A prospective clinical and biological database for pancreatic adenocarcinoma: the BACAP cohort.

BACKGROUND: The prognosis for pancreatic cancer remains poor despite diagnostic advances and treatments with new chemotherapeutic regimens. The five year survival rate remains below 3%. Consequently, there is an urgent need for new treatments to significantly improve the prognosis. In addition, there is a big gap in terms of the screening, early diagnosis and prevention of pancreatic cancer the incidence of which is increasing dramatically. METHODS: Design: the BACAP cohort is a prospective multicenter pancreatic cancer cohort (pancreatic ductal carcinoma) with clinical and multiple biological samples; Participating centers: 15 French academic and private hospitals; Study Population: any cytologically and/or histologically proven pancreatic carcinoma regardless of the stage (resectable, borderline, locally advanced or metastatic) or treatment (surgery, palliative chemotherapy, best supportive care). At least 1500 patients will be included. Clinical data collected include: disease presentation, epidemiological and social factors, baseline biology, radiology, endoscopic ultrasound, staging, pathology, treatments, follow-up (including biological and radiological), and survival. All these data are collected and stored through an e-observation system at a centralized data center. Biological samples and derived products (i.e. before any treatment): blood, saliva, endoscopic ultrasound-guided fine needle aspiration materials from the primary tumor, fine needle biopsy of metastases and surgically resected tissue. DNA and RNA are extracted from fine needle aspiration materials and are quantified and characterized for quality. Whole blood, plasma and serum are isolated from blood samples. Frozen tissues were specifically allocated to the cohort. All derived products and saliva are stored at - 80 °C. Main end-points: i) to centralize clinical data together with multiple biological samples that are harmonized in terms of sampling, the post sampling process and storage; ii) to identify new molecular markers for the diagnosis, prognosis and possibly the predictive response to pancreatic cancer surgery and or chemotherapy. DISCUSSION: The BACAP cohort is a unique prospective biological clinical database that provides the opportunity to identify correlations between the presence/expression of a broad panel of biomarkers (DNA, RNA, miRNA, proteins, etc.), epidemiological and social data, various clinical situations, various stages and the differentiation of the tumor, treatments and survival. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02818829 . Registration date: June 30, 2016.

Identification of biomarkers of human pancreatic adenocarcinomas by expression profiling and validation with gene expression analysis in endoscopic ultrasound-guided fine needle aspiration samples.

AIM: To compare gene expression profiles of pancreatic adenocarcinoma tissue specimens, human pancreatic and colon adenocarcinoma and leukemia cell lines and normal pancreas samples in order to distinguish differentially expressed genes and to validate the differential expression of a subset of genes by quantitative real-time RT-PCR (RT-QPCR) in endoscopic ultrasound-guided fine needle aspiration (EUS-guided FNA) specimens. METHODS: Commercially dedicated cancer cDNA macroarrays (Atlas Human Cancer 1.2) containing 1176 genes were used. Different statistical approaches (hierarchical clustering, principal component analysis (PCA) and SAM) were used to analyze the expression data. RT-QPCR and immunohistochemical studies were used for validation of results. RESULTS: RT-QPCR validated the increased expression of LCN2 (lipocalin 2) and for the first time PLAT (tissue-type plasminogen activator or tPA) in malignant pancreas as compared with normal pancreas. Immunohistochemical analysis confirmed the increased expression of LCN2 protein localized in epithelial cells of ducts invaded by carcinoma. The analysis of PLAT and LCN2 transcripts in 12 samples obtained through EUS-guided FNA from patients with pancreatic adenocarcinoma showed significantly increased expression levels in comparison with those found in normal tissues, indicating that a sufficient amount of high quality RNA can be obtained with this technique. CONCLUSION: Expression profiling is a useful method to identify biomarkers and potential target genes. Molecular analysis of EUS-guided FNA samples in pancreatic cancer appears as a valuable strategy for the diagnosis of pancreatic adenocarcinomas.

Severe sinusoidal lesions: a serious and overlooked complication of oxaliplatin-containing chemotherapy?

The main toxicity of Oxaliplatin, a major drug in the treatment of metastatic colorectal carcinoma, is neurologic. Severe sinusoidal lesions of the liver have been recently described in patients receiving pre-operative (neoadjuvant) oxaliplatin-containing chemotherapy, but their clinical relevance is unknown. Four patients with metastatic colon cancer receiving oxaliplatin, 5 fluorouracil and elvorin, developped a progressive increase in gammaglutamyl transpeptidase and alkaline phosphatase, contrasting with tumour regression established by CT-scan and decrease in serum carcinoembryonic antigen concentrations. Histological examination of liver biopsies showed sinusoidal dilatation in all cases, with perisinusoidal fibrosis and centrilobular vein lesions in 3, peliosis in 1 (in a patient receiving oxaliplatine by intraarterial hepatic route), and nodular regenerative hyperplasia in 1. The patient with peliosis developped ascites, and died from hepatic failure, despite withdrawal of the drug. The patient with nodular regenerative hyperplasia developped jaundice, ascites and severe infection following a right hepatectomy. In the three surviving patients, liver function tests improved after the withdrawal of oxaliplatin, and, in one, deteriorated again after reintroduction of the drug. The prevalence of liver sinusoid lesions induced by oxaliplatin-containing chemotherapeutic regimens is probably underestimated. Careful monitoring of gamma-glutamyl transpeptidase and alkaline phosphatase is mandatory in treated patients, especially in those receiving adjuvant therapy, in whom significant sequelae could occur despite initially asymptomatic lesions.

The underestimated role of opiates in patients with suspected sphincter of Oddi dysfunction after cholecystectomy.

AIMS: Pain recurrence after cholecystectomy is often attributed to sphincter of Oddi dysfunction, whose diagnostic criteria and treatments remain uncertain. We performed a retrospective study to assess the possible precipitating role of opiate ingestion in this setting. METHODS: The retrospective study of the files of 147 consecutive patients investigated for post-cholecystectomy syndrome by endoscopic ultrasonography and/or endoscopic retrograde cholangiography yielded 37 cases of suspected biliary-type sphincter of Oddi dysfunction. RESULTS: Thirteen patients (30%) with suspected sphincter of Oddi dysfunction had taken opiate-containing drugs 15 minutes to two hours (median 1 hr) before the onset of pain ("Opiate group"). When compared with the 23 patients having not taken opiates ("Non Opiate Group"), they were significantly younger (47 vs. 60 yrs), had a narrower common bile duct (5.0 vs. 7.7 mm), but had similar biochemical abnormalities and belonged to the same Milwaukee's classes, mainly class II. None of the patients in the "Opiate group" were submitted to retrograde cholangiography or endoscopic sphincterotomy vs. 52% and 39%, respectively of the patients of the "Non-Opiate Group". After a mean follow-up of 3.5 years, there were three recurrences of biliary-type pain (1 choledochal stone, and 2 suspected sphincter of Oddi dysfunction) in the "Opiate Group", and 2 (1 choledochal stone, 1 after codeine intake) in the "Non-Opiate Group". CONCLUSIONS: Opiate intake is a frequent cause of suspicion of sphincter of Oddi dysfunction after cholecystectomy, especially in young patients with a narrow common bile duct. A careful history taking is essential to avoid unnecessary and potentially harmful procedures.

Frequent deletions of tumor suppressor genes in pure pancreatic juice from patients with tumoral or nontumoral pancreatic diseases.

BACKGROUND/AIMS: K-ras codon 12 mutation is the most frequent genetic alteration in pancreatic cancer. Sensitivity and specificity of K-ras are not high enough to detect all pancreatic cancers, especially at early stage. This study investigated whether detection of p16 and/or DPC4 deletions along with K-ras mutation in DNA samples could improve the definition of patients at risk of pancreatic cancer. METHODS: K-ras mutations were investigated by sequencing. p16 and DPC4 homozygous deletions were studied using comparative multiplex polymerase chain reaction of DNA in pancreatic juice sampled during endoscopic retrograde pancreatography in 57 patients with either pancreatic cancer (group I, 18 patients), chronic pancreatitis (group II, 20 patients), or nontumoral pancreatobiliary disease (group III, 19 patients). RESULTS: The frequencies of Ki-ras mutations were 61% in group I, 10% in group II, and 10.5% in group III. The frequencies of p16 exon 2 and DPC4 deletions were, respectively, 28 and 36% in group I, 50 and 58% in group II, and 24 and 36% in group III. CONCLUSIONS: The combination of p16 and DPC4 deletions with K-ras mutation does not improve the diagnosis of pancreatic cancer based on K-ras mutation alone. These data suggest that tumor suppressor gene inactivation can occur with a high frequency during nonmalignant pancreatic diseases.

Cirrhosis and bleeding: the need for very early management.

BACKGROUND/AIMS: Retrospective studies suggest that the prognosis of patients with cirrhosis and variceal hemorrhage has improved in more recent decades. In a prospective cohort study in which the choice of prophylactic therapy was left to each practitioner, we followed cirrhotic patients with medium/large varices to determine factors predictive of bleeding and death. METHODS: Three hundred fourteen patients with grades 2 or 3 esophageal varices (Child A and B/C: 218 and 96) were enrolled. One hundred seventy-three patients had no previous history of variceal bleeding. Only 245 patients (100% of patients with prior variceal hemorrhage, 61% of patients without prior hemorrhage) were receiving some form of prophylactic therapy. The median follow-up was 18 months. RESULTS: There were 76 bleeding events and 14 related deaths (18%); nine of these deaths occurred within 24 h of bleeding onset (two at home, two during hospital transfer, and five in hospital, a mean of 2.5 h after onset; six involved Child C patients). Twenty-five deaths were not due to bleeding but were closely related to cirrhosis. In a Cox model, the presence of tense ascites (relative risk 3.4, 95% confidence interval, CI 2.5-5.9) and a prior history of hemorrhage (relative risk 4.4, 95% CI 2.6-7.5) were independent predictors of variceal hemorrhage. In patients without a prior history of bleeding, bleeding risk was higher with more prolonged prothrombin time and lower when patients were receiving propranolol. CONCLUSIONS: Despite the advent of effective drugs and endoscopic therapy for variceal bleeding, about a quarter of deaths occur very early after bleeding onset, confirming the need for rapid specific management.