The impact of the 'hub and spoke' model of care for lung cancer and equitable access to surgery.

OBJECTIVES: To determine the influence of where a patient is first seen (either surgical or non-surgical centre) and patient features on having surgery for non-small cell lung cancer (NSCLC). DESIGN: Cross-sectional study from individual patients, between 1January 2008 and 31March 2012. SETTING: Linked National Lung Cancer Audit and Hospital Episode Statistics datasets. PARTICIPANTS: 95,818 English patients with a diagnosis of NSCLC, of whom 12,759 (13%) underwent surgical resection. MAIN OUTCOME MEASURE: Odds of having surgery based on the empirical catchment population of the 30 thoracic surgical centres in England and whether the patient is first seen in a surgical centre or a non-surgical centre. RESULTS: Patients were more likely to be operated on if they were first seen at a surgical centre (OR 1.37; 95% CI 1.29 to 1.45). This was most marked for surgical centres with the largest catchment populations. In these surgical centres with large catchment populations, the resection rate for local patients was 18% and for patients first seen in a non-surgical centre within catchment was 12%. CONCLUSIONS: Surgical centres that serve the largest catchment populations have high resection rates for patients first seen in their own centre but, in contrast, low resection rates for patients first seen at the surrounding centres they serve. Our findings demonstrate the importance of going further than relating resection rates to hospital volume or surgeon number, and show that there is a pressing need to design lung cancer services which enable all patients, including those first seen at non-surgical centres, to have equal access to lung cancer surgery.

Utility of an immune cell function assay to differentiate rejection from infectious enteritis in pediatric intestinal transplant recipients.

The Cylex Immune Cell Function Assay measures cell-mediated immunity based on ATP production by stimulated CD4 + cells. We hypothesized that this test would discriminate acute cellular rejection (ACR) from infectious enteritis (IE) in pediatric intestinal transplant (ITx) recipients with allograft dysfunction. We retrospectively analyzed 224 Cylex assays drawn in 47 children who received 53 ITx. Samples were classified as stable, ACR, or IE based on clinical status. ATP values were analyzed using Kruskal-Wallis and t-tests. Overall, there was a statistically significant difference in ATP values based on clinical status (p = 0.03); however, overlap was observed between groups. The median ATP value during ACR was significantly greater than during stable periods (p = 0.02). No difference was seen in IE vs. stability (p = 0.8). The difference in median ATP value in ACR vs. IE approached significance (p = 0.1). Relative to previous levels, ACR episodes were associated with a median ATP increase of 101 ng/mL and IE episodes with a decrease of 3 ng/mL (p = 0.3). These data indicate that the Cylex assay has limited utility in differentiating ACR from IE, largely due to interpatient variability. Following longitudinal intrapatient trends may be an adjunctive tool in discriminating IE from ACR and guiding immunosuppression adjustments in select patients.

Discovery of Novel, Orally Bioavailable Pyrimidine Ether-Based Inhibitors of ELOVL1.

In our efforts to identify novel small molecule inhibitors for the treatment of adrenoleukodystrophy (ALD), we conducted a high-throughput radiometric screen for inhibitors of elongation of very long chain fatty acid 1 (ELOVL1) enzyme. We developed a series of highly potent, central nervous system (CNS)-penetrant pyrimidine ether-based compounds with favorable pharmacokinetics culminating in compound 22. Compound 22 is a selective inhibitor of ELOVL1, reducing C26:0 VLCFA synthesis in ALD patient fibroblasts and lymphocytes in vitro. Compound 22 reduced C26:0 lysophosphatidyl choline (LPC), a subtype of VLCFA, in the blood of ATP binding cassette transporter D1 (ABCD1) KO mice, a murine model of ALD to near wild-type levels. Compound 22 is a low-molecular-weight, potent ELOVL1 inhibitor that may serve as a useful tool for exploring therapeutic approaches to the treatment of ALD.

Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors.

OBJECTIVE: To evaluate patient survival and allograft function and health-related quality of life (HRQOL) 20 years after orthotopic liver transplantation (LT). SUMMARY OF BACKGROUND DATA: Although LT is the established treatment of choice for acute and chronic liver failure, allograft function and recipient HRQOL 20 years after LT remain undefined. METHODS: We performed a prospective, cross-sectional study of LT recipients surviving 20 years or more. Clinical data were reviewed to identify factors associated with 20-year survival. Survivors were directly contacted and offered a survey to assess HRQOL (SF-36; Liver Disease Quality of Life), social support, and cognition (Neuropsychological Impairment Scale). Logistic regression analysis was performed to identify clinical factors influencing HRQOL 20 years after LT. RESULTS: Between February 1, 1984 and December 31, 1988, a total of 293 patients (179 adults, 114 children) received 348 LTs. Of the 293 patients, 168 (56%) survived for 20 years or more. Actuarial 20-year survival was 52% (patient) and 42% (graft). Factors associated with 20-year survival included recipient age <18 (P = 0.01), nonurgent LT (P = 0.01), no retransplantation (0.02), female gender (0.03), absence of biliary complications (P = 0.04), and short total ischemia time (P = 0.05). Rejection episodes were seen in a greater proportion of 20-year survivors than in nonsurvivors (35% vs. 27%; P = 0.3). Of the 168 survivors, 87 were contacted, and 68 (78%) completed the HRQOL surveys. Compared with the general population, survivors had lower physical scores (P < 0.01) but comparable mental scores on the SF-36. Overall HRQOL was significantly better in 20-year survivors than in patients with chronic liver disease, congestive heart failure, or diabetes. Clinical factors associated with improved post-LT HRQOL were younger age at LT, allograft longevity, and strong social support. More than 90% of pediatric survivors completed high school. After LT, 34% of pediatric recipients married, and 79% remained married at 20 years' follow-up. CONCLUSIONS: More than 50% of LT recipients survive 20 years, achieve important socioeconomic milestones, and report quality of life superior to patients with liver disease or other chronic conditions. LT is a durable surgery that restores both long-term physiologic and psychologic well-being in patients with end-stage liver disease.

Survival in Asian Americans after treatments for hepatocellular carcinoma: a seven-year experience at UCLA.

BACKGROUND/RATIONALE: Hepatocellular carcinoma (HCC) is a common malignancy in Asians and is related to the high incidence of chronic viral hepatitis in this ethnic population. The aims of this study were to examine the tumor characteristics and liver disease status in HCC patients of Asian ancestry and determine their survival after treatments for HCC. RESULTS: Between September 2000 and December 2007, 278 patients, mean age 61.5 years, presented with HCC to the University of California Los Angeles (UCLA) Liver Cancer Center. Hepatitis B (HBV) infection was detected in up to 68% of Chinese, Korean, and Vietnamese patients, whereas 60% of Japanese patients had Hepatitis C (HCV) infection. Compared with HCC patients who presented with symptoms, those detected by surveillance had more tumors within the Milan and University of California, San Francisco (UCSF) criteria and more patients in Child-Turcotte-Pugh class A. On the basis of a predefined UCLA treatment algorithm, 83% of patients received surgical and/or loco-regional therapies. Compared with other treatments, orthotopic liver transplantation (OLT), and radiofrequency ablation had the highest overall patient survival (P<0.0001) and OLT has the highest disease free survival rates (P<0.0001). Independent baseline predictors for: (1) patient survival were HBV [hazard ratio (HR) 0.62, P=0.005], UCSF criteria (HR 0.46, P<0.0001), Child Turcotte Pugh class A (HR 0.57, P=0.005), alphafetoprotein per log10 increase (HR 1.26, P=0.0012), and alkaline phosphatase per log10 increase (HR 2.32, P=0.02); and for (2) disease free survival were UCSF criteria (HR 0.66 P=0.007), aspartate aminotransferase per log10 increase (HR 1.50, P=0.04), and age per year increase (HR=1.02, P=0.04). The 4 Asian subgroups had similar survival rates. CONCLUSIONS: HBV and Hepatitis C were associated with over 90% of HCC cases in Asian Americans. HCC detected by surveillance identified more patients eligible for surgical and loco-regional therapies, which improved the overall and disease free survival.

A novel chemotype of kinase inhibitors: Discovery of 3,4-ring fused 7-azaindoles and deazapurines as potent JAK2 inhibitors.

Pictet-Spengler condensation of aldehydes or alpha-keto-esters with 4-(2-anilinophenyl)-7-azaindole (11) or deazapurine (12) gave high yields of the 3,4-fused cyclic compounds. SAR studies, by varying the substituted benzaldehyde components, lead to the discovery of a series of potent JAK2 kinase inhibitors.

Ileostomy After Intestinal Transplantation: The First in Depth Report on Techniques, Complications, and Outcomes.

BACKGROUND: Temporary ileostomy during intestinal transplantation (ITx) is the standard technique for allograft monitoring. A detailed analysis of the ITx ileostomy has never been reported. METHODS: A retrospective review of a single-center ITx database was performed. The analysis was divided into ileostomy formation and takedown episodes. RESULTS: One hundred thirty-five grafts underwent ileostomy formation, and 79 underwent ileostomy takedown. Median age at ITx was 7.7 years and weight was 23 kg. Allograft types were intestine (22%), liver/intestine (55%), multivisceral (16%), and modified multivisceral (7%). Sixty-four percent had 1-stage ITx, whereas 36% required 2-staged ITx. Final ileostomy types were end (20%), loop (10%), distal blowhole (59%), and proximal blowhole (11%). Ileostomy formation: Thirty-one grafts had complications (23%), including prolapse (26%), ischemia (16%), and parastomal hernia (19%). Twelve required surgical revision. There were no significant differences in graft type, ileostomy type, survival, and ileostomy takedown rate between grafts with and without complications. Colon inclusive grafts had higher complication rates (P = 0.002). Ileostomy takedown: Ileostomy takedown occurred at a median of 422 days post-ITx. Twenty-five complications occurred after 22 takedowns (28%), including small bowel obstruction (27%) and abscess (18%). Fifteen grafts required surgical correction. Recipients with complications had longer hospital stay (17 versus 9 d; P = 0.001) than those without complications. Graft type, ileostomy type, and survival were not different. CONCLUSIONS: The first of its kind analysis of the surgical ileostomy after ITx reveals that most recipients can undergo successful ileostomy formation/takedown, complication rates are significant but within an acceptable range, and complications do not affect survival. This study demonstrates that the routine use of transplant ostomies remains an acceptable practice after ITx. However, true analysis of risk and benefit will require a randomized control trial.

Fulminant hepatic failure in children: superior and durable outcomes with liver transplantation over 25 years at a single center.

OBJECTIVE(S): Death occurs in half of all children with fulminant hepatic failure (FHF). Although liver transplantation (LT) is potentially life-saving, there are only a few published series with limited experience. The aim was to examine predictors of survival after LT for FHF. METHODS: Between 1984 and 2008, all LT for FHF performed in recipients less than or equal to 18 years of age were analyzed from a prospectively maintained database using 35 demographic, laboratory, and operative variables. Unique calculated variables included creatinine clearance (cCrCl) and Pediatric End-Stage Liver Disease score (PELD). Study end-points were patient and death censored graft survival. Median follow-up was 98 months. Statistical analysis involved the log-rank test and Cox proportional hazards model. RESULTS: A total of 122 children underwent 159 LTx. Cryptogenic was the primary etiology (70%) and the median age was 53 months. The significant (P < 0.05) univariate predictors of worse graft survival were: recipient age <24 months, cCrCl <60 mL/min/1.73m, PELD >25 points, and warm ischemia time >60 minutes. The significant (P < 0.05) univariate predictors of worse patient survival were: recipient African-American and Asian race, recipient age <24 months, cCrCl <60 mL/min/1.73m, and time from onset jaundice to encephalopathy <7 days. On multivariate analysis, survival was significantly impacted by 4 variables: cCrCl <60 mL/min/1.73m (GRAFT and PATIENT), PELD >25 points (GRAFT), recipient age <24 months (GRAFT), and time from onset jaundice to encephalopathy <7 days (PATIENT). While overall 5- and 10-year survival was 73% and 72% (GRAFT) and 77% and 73% (PATIENT), these were significantly worse when a combination of multivariate risk-factors were present. CONCLUSIONS: This data from a large, single-center experience demonstrates that LT is the treatment of choice for FHF and results in durable survival. Analysis revealed 4 novel outcome predictors. Young children with rapid onset acute liver failure are a high-risk subpopulation. Unique to this study, cCrCl and PELD accurately predicted the end-points. This analysis identifies patient subpopulations requiring early aggressive intervention with LT.

2-Aminopyrazolo[1,5-a]pyrimidines as potent and selective inhibitors of JAK2.

Constitutive activation of the EPO/JAK2 signaling cascade has recently been implicated in a variety of myeloproliferative disorders including polycythemia vera, essential thrombocythemia and myelofibrosis. In an effort to uncover therapeutic potential of blocking the EPO/JAK2 signaling cascade, we sought to discover selective inhibitors that block the kinase activity of JAK2. Herein, we describe the discovery and structure based optimization of a novel series of 2-amino-pyrazolo[1,5-a]pyrimidines that exhibit potent inhibition of JAK2.

Residual apical space following surgery for pneumothorax increases the risk of recurrence.

OBJECTIVE: Residual air spaces on chest radiographs after pneumothorax surgery are not uncommon. We aimed to study their incidence and impact on surgical outcomes. METHODS: Four hundred and twenty-seven patients [283 men and 144 women with a median age of 31 (14-96) years] underwent surgery for pneumothorax from 1995 to 2005 in a single unit. Video-assisted thoracoscopy was used in 225 cases (53%). Outcomes were: duration of intercostal drainage and hospital stay, recurrence, re-operation and referral to chronic pain clinic. RESULTS: Median duration of intercostal drainage and hospital stay were 5 and 6 days, respectively. We found a recurrence rate of 6.6% (n=28), re-operation rate of 2.8% (n=12) and need for referral to pain clinic of 7% (n=30). In 129 patients (30%) a small residual apical space (RAS) was reported on chest radiograph prior to discharge. Hospital stay and duration of drainage were longer in these cases (p=0.002 and 0.02, respectively). On multivariate analysis RAS on chest radiograph was associated with increased risk of recurrence [hazard ratio 3.1 (1.4-6.8 95% CI)] (p=0.005); but no need for re-operation or referral to pain clinic. Re-operation was associated with VATS surgery (p=0.001) and when no abnormalities were identified at operation (p=0.04). Referral to pain clinic was more common after open surgery (p=0.01). DISCUSSION: The risk of recurrence after pneumothorax surgery is low. But the presence of a residual apical space on chest radiography after surgery increases it significantly. Recurrence may be due to the failure to achieve early pleural symphysis.

Multicomponent analysis of the tumour microenvironment reveals low CD8 T cell number, low stromal caveolin-1 and high tenascin-C and their combination as significant prognostic markers in non-small cell lung cancer.

The complex interplay of the tumour microenvironment (TME) and its role in disease progression and response to therapy is poorly understood. The majority of studies to date focus on individual components or molecules within the TME and so lack the power correlative analysis. Here we have performed a multi-parameter analysis of the TME in 62 resectable non-small cell lung cancer (NSCLC) specimens detailing number and location of immune infiltrate, assessing markers of cancer-associated fibroblasts, caveolin-1 and tenascin-C, and correlating with clinicopathological details, as well as markers of disease progression such as epithelial-to-mesenchymal transition (EMT). The influence of individual parameters on overall survival was determined in univariate and multivariate analysis and the combination of risk factors and interplay between components analysed. Low numbers of CD8 T cells, low stromal levels of caveolin-1 or high levels of tenascin-C were significant prognostic markers of decreased overall survival in both univariate and multivariate analysis. Patients with two or more risk factors had dramatically reduced overall survival and those with all three a median survival of just 7.5 months. In addition, low levels of tumour E-cadherin correlated with reduced immune infiltrate into the tumour nests, possibly linking EMT to the avoidance of CD8 T cell control. The multicomponent approach has allowed identification of the dominant influences on overall survival, and exploration of the interplay between different components of the TME in NSCLC.

Nutritional status affects long term survival after lobectomy for lung cancer.

STUDY OBJECTIVES: Nutritional status has been reported as a predictor of complications following surgery for lung cancer. However, the impact of impaired nutrition in the long term has not been extensively studied. We have analysed our own experience after lobectomy for non-small cell lung cancer (NSCLC). PATIENTS: Six hundred and forty-two consecutive patients undergoing lobectomy for primary lung cancer in a single centre between October 1991 and April 2004 were included in the study. STUDY DESIGN: Impaired nutritional status was defined as any of low pre-operative albumin level (less than 30g/L), recent history of weight loss or low body mass index (BMI)--less than 18.5kg/m(2). There were 400 males and 242 females, median age 66 (range 32-89 years). Outcomes studied were hospital mortality and complications, and long term survival. RESULTS: A high proportion of patients (185 of 642, 28%) were classed as having poor nutritional status. There were 12 hospital deaths (1.9%). Nutritional depletion had no significant impact on hospital mortality (1.3% versus 2.7%), cardiac (14.4% versus 16.8%), or respiratory (17.5% versus 18.9%) complications. The overall median survival was 48+/-6 months (standard error). On Cox multivariate analysis, impaired nutritional status, tumour stage and need for en bloc chest wall excision were all independent predictors of survival. CONCLUSIONS: Nutritional status does not appear to significantly influence immediate outcomes following lobectomy for lung cancer. However, it is a predictor of survival in the long term independently of tumour extension and staging.

Discovery of Novel, Orally Bioavailable ß-Amino Acid Azaindole Inhibitors of Influenza PB2.

In our efforts to develop novel small-molecule inhibitors for the treatment of influenza, we utilized molecular modeling and the X-ray crystal structure of the PB2 subunit of the influenza polymerase to optimize a series of acyclic ß-amino acid inhibitors, highlighted by compound 4. Compound 4 showed good oral exposure in both rat and mouse. More importantly, it showed strong potency versus multiple influenza-A strains, including pandemic 2009 H1N1 and avian H5N1 strains and showed a strong efficacy profile in a mouse influenza model even when treatment was initiated 48 h after infection. Compound 4 offers good oral bioavailability with great potential for the treatment of both pandemic and seasonal influenza.

A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery.

OBJECTIVE: Our questionnaire study set out to assess the prevalence of chronic pain after thoracic surgery, the contribution of the neuropathic component of chronic pain and the impact of chronic pain on patients' lives. METHODS: A questionnaire was sent to 1152 patients who had undergone thoracic surgery in our department between 7 months and 7 years ago. The questionnaire was designed specifically for the study and included questions on neuropathic symptoms. Responses were correlated with data from our prospectively entered database for analysis. RESULTS: Nine hundred and forty-eight people were included in the study, of which 600 responded (63%). Prevalence of chronic pain is 57% at 7-12 months, 36% at 4-5 years and 21% at 6-7 years. Patient age, consultant and time since the operation all have significant effects. Surgical approach (video-assisted thoracoscopic surgery, thoracotomy) and diagnosis are not significant. Thirty-nine percent of those with pain take analgesia, 46% felt their pain is their worst medical problem and 40% reported it limits their daily activities. The prevalence of each neuropathic symptom is between 35 and 83%. The presence of a neuropathic symptom is associated with significantly more severe pain, more analgesia use and pain more likely to limit daily activity. CONCLUSIONS: Chronic pain has a significant prevalence and impact on patients' lives for several years after thoracic surgery. Nerve dysfunction is associated with more severe pain, a greater impact and tends to persist. The reason for the individual consultant being an important factor in post-thoracotomy pain needs further investigation.

A study exploring the role of intercostal nerve damage in chronic pain after thoracic surgery.

OBJECTIVE: Our aim was to investigate the prevalence of intra-operative nerve damage and its association with chronic pain. METHODS: Our prospective study of 33 patients used nerve conduction studies to assess intercostal nerve function during elective thoracic surgical procedures. We used two methods to study nerve conduction: pre-operative magnetic stimulation (in 10 patients) and intra-operative nerve conduction studies (in all patients) We correlated these findings with specific intra-operative parameters, pain and psychological questionnaires pre-op and 3 month post-op and altered cutaneous sensation. RESULTS: Magstim (magnetic stimulation) assessments were not reliable and were therefore abandoned. Intraoperative intercostal nerve studies revealed two distinct patterns of nerve injury and also that nerve injury was less in those cases where a rib was not resected. However, intercostal nerve damage detected at the time of operation is not associated with chronic pain or altered cutaneous sensation at 3 months post-op. CONCLUSIONS: The study findings suggest that either the amount of intra-operative intercostal nerve damage is not indicative of long-term nerve damage or that there is a more significant cause for chronic pain other than intercostal nerve injury.

Unplanned splenectomy during oesophagectomy does not affect survival.

OBJECTIVE: There are limited and conflicting data available concerning the incidence of inadvertent splenectomy and its impact on the outcome in patients who have undergone oesophagectomy. The aim of this study is to identify the factors associated with a likelihood of inadvertent splenectomy and its influence on early and long-term outcome in patients having oesophagectomy for oesophageal carcinoma. METHODS: A consecutive series of 738 oesophagectomies performed between 1991 and 2004 was analysed. In our practice, the spleen was removed only if damaged intraoperatively. Routine chemo- and immunoprophylaxis would subsequently be used. Multivariate analysis with logistic and Cox models determined significant variables. RESULTS: Of the 738 oesophagectomies, 48 (6.5%) had splenectomy. Neoadjuvant chemotherapy was administered to a minority of patients; none subsequently had splenectomy. There were significant differences between types of operation (Ivor-Lewis 18 (9.0%), left thoracolaparotomy 14 (9.9%) and left thoracophrenotomy 15 (3.9%), p=0.01). Splenectomy was more common with advanced N stage disease (OR=0.44 [0.20-0.95]; p=0.04). Splenectomy resulted in more blood transfusions (median, 2 units vs 0 units; p=0.03) more anastomotic leaks (7 [14.6%] vs 42 [6.1%]; p=0.02) but not an increase in pulmonary complications (p=0.64) or in-hospital mortality (1 [4.6%] vs 37 [5.4%]; p=0.30). Splenectomy did not significantly affect median survival (551 [332-770] days vs 627 [554-700] days; p=0.63). CONCLUSION: Although inadvertent splenectomy increased the morbidity of oesophagectomy, it did not impair survival. Type of operation and advanced N stage are important risks for splenectomy. Though best avoided, most of the consequences of splenectomy can be managed. An unexpected relationship between splenectomy and anastomotic leaks needs further investigation.

3-Dimensional Patient-Derived Lung Cancer Assays Reveal Resistance to Standards-of-Care Promoted by Stromal Cells but Sensitivity to Histone Deacetylase Inhibitors.

There is a growing recognition that current preclinical models do not reflect the tumor microenvironment in cellular, biological, and biophysical content and this may have a profound effect on drug efficacy testing, especially in the era of molecular-targeted agents. Here, we describe a method to directly embed low-passage patient tumor-derived tissue into basement membrane extract, ensuring a low proportion of cell death to anoikis and growth complementation by coculture with patient-derived cancer-associated fibroblasts (CAF). A range of solid tumors proved amenable to growth and pharmacologic testing in this 3D assay. A study of 30 early-stage non-small cell lung cancer (NSCLC) specimens revealed high levels of de novo resistance to a large range of standard-of-care agents, while histone deacetylase (HDAC) inhibitors and their combination with antineoplastic drugs displayed high levels of efficacy. Increased resistance was seen in the presence of patient-derived CAFs for many agents, highlighting the utility of the assay for tumor microenvironment-educated drug testing. Standard-of-care agents showed similar responses in the 3D ex vivo and patient-matched in vivo models validating the 3D-Tumor Growth Assay (3D-TGA) as a high-throughput screen for close-to-patient tumors using significantly reduced animal numbers. Mol Cancer Ther; 15(4); 753-63. ©2016 AACR.

Influence of hypoxia and neoangiogenesis on the growth of pancreatic cancer.

As with other solid tumors, the growth and metastasis of pancreatic cancer is critically dependent on tumor angiogenesis. A major stimulus for a tumor's recruitment of additional blood vessels is cellular hypoxia, a condition which is especially pronounced in this neoplasm. Hypoxia induces transcriptional activation of genes that alter cellular metabolism and promote neoangiogenesis. Pancreatic cancer cells have demonstrated activation of such adaptive pathways even in the absence of hypoxia. A highly-angiogenic response in this neoplasm correlates with increased tumor growth, increased metastasis, and decreased survival. Pancreatic cancers expressing high levels of vascular endothelial growth factor, a potent pro-angiogenic cytokine, also have a higher incidence of metastasis and poorer prognosis. Pancreatic cancer cells uniquely express receptors for vascular endothelial growth factor, indicating a role for an autocrine loop in tumor proliferation and invasion. Multiple experimental anti-angiogenic strategies, many of which target vascular endothelial growth factor, reduce pancreatic cancer growth, spread, and angiogenesis. Anti-angiogenic treatments for pancreatic cancer will likely be most effective when used as an integral part of a combination chemotherapeutic regimen.

Nerve growth factor stimulates MMP-2 expression and activity and increases invasion by human pancreatic cancer cells.

Pancreatic cancer frequently invades and migrates along neural tissue. Although the exact mechanisms are unknown, perineural invasion negatively impacts prognosis for pancreatic cancer patients. Matrix metalloproteinases (MMPs) are overexpressed in pancreatic cancer and are associated with poor prognosis. We hypothesized that nerve growth factor (NGF) released from neural tissue increases the invasive properties of pancreatic cancer cells. In the present study we investigated the effect of NGF on the expression and activity of MMP-2 in human pancreatic cancer cells. NGF dose dependently increased MMP-2 protein in the culture medium and stimulated MMP-2 gelatinolytic activity. This effect was mediated by specific binding of NGF to its receptor trk A, which was detected on all pancreatic cancer cells, with subsequent activation of the p44/42 MAPK signaling pathway. The NGF-induced increase in MMP-2 expression and activity lead to an enhanced invasion in vitro. These findings support the hypothesis that neurotrophic factors, e.g., NGF, are critically involved in mediating perineural invasion of pancreatic cancer.

Glial cell-derived neurotrophic factor upregulates the expression and activation of matrix metalloproteinase-9 in human pancreatic cancer.

BACKGROUND: We have previously reported that the glial cell-derived neurotrophic factor (GDNF) promotes pancreatic cancer cell invasion in vitro. The purpose of this study was to determine whether GDNF regulates the expression and activation of matrix metalloproteinase-9 (MMP-9) in human pancreatic cancer cells. METHODS: We used human pancreatic cancer cell line MIA PaCa-2. The effect of GDNF on mRNA and protein expression was measured by Northern blot, Western blot and enzyme-linked immunosorbent assay. MMP proteolytic activity was detected by gelatin zymography. To determine which intracellular pathways were involved, we used the following inhibitors: tyrosine kinase inhibitor Genistein, MEK-1 inhibitor PD98059 and PI3-K inhibitor Wortmannin. RESULTS: GDNF increased MMP-9 mRNA and protein expression in MIA PaCa-2 cells in a dose-dependent manner. Treatment with GDNF enhanced gelatinolytic activity of the pro and active form of MMP-9. Inhibitor experiments showed that the expression and activity of pro MMP-9 was totally inhibited by Genistein and partially by Wortmannin, whereas PD98059 had no effect. All three compounds inhibited the activity of the active form of MMP-9. CONCLUSIONS: GDNF upregulates the expression and enzymatic activity of MMP-9 through different signaling pathways in MIA PaCa-2. These findings suggest that GDNF modulates MMP-9 expression and activation, and this may promote pancreatic cancer invasion.