenesis

Abstract Biological stresses that are cell-intrinsic (e.g., oncogene-induced imbalances in protein translation, lipid synthesis, mitochondrial dysfunction) or cell-extrinsic (e.g., nutrient deprivation, hypoxia, drug exposure) disrupt cellular function and viability if not mitigated. The Integrated Stress Response (ISR) consists of upstream regulatory kinases (PERK, GCN2, HRI, PKR) that respond to such stresses in part by activating the ATF4 transcription factor. ATF4 then rewires nutrient uptake, cellular metabolism, mitochondrial function, and protein chaperone networks to restore cellular homeostasis. We have shown that ATF4 is upregulated in mouse and human pancreatic ductal adenocarcinoma (PDAC), even compared to normal acinar cells where ATF4 is expressed at relatively high levels. To investigate the role of ATF4 in PDAC, we generated mice with inducible acinar-specific deletion of Atf4 using Ptf1a-CreERT to delete Atf4 following treatment of adult Atf4-floxed mice with tamoxifen. In contrast to previous studies showing germline deletion of Atf4 in mice caused premature mortality at approximately 3 weeks of age due to pancreatic insufficiency, inducible deletion of Atf4 in adult acinar cells does not cause pancreatic deficiency or animal demise. Rather, adult Ptf1a-CreERT;Atf4fl/fl (CA) mice are viable although more sensitive to cerulein-induced pancreatitis. Specifically, compared to control (WT) mice, CA mice exhibit more extensive acinar-ductal metaplasia (ADM), including more extensive expression of cytokeratin-19 (CK19), increased cell death and take longer to recover normal pancreatic architecture following in vivo cerulein challenge. Using ex vivo acinar explant assays derived from WT and CA mice, we further show that induction of ADM in WT acinar cells with TGF-a is associated with down-regulation of Atf4 and Atf4 target genes in WT acinar explants while CA explants undergo accelerated ADM. Furthermore, expression of exogenous Atf4 in acinar cells inhibited ADM. These in vivo and ex vivo findings are consistent with down-regulation of Atf4 being required for ADM. Given the tumor-promoting role of ADM in the early stages of PDAC, we next crossed the CA mice to LSL-KRasG12D mice to generate LSL-KRasG12D;Ptf1a-CreERT;Atf4fl/fl (KCA) mice to examine how loss of Atf4 affected pancreatic intraepithelial neoplasia (PanIN) and PDAC formation. Surprisingly, given the critical need to down-regulate Atf4 in ADM, we show for the first time that genetic deletion of Atf4 in pancreatic acinar cells blocks both PanIN and PDAC formation in KCA mice compared to age-matched KC mice. Rather, KCA mice developed a fatty pancreas devoid of tumor with very few CK19-positive cells forming. These results suggest that Atf4 is critical for PanIN formation and prevents PDAC. This also suggests that Atf4 plays a different role in PanIN formation than in ADM where its down-regulation was critical and indicates a dynamic role for Atf4 depending on oncogenic versus proteotoxic stress, as will be discussed. Citation Format: Leah M. Ziolkowski, Kay F. Macleod. Novel functions of ATF4 in early stages of pancreatic cancer tumorigenesis [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr C100.

Abstract A040: Assessing the ability of Fc3TSR to remodel the tumor microenvironment and enhance efficacy of immunotherapies and chemotherapy in a murine model of pancreatic ductal adenocarcinoma

Abstract Introduction: Pancreatic Ductal Adenocarcinoma (PDAC) has a poor survival rate due to late diagnosis where metastasis has often occurred. Angiogenesis, the process by which new vessels form from pre-existing vasculature, is crucial for tumor growth and metastasis. Tumors aggressively upregulate expression of pro-angiogenic factors, stimulating rapid vessel formation. These vessels often lack pericyte coverage and have dysfunctional morphology, leading to high interstitial fluid pressure (IFP). Impaired perfusion and high IFP impede therapy uptake. Fc3TSR is a novel fusion protein derived from the potent angiogenic inhibitor thrombospondin 1, which we have shown to normalize vasculature in ovarian cancer, significantly decreasing tumor size and improving uptake of many therapies. In this study, we evaluated Fc3TSR’s ability to remodel the tumor microenvironment to induce tumor regression and to enhance efficacy of other therapies. Methods: We developed an orthotopic syngeneic murine model of PDAC, whereby we surgically injected 2.5 × 104 murine PDAC cells (KPC) into the tail of the pancreas of C57BL/6 mice. Tumors were allowed to progress for 14 days before intraperitoneal (IP) administration of Fc3TSR (0.158mg/kg) or PBS (control) on day 14 and 21. Gemcitabine (GEM) chemotherapy treated mice received either daily, metronomic dosages of GEM, or weekly, maximum tolerated dosages GEM starting on day 23. Checkpoint inhibitor mice received either PD-L1 (25ug) or CTLA4 (25ug) checkpoint inhibitors on day 23 and 26. Mice were euthanized on day 30 and tumors and the draining lymph nodes were collected and weighed. 1 hour before euthanasia, Fc3TSR and PBS mice were IP injected with Hypoxyprobe (Pimonidazole Hydrochloride) and tumors were immunostained for markers of blood vessels and tumor hypoxia. Results: Fc3TSR induced tumor regression when compared to PBS, but GEM at either dosage did not further enhance this effect. Following Fc3TSR, PD-L1, but not CTLA-4 checkpoint inhibitors significantly reduced tumor size when compared to mice pre-treated with PBS. Fc3TSR treatment also reduced the area of tumor hypoxia. Tumor vasculature is currently being imaged and analyzed for Fc3TSR’s effect on vessel morphology. Conclusion: Our data suggests that normalizing the tumor microenvironment can enhance the uptake and efficacy of combination therapies. Enhanced perfusion could facilitate the migration of activated immune cells and may enhance immune responses in PDAC patients. Here we demonstrate a novel approach to optimize therapeutic efficacy in advanced stage PDAC. Citation Format: Bianca Garlisi, Caroline Aitken, Sylvia Lauks, Julia Stewart, Duncan Petrik, Jack Lawler, Jim Petrik. Assessing the ability of Fc3TSR to remodel the tumor microenvironment and enhance efficacy of immunotherapies and chemotherapy in a murine model of pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr A040.

Abstract A014: Combinations of previously reported biomarkers achieve improved sensitivity and specificity of detection of early stage pancreatic ductal adenocarcinoma

Abstract A promising approach to the early detection of pancreatic ductal adenocarcinoma (PDAC) is surveillance among people at elevated risk for the disease using a blood test. Several groups have reported promising biomarkers, but no single biomarker delivers the rate of positively predicting cancers and of negatively predicting non-cancers needed for routine use. We hypothesized that combinations of previously reported PDAC biomarkers could contribute complementary detection across heterogeneous subgroups of patients and consequently improve biomarker performance. Blood plasma specimens from 427 individuals, grouped into a training set (n = 132) and a validation set (n = 295), were distributed to four different laboratories for analysis using their independently developed biomarker assays. We analyzed the training set to identify biomarker combinations that improved upon CA19-9 for identification of early stage PDAC relative to benign disease conditions, both for improved sensitivity while controlling for high specificity and improved specificity while controlling for high sensitivity. We then applied the biomarker combinations to the validation set to determine their performance. The combination of CA19-9 with the glycan biomarker CA199.STRA improved sensitivity from 0.44 sensitivity with 0.98 specificity for CA19-9 to 0.71 sensitivity with 0.94 specificity (p &amp;lt; 0.001, 1000-fold bootstrap), and CA19-9 combined with the protein biomarker LRG1 and CA199.STRA improved specificity from 0.16 specificity and 0.94 sensitivity for CA19-9 to 0.58 specificity and 0.89 sensitivity (p &amp;lt; 0.001, 1000-fold bootstrap). Notably, cross-laboratory biomarker combinations that did not include CA19-9 in the panel significantly improved upon CA19-9. The combination of CA199.STRA with the protein biomarker MUC5AC improved sensitivity over CA19-9 with 0.61 sensitivity and 0.94 specificity (p = 0.0002, 1000-fold bootstrap), and the combination of CA199.STRA and the protein biomarkers MUC5AC, THSP2, and ANG improved specificity over CA19-9 with 0.66 specificity and 0.88 sensitivity (p &amp;lt; 0.0001, 1000-fold bootstrap). By coordinating this biomarker study across independent laboratories, we have identified novel biomarker combinations that significantly increase the sensitivity and specificity of early stage PDAC detection and that demonstrate the future feasibility of surveillance for PDAC using combinations of serum assays. Citation Format: Brian Haab, Lu Qian, Ben Staal, Maneesh Jain, Johannes Fahrmann, Christine Worthington, Denise Prosser, Liudmila Velokokhatnaya, Camden Lopez, Runlong Tang, Mark Hurd, Gopalakrishnan Natarajan, Sushil Kumar, Lynette Smith, Samir Hanash, Surinder Batra, Anirban Maitra, Anna Lokshin, Ying Huang, Randall E. Brand, Liudmila Velokokhatnaya. Combinations of previously reported biomarkers achieve improved sensitivity and specificity of detection of early stage pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr A014.