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We integrated clinical, genomic and transcriptomic data from 217 primaries and 101 metastases from 289 patients to characterize progression of pancreatic ductal adenocarcinoma. Driver genes alterations, mutational and expression-based signatures were mostly preserved, and discordances implied Halstedian tumour spread. Cell cycle progression increased with sequential inactivation of tumour suppressors, yet remained higher in metastases, perhaps driven by cell cycle regulatory gene mutations. Half of the cases were hypoxic by expression markers, overlapping with molecular subtypes. Inter-tumoural heterogeneity showed conserved truncations, inversions and translocations and therefore likely driver events. Multiple synchronous and metachronous PDAC arising in the same patients were actually intra-parenchymal metastases, and not independent primary tumours. Established clinical co-variates dominated survival analyses, though cell cycle progression, hypoxia and inter-tumoural heterogeneity may inform clinical practice.

We integrated clinical, genomic, and transcriptomic data from 224 primaries and 95 metastases from 289 patients to characterize progression of pancreatic ductal adenocarcinoma (PDAC). Driver gene alterations and mutational and expression-based signatures were preserved, with truncations, inversions, and translocations most conserved. Cell cycle progression (CCP) increased with sequential inactivation of tumor suppressors, yet remained higher in metastases, perhaps driven by cell cycle regulatory gene variants. Half of the cases were hypoxic by expression markers, overlapping with molecular subtypes. Paired tumor heterogeneity showed cancer cell migration by Halstedian progression. Multiple PDACs arising synchronously and metachronously in the same pancreas were actually intra-parenchymal metastases, not independent primary tumors. Established clinical co-variates dominated survival analyses, although CCP and hypoxia may inform clinical practice.