Stroma-regulated HMGA2 is an independent prognostic marker in PDAC and AAC.

BACKGROUND: The HMGA2 protein has experimentally been linked to EMT and cancer stemness. Recent studies imply that tumour-stroma interactions regulate these features and thereby contribute to tumour aggressiveness. METHODS: We analysed 253 cases of pancreatic ductal adenocarcinoma (PDAC) and 155 cases of ampullary adenocarcinoma (AAC) for HMGA2 expression by IHC. The data were correlated with stroma abundance and supplemented by experimental studies. RESULTS: HMGA2 acts as an independent prognostic marker associated with a significantly shorter overall survival in both tumour types. Overall, HMGA2-positivity was more frequent in patients with PDAC than with AAC. The HMGA2 status in tumour cells significantly correlated with the abundance of PDGFRß-defined stroma cells. In vivo co-injection of Panc-1 cancer cells with pancreatic stellate cells increased tumour growth in a manner associated with increased HMGA2 expression. Furthermore, in vitro treatment of Panc-1 with conditioned media from PDGF-BB-activated stellate cells increased their ability to form tumour spheroids. CONCLUSIONS: This study identifies HMGA2 expression in tumour cells as an independent prognostic marker in PDAC and AAC. Correlative data analysis gives novel tissue-based evidence for a heterotypic cross-talk with stroma cells as a possible mechanism for HMGA2 induction, which is further supported by experimental models.

The potential diagnostic value of serum microRNA signature in patients with pancreatic cancer.

Biomarkers for early diagnosis of patients with pancreatic cancer (PC) are needed. Our aim was to identify panels of miRNAs in serum in combination with CA 19-9 for use in the diagnosis of PC. Four hundred seventeen patients with PC were included prospectively from Denmark (n = 306) and Germany (n = 111). Controls included 59 patients with chronic pancreatitis (CP) and 248 healthy subjects (HS). MiRNAs were analyzed in pretreatment serum samples from 3 cohorts: discovery cohort (754 human miRNAs, TaqMan(®) Human MicroRNA assay, Applied Biosystem; PC n = 133, controls n = 72); training cohort (34 miRNAs, real-time qPCR using the Fluidigm BioMark™ System; PC n = 198, controls n = 184); validation cohort (13 miRNAs, real-time qPCR using the Fluidigm BioMark™ System; PC n = 86, controls n = 51). We found that 34 miRNAs in serum from PC patients in the discovery cohort were expressed differently than in controls. These miRNAs were tested in the training cohort, and four diagnostic panels were constructed that included 5 or 12 miRNAs (miR-16, -18a, -20a, -24, -25, -27a, -29c, -30a.5p, -191, -323.3p, -345 and -483.5p). Diagnostic accuracy of detecting PC in the training cohort was AUC (Index I 0.85; II 0.87; III 0.85; IV 0.95; CA 19-9 0.93); specificity (I 0.71; II 0.76; III 0.66; IV 0.90 (fixed sensitivity at 0.85); CA 19-9 0.93). Combining serum CA 19-9 and Index II best discriminated Stages I and II PC from HS [AUC 0.93 (0.90-0.96), sensitivity 0.77 (0.69-0.84), specificity 0.94 (0.90-0.96) and accuracy 0.88 (0.84-0.91)]. In conclusion, we identified four diagnostic panels based on 5 or 12 miRNAs in serum that could distinguish patients with PC from HS and CP.

TOP1 gene copy numbers are increased in cancers of the bile duct and pancreas.

BACKGROUND: Bile duct and pancreatic cancer (PC) have poor prognoses and treatment options for inoperable patients are scarce. In order to improve outcome for these patients, there is an urgent need for biomarkers predictive of treatment effect. Irinotecan is a topoisomerase 1 (Top1) poison. Top1 protein, TOP1 gene copy number and mRNA expression, respectively, have been proposed as predictive biomarkers of response to irinotecan in other cancers. Here we investigate the occurrence of TOP1 gene aberrations in cancers of the bile ducts and pancreas. MATERIAL AND METHODS: TOP1 and centromere 20 (CEN-20) numbers were investigated by fluorescence in situ hybridization analyses in tumor tissue from 226 patients. The frequencies of aberration in the TOP1 gene copy number, the CEN-20 copy number and the TOP1/CEN-20 ratio were analyzed. As TOP1 is located on chromosome 20, the CEN-20 probe was included to distinguish between chromosomal and gene amplifications. RESULTS: In PC, 29.8% had an increased TOP1 copy number (≥ 3.5n gene copies per cell) and 10.8% had a TOP1/CEN-20 ratio >1.5. In bile duct cancer, 12.8 % had an increased TOP1 copy number and 6.4% had a TOP1/CEN-20 ratio >1.5. Neither the TOP1 copy number nor the TOP1/CEN-20 ratios could predict overall survival. CONCLUSION: We here report that a substantial number of patients with bile duct or PC have increased TOP1 copy number and increased TOP1/CEN-20 ratio making further analyses on the association between TOP1 gene copy number and irinotecan efficacy clinically relevant.

Laparoscopic repair of paraesophageal hernia with anterior gastropexy: a multicenter study.

BACKGROUND: The approach to repair of paraesophageal hernias (PEHs) is controversial. Recent data suggest that mesh repair leads to recurrence rates similar to non-mesh approaches, while subjecting patients to mesh-associated complications. Routine fundoplication during PEH repair has been favored despite significant dysphagia rates. We present our multicenter prospective data on laparoscopic PEH repairs using a modified Boerema anterior gastropexy without fundoplication. METHODS: We prospectively followed patients after modified Boerema PEH repair at three institutions. Patient demographics, perioperative data, and postoperative outcomes were evaluated. Subjective and objective outcomes were assessed via clinical assessment, follow-up questioning, endoscopy, and radiographic swallow studies. RESULTS: A total of 101 patients were followed a mean of 10.8 (median, 12) months. We encountered 9 (8.9%) intraoperative complications and 13 (12.9%) postoperative complications. There was no mortality. Reflux symptoms were absent in 71 patients (70.3%) postoperatively. Of the remaining subjects, 8 (7.9%) had mild intermittent reflux without the need for proton pump inhibitors (PPI), 12 (11.9%) had moderate reflux necessitating PPI as needed, and 10 (9.9%) had reflux requiring daily PPI. Our recurrence rate, assessed at postoperative endoscopy/barium swallow, was 16.8%. Of these, 10 (9.9%) were small segmental recurrences and 7 (6.9%) were large recurrences. CONCLUSION: Herein, we demonstrate a favorable recurrence rate while avoiding the potential major complications associated with mesh hiatoplasty. Our data tend to support a tailored approach to incorporation of fundoplication during PEH repair. Postoperative acid reflux was absent in most of our patients, and pharmacotherapy alone was sufficient for those experiencing reflux symptoms.

Intrathoracic anastomotic leakage after gastroesophageal cancer resection is associated with reduced long-term survival.

BACKGROUND: Most likely because of low statistical power, no previous studies have shown any significant association between long-term survival and anastomotic leakage in patients who have undergone gastroesophageal cancer resection. MATERIAL AND METHODS: The present study included, prospectively and consecutively, nationwide collected patients who underwent gastroesophageal cancer resection between 2003 and 2011 in Denmark. The operation was carried out as an Ivor Lewis procedure. Only patients with intrathoracic anastomosis were included in the analysis. RESULTS: From 2003 to 2011, 1,296 patients underwent gastroesophageal resection, and 128 (9.9 %) of these experienced anastomotic leakage. The overall 5-year survival rates in patients with and without anastomotic leakage were 20 and 35 % (P < 0.0001), respectively. After exclusion of 4 weeks mortality, the 5-year survival rate in patients with leakage was 22 % compared to 36 % in patients without anastomotic leakage (P < 0.001). After exclusion of 8 weeks mortality, the 5-year survival rate was 23 % in patients with leakage and 36 % in those without (P = 0.009). The corresponding median time of survival was 74 versus 128, 87 versus 138, and 95 versus 138 weeks, respectively. The overall hazard ratios of death after anastomotic leakage, unadjusted, and after adjusting for potentially confounding factors, were 1.59 (1.27-1.99) and 1.45 (1.14-1.84). The unadjusted and adjusted odds ratios after exclusion of 4 weeks mortality were 1.51 (1.19-1.90) and 1.41 (1.10-1.81). After exclusion of 8 weeks mortality the odds ratios were 1.38 (1.08-1.77) and 1.32 (1.02-1.71). CONCLUSIONS: This nationwide study confirms that patients experiencing anastomotic leakage after gastroesophageal cancer resection have a significantly lower long-term survival, even following full recovery after the leakage.

MicroRNA biomarkers in whole blood for detection of pancreatic cancer.

IMPORTANCE: Biomarkers for the early diagnosis of patients with pancreatic cancer are needed to improve prognosis. OBJECTIVES: To describe differences in microRNA expression in whole blood between patients with pancreatic cancer, chronic pancreatitis, and healthy participants and to identify panels of microRNAs for use in diagnosis of pancreatic cancer compared with the cancer antigen 19-9 (CA19-9). DESIGN, SETTING, AND PARTICIPANTS: A case-control study that included 409 patients with pancreatic cancer and 25 with chronic pancreatitis who had been included prospectively in the Danish BIOPAC (Biomarkers in Patients with Pancreatic Cancer) study (July 2008-October 2012) plus 312 blood donors as healthy participants. The microRNA expressions in pretreatment whole blood RNA samples were collected and analyzed in 3 randomly determined subcohorts: discovery cohort (143 patients with pancreatic cancer, 18 patients with chronic pancreatitis, and 69 healthy participants), training cohort (180 patients with pancreatic cancer, 1 patient with chronic pancreatitis, and 199 healthy participants), and validation cohort (86 patients with pancreatic cancer, 7 patients with chronic pancreatitis, and 44 healthy participants); 754 microRNAs were screened in the discovery cohort and 38 microRNAs in the training cohort and 13 microRNAs in the validation cohort. MAIN OUTCOMES AND MEASURES: Identification of microRNA panels (classifiers) for diagnosing pancreatic cancer. RESULTS: The discovery cohort demonstrated that 38 microRNAs in whole blood were significantly dysregulated in patients with pancreatic cancer compared with controls. These microRNAs were tested in the training cohort and 2 diagnostic panels were constructed comprising 4 microRNAs in index I (miR-145, miR-150, miR-223, miR-636) and 10 in index II (miR-26b, miR-34a, miR-122, miR-126*, miR-145, miR-150, miR-223, miR-505, miR-636, miR-885.5p). The test characteristics for the training cohort were index I area under the curve (AUC) of 0.86 (95% CI, 0.82-0.90), sensitivity of 0.85 (95% CI, 0.79-0.90), and specificity of 0.64 (95% CI, 0.57-0.71); index II AUC of 0.93 (95% CI, 0.90-0.96), sensitivity of 0.85 (95% CI, 0.79-0.90), and specificity of 0.85 (95% CI, 0.80-0.85); and CA19-9 AUC of 0.90 (95% CI, 0.87-0.94), sensitivity of 0.86 (95% CI, 0.80-0.90), and specificity of 0.99 (95% CI, 0.96-1.00). Performances were strengthened in the validation cohort by combining panels and CA19-9 (index I AUC of 0.94 [95% CI, 0.90-0.98] and index II AUC of 0.93 [95% CI, 0.89-0.97]). Compared with CA19-9 alone, the AUC for the combination of index I and CA19-9 was significantly higher (P = .01). The performance of the panels in patients with stage IA-IIB pancreatic cancer was index I AUC of 0.80 (95% CI, 0.73-0.87); index I and CA19-9 AUC of 0.83 (95% CI, 0.76-0.90); index II AUC of 0.91 (95% CI, 0.87-0.94); and index II and CA19-9 AUC of 0.91 (95% CI, 0.86-0.95). CONCLUSIONS AND RELEVANCE: This study identified 2 diagnostic panels based on microRNA expression in whole blood with the potential to distinguish patients with pancreatic cancer from healthy controls. Further research is necessary to understand whether these have clinical implications for early detection of pancreatic cancer and how much this information adds to serum CA19-9.

Warm-up in a virtual reality environment improves performance in the operating room.

OBJECTIVE: To assess the impact of warm-up on laparoscopic performance in the operating room (OR). BACKGROUND: Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR. The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP. METHODS: Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR. Participants were randomized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group. After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preoperative warm-up. All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale (from 7 to 35). RESULTS: There was significantly better surgical performance on the laparoscopic Cholecystectomy following preoperative warm-up, median 28.5 (range = 18.5-32.0) versus median 19.25 (range = 15-31.5), P = 0.042. The results demonstrated excellent reliability of the assessment tool used (Cronbach's alpha = 0.92). CONCLUSION: This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP. The suggested program is short, easy to perform, and therefore realistic to implement in the daily life in a busy surgical department. This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR resources.

Prediction of Unresectability and Prognosis in Patients Undergoing Surgery on Suspicion of Pancreatic Cancer Using Carbohydrate Antigen 19-9, Interleukin 6, and YKL-40.

OBJECTIVES: The aim was to determine whether serum levels of carbohydrate antigen (CA) 19-9, interleukin 6 (IL-6), and YKL-40 could identify advanced disease and poor prognosis in pancreatic cancer (PC) patients intraoperatively diagnosed with locally advanced or metastatic disease. METHODS: Two hundred ninety patients were included with preoperative blood samples. Plasma IL-6 and YKL-40 were determined by enzyme-linked immunosorbent assays. RESULTS: Interleukin 6 was elevated in patients with unresectable PC compared with resectable PC (P = 0.03). Carbohydrate antigen 19-9 and YKL-40 were similar. Patients with resectable tumors and greater than median preoperative CA 19-9, IL-6, and YKL-40 had shorter overall survival than patients with low levels (CA 19-9: hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.13-2.83; P = 0.01; IL-6: HR, 1.83; 95% CI, 1.20-2.78; P = 0.01; YKL-40: HR, 1.60; 95% CI, 1.02-2.49; P = 0.04). Patients with resectable tumors and 2 or 3 high biomarker levels had significantly reduced overall survival compared with patients with low levels (2 high: HR, 2.97; 95% CI, 1.44-6.10; P = 0.00; 3 high: HR, 3.10; 95% CI, 1.45-6.65; P = 0.00). CONCLUSIONS: Preoperative levels of CA 19-9, IL-6, and YKL-40 may be useful to identify a subgroup of PC patients with poor prognosis.

Tissue MicroRNA profiles as diagnostic and prognostic biomarkers in patients with resectable pancreatic ductal adenocarcinoma and periampullary cancers.

BACKGROUND: The aim of this study was to validate previously described diagnostic and prognostic microRNA expression profiles in tissue samples from patients with pancreatic cancer and other periampullary cancers. METHODS: Expression of 46 selected microRNAs was studied in formalin-fixed paraffin-embedded tissue from patients with resected pancreatic ductal adenocarcinoma (n = 165), ampullary cancer (n=59), duodenal cancer (n = 6), distal common bile duct cancer (n = 21), and gastric cancer (n = 20); chronic pancreatitis (n = 39); and normal pancreas (n = 35). The microRNAs were analyzed by PCR using the Fluidigm platform. RESULTS: Twenty-two microRNAs were significantly differently expressed in patients with pancreatic cancer when compared to healthy controls and chronic pancreatitis patients; 17 miRNAs were upregulated (miR-21-5p, -23a-3p, -31-5p, -34c-5p, -93-3p, -135b-3p, -155-5p, -186-5p, -196b-5p, -203, -205-5p, -210, -222-3p, -451, -492, -614, and miR-622) and 5 were downregulated (miR-122-5p, -130b-3p, -216b, -217, and miR-375). MicroRNAs were grouped into diagnostic indices of varying complexity. Ten microRNAs associated with prognosis were identified (let-7 g, miR-29a-5p, -34a-5p, -125a-3p, -146a-5p, -187, -205-5p, -212-3p, -222-5p, and miR-450b-5p). Prognostic indices based on differences in expression of 2 different microRNAs were constructed for pancreatic and ampullary cancer combined and separately (30, 5, and 21 indices). CONCLUSION: The study confirms that pancreatic cancer tissue has a microRNA expression profile that is different from that of other periampullary cancers, chronic pancreatitis, and normal pancreas. We identified prognostic microRNAs and microRNA indices that were associated with shorter overall survival in patients with radically resected pancreatic cancer.

Intrathoracic anastomotic leakage after gastroesophageal cancer resection is associated with increased risk of recurrence.

OBJECTIVE: Intrathoracic anastomotic leakage after intended curative resection for cancer in the esophagus or gastroesophageal junction has a negative impact on long-term survival. The aim of this study was to investigate whether an anastomotic leakage was associated with an increased recurrence rate. METHODS: This nationwide study included consecutively collected data on patients undergoing curative surgical resection with intrathoracic anastomosis, alive 8 weeks postoperatively, between 2003 and 2011. Patients with incomplete resection, or metastatic disease intraoperatively, were excluded. Only biopsy-proven recurrences were accepted. RESULTS: In total, 1085 patients were included. The frequency of anastomotic leakage was 8.6%. The median follow-up time was 29 months (interquartile range [IQR]: 13-58 months). Overall, 369 (34%) patients had disease recurrence, of which 346 patients died of recurrent gastroesophageal carcinoma. Twenty-three patients were alive with recurrence at the censoring date. In the study period, 333 patients died without signs of recurrent disease. The overall median time to recurrence was 66 weeks (IQR: 38-109 weeks). Distant metastases were found in 267 (25%), and local disease recurrence in 102 (9%) patients. Overall, 5-year disease-free survival in patients with leakage was 27%, versus 39% in those without leakage (P = .017). Anastomotic leakage was independently associated with higher risk of recurrence (hazard ratio [HR] = 1.63; 95% confidence interval [CI]: 1.17-2.29, P = .004) and all-cause mortality (HR = 1.57; 95% CI: 1.23-2.05, P < .0001). CONCLUSIONS: Intrathoracic anastomotic leakage increased the risk of recurrence in patients who underwent curative gastroesophageal cancer resection.

GLP-1 receptor localization in monkey and human tissue: novel distribution revealed with extensively validated monoclonal antibody.

Glucagon-like peptide 1 (GLP-1) analogs are increasingly being used in the treatment of type 2 diabetes. It is clear that these drugs lower blood glucose through an increase in insulin secretion and a lowering of glucagon secretion; in addition, they lower body weight and systolic blood pressure and increase heart rate. Using a new monoclonal antibody for immunohistochemistry, we detected GLP-1 receptor (GLP-1R) in important target organs in humans and monkeys. In the pancreas, GLP-1R was predominantly localized in ß-cells with a markedly weaker expression in acinar cells. Pancreatic ductal epithelial cells did not express GLP-1R. In the kidney and lung, GLP-1R was exclusively expressed in smooth muscle cells in the walls of arteries and arterioles. In the heart, GLP-1R was localized in myocytes of the sinoatrial node. In the gastrointestinal tract, the highest GLP-1R expression was seen in the Brunner's gland in the duodenum, with lower level expression in parietal cells and smooth muscle cells in the muscularis externa in the stomach and in myenteric plexus neurons throughout the gut. No GLP-1R was seen in primate liver and thyroid. GLP-1R expression seen with immunohistochemistry was confirmed by functional expression using in situ ligand binding with (125)I-GLP-1. In conclusion, these results give important new insight into the molecular mode of action of GLP-1 analogs by identifying the exact cellular localization of GLP-1R.

Diagnostic and Prognostic Impact of Circulating YKL-40, IL-6, and CA 19.9 in Patients with Pancreatic Cancer.

PURPOSE: We tested the hypothesis that high plasma YKL-40 and IL-6 associate with pancreatic cancer and short overall survival. PATIENTS AND METHODS: In all, 559 patients with pancreatic cancer from prospective biomarker studies from Denmark (n = 448) and Germany (n = 111) were studied. Plasma YKL-40 and IL-6 were determined by ELISAs and serum CA 19.9 by chemiluminescent immunometric assay. RESULTS: Odds ratios (ORs) for prediction of pancreatic cancer were significant for all biomarkers, with CA 19.9 having the highest AUC (CA 19.9: OR = 2.28, 95% CI 1.97 to 2.68, p<0.0001, AUC = 0.94; YKL-40: OR = 4.50, 3.99 to 5.08, p<0.0001, AUC = 0.87; IL-6: OR = 3.68, 3.08 to 4.44, p<0.0001, AUC = 0.87). Multivariate Cox analysis (YKL-40, IL-6, CA 19.9, age, stage, gender) in patients operated on showed that high preoperative IL-6 and CA 19.9 (dichotomized according to normal values) were independently associated with short overall survival (CA 19.9: HR = 2.51, 1.22-5.15, p = 0.013; IL-6: HR = 2.03, 1.11 to 3.70, p = 0.021). Multivariate Cox analysis of non-operable patients (Stage IIB-IV) showed that high pre-treatment levels of each biomarker were independently associated with short overall survival (YKL-40: HR = 1.30, 1.03 to 1.64, p = 0.029; IL-6: HR = 1.71, 1.33 to 2.20, p<0.0001; CA 19.9: HR = 1.54, 1.06 to 2.24, p = 0.022). Patients with preoperative elevation of both IL-6 and CA 19.9 had shorter overall survival (p<0.005) compared to patients with normal levels of both biomarkers (45% vs. 92% alive after 12 months). CONCLUSIONS: Plasma YKL-40 and IL-6 had less diagnostic impact than CA 19.9. Combination of pretreatment YKL-40, IL-6, and CA 19.9 may have clinical value to identify pancreatic cancer patients with the poorest prognosis.

Good results after repeated resection for colorectal liver metastases.

INTRODUCTION: Our study aim was to evaluate the perioperative events, postoperative events and survival after a second liver resection due to colorectal liver metastases (CLM), compared with a matched control group that had only undergone primary liver resection due to CLM. MATERIAL AND METHODS: Retrospective review of charts from patients having undergone a second liver resection due to CLM. A control group was identified by selecting the first liver resection due to CLM occurring after a second resection due to CLM. Twenty-four patients were hereby included in both the primary resection group (PRG) and the second resection group (SRG). The groups were compared statistically with regard to demographics, primary tumour and hepatic involvement. RESULTS: No significant differences between the groups were noted in terms of perioperative events, although there was a trend towards PRG resections involving more liver segments than SRG resections (p = 0.08). The rate of postoperative surgical complications was 17.4% in the PRG and 4% in the SRG (p = 0.18). The admission time was 10.6 days in the PRG and 8.4 days in the SRG (p = 0.71). 30-day mortality was 4% in the PRG and 0% in the SRG (p = 0.41). The five-year survival was 36% in the PRG and 42% in the SRG (p = 0.17) CONCLUSION: This study shows that a second hepatic resection due to recurrent CLM is safe and feasible. It also shows that patients undergoing a second liver resection due to CLM have five-year survival rates comparable to those of patients who have only undergone one hepatic resection due to CLM. FUNDING: Not relevant. TRIAL REGISTRATION: Not relevant.