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Pancreatic cancer (PC) is one of the leading causes of cancer-related death worldwide. Identification of novel tumor biomarkers is highly advocated in PC to optimize personalized treatment algorithms. Blood-circulating extracellular vesicles hold promise for liquid biopsy application in cancer. We used an optimized flow cytometry protocol to study leukocyte-derived EVs (CD45+) and PD-L1+ EVs in blood from 56 pancreatic cancer patients and 48 healthy controls (HCs). Our results show that PC patients presented higher blood levels of total EVs (p = 0.0003), leukocyte-derived EVs (LEVs) (p = 0.001) and PD-L1+ EVs (p = 0.01), as compared with HCs. Interestingly, a blood concentration of LEVs at baseline was independently associated with improved overall survival in patients with borderline resectable or primary unresectable PC (HR = 0.17; 95% CI 0.04–0.79; p = 0.02). Additionally, increased blood-based LEVs were independently correlated with prolonged progression-free survival (HR = 0.10; 95% CI 0.01–0.82; p = 0.03) and significantly associated with higher disease control rate (p = 0.02) in patients with advanced PC receiving standard chemotherapy. Notably, a strong correlation between a decrease in blood LEVs concentration during chemotherapy and disease control was observed (p = 0.005). These intriguing findings point to the potential of LEVs as novel blood-based EV biomarkers for improved personalized medicine in patients affected by PC.

Aim Pathological complete response (pCR) and clinical outcomes [overall survival (OS), disease-free survival (DFS), locoregional control (LC)] were evaluated in a single-institution experience of different schedules of neoadjuvant chemoradiotherapy (CRT) for patients with locally advanced rectal cancer (LARC). Patients and methods Data for 322 patients with LARC were retrospectively analyzed. pCR was evaluated according to Mandard tumor regression grade (TRG). The Kaplan-Meier method was used to estimate OS, DFS and LC. Results Three hundred and three (94.1%) patients underwent surgery. pCR was observed in 81 patients (26.7%), with TRG1-2 rate of 41.8%. The 5- and 10-year OS, DFS and LC rates were 82.5%±2.5% and 65.5%±3.8%, 81.2%±2.4% and 79.3%±2.9%, 93.1%±1.7% and 90.5%±2.1%, respectively. Conclusion Neoadjuvant CRT in LARC patients resulted in favorable long-term oncological outcomes, with a high pCR rate and acceptable toxicity.

To compare tumor detectability and conspicuity of standard b = 1000 s/mm2 (b1000) versus ultrahigh b = 2000 s/mm2 (b2000) diffusion-weighted imaging (DWI) in rectal cancer. Fifty-five patients for a total of 81 3T DWI-MR scans were retrospectively evaluated by two differently experienced readers. A comparison between b1000 and b2000 for tumor detectability and conspicuity was performed. The conspicuity was qualitatively and quantitatively assessed by using three-point scale and whole tumor volume manual delineation, respectively. Receiver-operating characteristic curve (ROC) with area under the curve (AUC) analysis provided diagnostic accuracy in tumor detectability of restaging MR scans. Qualitative scores and quantitative features including mean signal intensity, variance, 10th percentile and 90th percentile, were compared using the Wilcoxon test. Interobserver agreement (IOA) for qualitative and quantitative data was calculated using Cohen’s Kappa and intraclass correlation coefficient (ICC) respectively. Diagnostic accuracy was comparable between b1000 and b2000 for both readers (p > 0.05). Overall quality scores were significantly better for b2000 than b1000 (2.29 vs 1.65 Reader 1, p = 0.01; 2.18 vs 1.69 Reader 2, p = 0.04). IOA was equally good for both b values (k = 0.86 b1000, k = 0.86 b2000). Quantitative analysis revealed more uniform signal (measured in variance) of b2000 in both healthy surrounding tissue (p

Background. Laparoscopic reversal of Hartmann’s procedure (LHR) offers reduced morbidity compared with open Hartmann’s reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal. Materials and Methods. Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient’s age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated. Results. The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value p value p value

The rates of post-operative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) are between 5% and 30%. Nowadays, pancreaticojejunostomy (PJ) represents the most common type of reconstruction after PD, but the ideal technique is still debated. Our randomized trial was conceived with the intent to evaluate if two variants of PJ could influence the post-operative outcome in term of early complications.Forty-eight consecutive patients treated with PD were randomized into 2 groups (Group 1 or Large Jejunal Incision or LJI group and Group 2 or Small Jejunal Incision or SJI group). Outcome measures were the operative time, postoperative complications, length of postoperative hospital stay, amylase content in drains.wenty-two patients were enrolled in the LJI and 26 in the SJI group. Median operative times did not differ between the 2 groups. The groups were homogeneous in respect to the median age of patients, the clinical presentation of jaundice and the presence of percutaneous biliary drainage (PBD). POPF developed in 3/22 (13.6%) and 1/26 (4%) patients among the LJI and SJI group respectively (3 grade B and 1 grade C respectively) (p=0.341). PPH occurred in 8/22 (36%) and 2/26 (8%) patients among the LJI and SJI group, respectively (p=0.018). The Amylase content in the drainage fluid measured at the 5th postoperative day showed a higher value in patients who underwent LJI anastomosis compared to those with SJI anastomosis [LJI group: 26.5 (6-254) U/l vs SJI group: 7 (0-38) U/l; p=0.051]. Delayed Gastric Emptying (DGE) was not different. The multivariate logistic regression analysis demonstrated both LJI anastomosis and DGE as independent predictors for pancreatic fistula (DGE: OR=20.04, CI 95%=1.92-208.83, P=0.012; LJI anastomosis: OR=24.58, CI 95%=1.71-354.32, P=0.019) and PPH (DGE: 30.5, CI 95%=3.02-308.16, P=0.004; LJI anastomosis: OR=12.71, CI 95%=1.23-131.55, P=0.033).Based on the present results, we suggest to adopt what a "pancreas duct-oriented" approach: if pancreas duct is large a SJI-PJ is recommended; if the duct isthan 3 mm, a LJI must be preferred. Our conclusion is that the association of some surgeons to perform always the techniques with them are more confident is a concept of the past: recent data suggest that the pancreatic surgeon must have the different techniques in his "armamentarium" and varying the technique depending on local characteristic of the pancreas to allow a tailored approach to the patient.Pancreaticojejunostomy, Pancreatic fistula, Surgical Sutcome.Il tasso di fistola pancreatica post-operatoria (POPF) post- duodenopancreatectomia (PD) oscilla tra il 5% e il 30%. Ad oggi, nonostante la tecnica ideale è ancora oggi oggetto di dibattito scientifico, la pancreaticodigiunostomia (PJ) risulta essere la tipologia più frequente di ricostruzione dopo PD. Questo studio è un trial randomizzatofinalizzato a valutare come due variantitecniche di PJ possanoinfluenzarel’outcome postoperatorio in termini di complicanzeprecoci.Quarantotto (48) pazienti sottoposti a PD sono stati randomizzati in due (2) gruppi (Gruppo1 o Large Jejunal Incision o Gruppo LJI, e il Gruppo 2 o Small Jejunal Incision o Gruppo SJI). Le variabili post operatorie valutate sono state il tempo operatorio medio, le complicanze post-operatorie, la degenza ospedaliera ed il contenuto di amilasi nel liquido di drenaggio.Venti-due pazienti sono stati arruolati nel gruppo LJI e venti-sei nel gruppo SJI. I due gruppi sono risultati omogenei per quanto riguarda età media, presentazione clinica con ittero e la presenza di drenaggio biliare percutaneo (PBD). Nei 2 gruppi non si sono osservate differenze in termini di tempo operatorio medio. In 3/22 (13.6%) pazienti del gruppo LJI e in 1/26 (4%) pazienti del gruppo SJI (3grado B e 1 grado C, rispettivamente) (p=0.341) hanno sviluppato una fistola pancreatica post operatoria. L’emorragia post-pancreatectomia (PPH) si è sviluppata rispettivamente in 8/22 (36%) pazienti del gruppo LJI e 2/26 (8%) pazienti del gruppo SJI, rispettivamente (p=0.018). Il dosaggio dell’amilasemia eseguito in quinta giornata post operatoria nel liquido di drenaggio ha evidenziato un valorepiù alto neipazienti del gruppo LJI rispettoaipazienti del gruppo SJI [gruppo LJI: 26.5 (6-254) U/l vs gruppo SJI: 7 (0-38) U/l; p=0.051]. Non sono state osservate differenze statisticamente significative in termini di ritardato svuotamento gastrico [Delayed Gastric Emptying (DGE)]. L’analisi di regressione logistica ha dimostrato come sial’anastomosi LJI che DGE risultanoesserefattoriindipendentipredittivi di POPF (DGE: OR=20.04, CI 95%=1.92- 208.83, P=0.012; anastomosiLJI: OR=24.58, CI 95%=1.71-354.32, P=0.019) e PPH (DGE: 30.5, CI 95%=3.02-308.16, P=0.004; anastomosi LJI: OR=12.71, CI 95%=1.23-131.55, P=0.033).I risultati del presente studio ci consentono di suggerire un approccio basato sul dotto pancreatico o “pancreas duct-oriented”: in casi con dotto pancreatico3 mm è raccomandata una anastomosi di tipo SJI, viceversa, se il dotto è inferiore ai 3 mm è preferibile confezionare una anastomosi LJI. Concludendo, riteniamo che non sia più valido il vecchio paradigma secondo cui il chirurgo pancreatico debba eseguire ed affinare la tecnica ricostruttiva con cui egli è più confidente. I dati più recenti suggeriscono che ogni chirurgo, bensì, debba possedere nel proprio armamentario le diverse tecniche ricostruttive e, pertanto, adattarle alle caratteristiche locali del pancreas affinché si possa raggiungere un approccio “su misura” per ogni paziente.

Neoadjuvant chemo-radiotherapy (CRT) followed by total mesorectal excision (TME) represents the standard treatment for patients with locally advanced (³ T3 or N+) rectal cancer (LARC). Approximately 15% of patients with LARC shows a complete response after CRT. The use of pre-treatment MRI as predictive biomarker could help to increase the chance of organ preservation by tailoring the neoadjuvant treatment. We present a novel machine learning model combining pre-treatment MRI-based clinical and radiomic features for the early prediction of treatment response in LARC patients. MRI scans (3.0T, T2-weighted) of 72 patients with LARC were included. Two readers independently segmented each tumor. Radiomic features were extracted from both the “tumor core” (TC) and the “tumor border” (TB). Partial least square (PLS) regression was used as the multivariate, machine learning, algorithm of choice and leave-one-out nested cross-validation was used to optimize hyperparameters of the PLS. The MRI-Based “clinical-radiomic” machine learning model properly predicted the treatment response (AUC=0.793, p =5.6·10-5). Importantly, the prediction improved when combining MRI-based clinical features and radiomic features, the latter extracted from both TC and TB. Prospective validation studies in randomized clinical trials are warranted to better define the role of radiomics in the development of rectal cancer precision medicine.

BACKGROUND Although laparoscopic cholecystectomy (LC) is the gold standard for symptomatic gallbladder disease, a single-incision approach may be a new challenge in order to achieve minimization of surgical trauma. Single-site robotic cholecystectomy (SSRC) is able to offset the ergonomic limitation of laparoscopic single-site cholecystectomy and improves cosmesis. METHODS We present a single-institution initial experience of SSRC for cholecystolithiasis. Intra-operative and post-operative data of patients were reviewed to assess the technical feasibility and cosmetic outcome. RESULTS We evaluated a series of 27 consecutive patients retrospectively analyzed and prospectively collected who underwent SSRC. One patient was excluded from the final analysis because they converted to open procedure. The female/male ratio was 17/9, with mean age of 48 ± 12 years. The body mass index mean value was 26.0 ± 4.2. The mean operative time was 99.6 ± 21.5 minutes. No intra- or post-operative complications and readmissions were recorded. At 12 months follow up, every patient received the Body Image Questionnaire (BIQ) and a Photo Series Questionnaire. We recorded three patients (11.5%) with post-operative incisional hernia. Scores of the BIQ subscale for body image perception were 6 ± 1.2, while the scores of scar cosmesis were 21.1 ± 3.0. A statistically significant improvement in scar self-rating from T0 to T1 (P

Trans-duodenal surgical ampullectomy (TSA) was first described in 1899. Nowadays its role in ampullary tumor surgery is still a matter of debate and requires a multidisciplinary approach. The aim of this study is to evaluate the results of TSA as a curative treatment for benign and selected malignant tumors arising from the ampulla in a single-institution experience. Sixteen patients with periampullary tumors that underwent TSA in our surgical units between January 2012 and January 2017 were included in the study. Patient demographic characteristics, pre or postoperative endoscopic interventions, operative procedures, postoperative morbidity and mortality, hospitalization, follow-up time, and quality of life questionnaire were analyzed. Mean operative time was 238.5 min (range 180–390), mean tumor size was 2.3 cm (range 1.5–3.9). The microscopic surgical outcome was R0 for 14 patients. The most frequent findings in terms of histological type were high-grade dysplasia/pTis (43.7%), low-grade dysplasia in 37.5% patients, invasive adenocarcinoma in 2 cases (12.5%), chronic inflammation in 1 case (6.3%). The readmission rate was 18.8% (3/16) and in 2 cases (12.5%) relaparotomy was required. The cumulative median duration of follow-up was 50 months (range 1–96). 90-days mortality was 6.2%. Mean hospital stay was 12 days (range 8–60). Our results confirm that TSA offers good results in terms of morbidity and mortality; still, it remains a challenging procedure that requires particular surgical experience and operative skills. A pre-operative planning in a multidisciplinary board should be carried out prior to the procedure.

The cost effectiveness of the laparoscopic right hemicolectomy is still debated, and the current literature does not allow to be drawn certain conclusion. Our study compared direct clinical costs and outcomes for laparoscopic right hemicolectomy with the two most used type of anastomosis, such as ExtraCorporeal Anastomosis (ECA) and IntraCorporeal Anastomosis (ICA).In this retrospective study, all patients who underwent laparoscopic right hemicolectomy with intracorporeal and extracorporeal anastomosis between January 2016 and April 2018 were evaluated. Patients were divided into two groups according to the type of anastomosis: ECA or ICA.Thirty ECA and twenty-nine ICA patients were included in the study. Operative time was significantly longer in ICA group than ECA group (p0.001). No significant differences between the groups were seen in terms of timeto- first flatus, postoperative complications and re-admission rate. ICA group showed a shorter hospitalization (5 vs 6; p0.022). In the ICA group, considering only the surgical tools were more expensive than in ECA (1435.6 € vs 72 €). Nevertheless, the total cost of the two procedures in similar (14451.36 € in ECA group vs 14631.04 € in ICA group).ECA and ICA are comparable in terms of postoperative outcomes. ICA requires much more expensive charges, compared to a minor hospitalization. The ECA seems to be less expensive in terms of surgical supplies but the longer recovery determines an increase in the total cost resulting in a non-inferiority of one compared to the other technique.Cost-analysis, ExtraCorporeal Anastomosis, IntraCorporeal Anastomosis, Laparoscopy, Right Hemicolectomy.Il rapporto costo-efficacia dell’emicolectomia destra laparoscopica è tuttora oggetto di dibattito, ed un’analisi della letteratura attuale non consente di trarre conclusioni certe. Il nostro studio ha l’obiettivo di comparare i costi clinici diretti ed indiretti dell’emicolectomia destra laparoscopica mediante due tipologie di anastomosi: anastomosi extracorporea (Extra Corporeal Anastomosis) ed anastomosi intracorporea (Intra Corporeal Anastomosis).Retrospettivamente, dal Gennaio 2016 ad Aprile 2018, sono stati valutati tutti i pazienti sottoposti ad emicolectomia destra laparoscopica con anastomosi intracorporea ed extracorporea. In base al tipo di anastomosi utilizzata i pazienti sono stati divisi in due gruppi: gruppo ECA e gruppo ICA.Trenta ECA e venti-nove ICA sono stati inclusi nello studio. Il tempo operatorio è risultato significativamente più lungo nel gruppo ICA rispetto al gruppo ECA (p0.001). Non ci sono state significative differenze per quanto riguarda la prima canalizzazione, le complicanze post operatorie ed il tasso di riammissione. I pazienti sottoposti ad anastomosi intracorporea (ICA) hanno avuto tempi di degenza ospedaliera ridotti se comparati ai pazienti sottoposti ad anastomosi extracorporea (5 vs 6; p0.022). Considerando i costi diretti dei soli presidi chirurgici, il gruppo ICA è risultato più dispendioso rispetto al gruppo ECA (1435.6 € vs 72 €). Tuttavia, il costo totale delle due procedure, considerando anche i costi di degenza, (14451.36 € nel gruppo ECA versus 14631.04 € nel gruppo ICA) risultano equivalent.Le anastomosi extracorporea ed intracorporea risultano comparabili in termini di costi clinici ed outcome post-operatorio. L’anastomosi intracorporea (ICA) implica costi più elevati ma una ospedalizzazione minore. L’anastomosi extracorporea sembra essere meno costosa in termini di presidi utilizzati, ma la più lunga degenza ospedaliera media determina un’aumento dei costi totali risultando in una non-inferiorità dell’una o dell’altro tecnica.

Splenic flexure (SF) cancer is not a common condition and its treatment is still under discussion. Although laparoscopic surgery is well accepted for the treatment of colon cancer at any stage, complete mesocolon excision (CME) with selective vascular ligation using the laparoscopic approach for SF cancer remains technically demanding and represents a real challenge for surgeons. We present a single-institution experience of laparoscopic CME for SF cancer. Intra-operative, pathologic, and post-operative data of patients who underwent laparoscopic SF resection were reviewed to assess the technical feasibility and oncologic safety. Technical features, histopathology, morbidity, and mortality were evaluated. From February 2015 to October 2017, a minimally invasive approach was proposed to 17 patients (M/F 14/3) affected by splenic flexure cancer. In all patients, the procedure was completed by laparoscopy. The anastomosis was completed intra-corporeally in 89% of cases. The distal margin was 3.1 ± 2.6 cm and the proximal margin was 6.5 ± 3.3 cm from the tumor site. The number of mean harvested nodes was 13.9 ± 7. The mean operative time was 215.5 ± 65 min, and blood loss was 80 ± 27. In one case, a laparoscopic partial gastrectomy was associated due to tumor invasion. The mean post-operative stay was 6.7 ± 3.3 days. Readmission was necessary for two patients. No major morbidity was recorded. Despite the wide spread and increasing confidence in laparoscopic colectomy, SF resection remains one of the most challenging procedures in colorectal surgery with a complex learning curve. SF resection with CME and CVL is feasible and safe for the treatment of early-stage and locally advanced SF cancer.

// Tommaso Mazza 1 , Massimiliano Copetti 2 , Daniele Capocefalo 1, 8 , Caterina Fusilli 1 , Tommaso Biagini 1 , Massimo Carella 3 , Antonio De Bonis 4 , Nicola Mastrodonato 4 , Ada Piepoli 5 , Valerio Pazienza 5 , Evaristo Maiello 6 , Fabio Francesco di Mola 7 , Pierluigi di Sebastiano 7 , Angelo Andriulli 5 and Francesca Tavano 5 1 Unit of Bioinformatics, Research Hospital, San Giovanni Rotondo 71013, Italy 2 Unit of Biostatistics, Research Hospital, San Giovanni Rotondo 71013, Italy 3 Medical Genetics Unit, Research Hospital, San Giovanni Rotondo 71013, Italy 4 Department of Surgery, Research Hospital, San Giovanni Rotondo 71013, Italy 5 Division of Gastroenterology and Research Laboratory, San Giovanni Rotondo 71013, Italy 6 Department of Oncology IRCCS “Casa Sollievo della Sofferenza”, Research Hospital, San Giovanni Rotondo 71013, Italy 7 Division of Surgical Oncology “SS Annunziata” Hospital, Chieti 66100, Italy 8 Department of Cellular Biotechnologies and Haematology, Sapienza University of Rome, Rome 00161, Italy Correspondence to: Francesca Tavano, email: f.tavano@operapadrepio.it Keywords: microRNA; pancrearic ductal adenocarcinoma; ampullary carcinoma Received: December 06, 2016 Accepted: July 11, 2017 Published: October 31, 2017 ABSTRACT MiRNA expression abnormalities in adenocarcinoma arising from pancreatic ductal system (PDAC) and Vater’s papilla (PVAC) could be associated with distinctive pathologic features and clinical cancer behaviours. Our previous miRNA expression profiling data on PDAC (n=9) and PVAC (n=4) were revaluated to define differences/similarities in miRNA expression patterns. Afterwards, in order to uncover target genes and core signalling pathways regulated by specific miRNAs in these two tumour entities, miRNA interaction networks were wired for each tumour entity, and experimentally validated target genes underwent pathways enrichment analysis. One hundred and one miRNAs were altered, mainly over-expressed, in PDAC samples. Twenty-six miRNAs were deregulated in PVAC samples, where more miRNAs were down-expressed in tumours compared to normal tissues. Four miRNAs were significantly altered in both subgroups of patients, while 27 miRNAs were differentially expressed between PDAC and PVAC. Although miRNA interaction networks were more complex and dense in PDAC than in PVAC, pathways enrichment analysis uncovered a functional overlapping between PDAC and PVAC. However, shared signalling events were influenced by different miRNA and/or genes in the two tumour entities. Overall, specific miRNA expression patterns were involved in the regulation of a limited core signalling pathways in the biology landscape of PDAC and PVAC.

Introduction. Despite the widespread use of the robotic technology, only a few studies with small sample sizes report its application to pancreatic diseases treatment. Our aim is to present the results of a multicenter study on the safety and feasibility of robot-assisted distal pancreatectomy (RDP). Materials and Methods. All RDPs for benign, borderline, and malignant diseases performed in 5 referral centers from 2008 to 2016 were included. Perioperative outcomes were evaluated. Results. Two hundred thirty-six patients were included. Spleen preservation was performed in 114 cases (48.3%). Operative time was 277.8 ± 93.6 minutes. Progressive improvement in operative time was observed over the study period. Conversion rate was 6.3%. Morbidity occurred in 102 cases (43.2%), mainly due to grade A fistulas. Reoperation was required in 10 patients. Postoperatively, 2 patients died of sepsis due to a grade C fistula. Hospital readmission was necessary in 11 cases. A R0 resection was always achieved, with a mean number of 16.2 ± 15 harvested lymph nodes. Conclusion. To our knowledge, this is one of the largest RDP series. Safety and feasibility including the low conversion rate, the high spleen preservation rate, the adequate operative time, and the acceptable morbidity and mortality rates confirm the validity of this technique. Appropriate oncological outcomes have been also obtained.

Background Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies and is not a clinically homogeneous disease, but subsets of patients with distinct prognosis and response to therapy can be identified by genome-wide analyses. Mutations in major PDAC driver genes were associated with poor survival. By bioinformatics analysis, we identified protocadherins among the most frequently mutated genes in PDAC suggesting an important role of these genes in the biology of this tumor. Promoter methylation of protocadherins has been suggested as a prognostic marker in different tumors, but in PDAC this epigenetic modification has not been extensively studied. Thus, we evaluated whether promoter methylation of three frequently mutated protocadherins, PCDHAC2, PCDHGC5 and PCDH10 could be used as survival predictors in PDAC patients. Methods DNA extracted from 23 PDACs and adjacent non-neoplastic pancreatic tissues were bisulfite treated. Combined Bisulfite Restriction Analysis (COBRA) coupled to denaturing high-performance liquid chromatography (dHPLC) detection and bisulfite genomic sequencing (BGS) were used to determine the presence of methylated CpG dinucleotides in the promoter amplicons analyzed. Results In an exploratory analysis, two protocadherins showed the same pattern of CpG methylation in PDAC and adjacent non-neoplastic pancreatic tissues: lack of methylation for PCDHAC2, complete methylation for PCDHGC5. Conversely, the third protocadherin analyzed, PCDH10, showed a variable degree of CpG methylation in PDAC and absence of methylation in adjacent non-neoplastic pancreatic tissues. At Kaplan–Meier analysis, high levels of PCDH10 methylation defined according to the receiver operating characteristic (ROC) curve analysis were significantly associated with worse progression-free survival (PFS) rates (P = 0.008), but not with overall survival (OS). High levels of PCDH10 methylation were a prognostic factor influencing PFS (HR = 4.0: 95% CI, 1.3–12.3; P = 0.016), but not the OS. Conclusions In this study, we show for the first time that the methylation status of PCDH10 can predict prognosis in PDAC patients with a significant impact on the outcome in terms of progression-free survival. High levels of PCDH10 promoter methylation could be useful to identify patients at high risk of disease progression, contributing to a more accurate stratification of PDAC patients for personalized clinical management.

Background Pancreatic cancer (PC) is the fourth most common cause of cancer death. Combination therapies with classical chemotherapeutic agents improved treatment of advanced PC at the cost of a relevant toxicity, but the 5-year survival rate remains below 5%. Consequently, new therapeutic options for this disease are urgently needed. In this study, we explored the effect of two repurposed drug candidates nelfinavir and nitroxoline, approved for non-anticancer human use, in PC cell lines. Nelfinavir and nitroxoline were tested as single agents, or in combinations with or without erlotinib, a targeted drug approved for PC treatment. Methods The effects of the drugs on the viability of AsPC-1, Capan-2 and BxPC-3 PC cell lines were assessed by MTT. The impact of the treatments on cell cycle distribution and apoptosis was analyzed by flow cytometry. The effects of treatments on proteins relevant in cell cycle regulation and apoptosis were evaluated by western blot. Self-renewal capacity of PC cell lines after drug treatments was assessed using a clonogenic assay. Results When used as single agents, nelfinavir and nitroxoline decreased viability, affected cell cycle and reduced the expression of relevant cell cycle proteins. The effects on apoptosis were variable among PC cell lines. Moreover, these agents drastically impaired clonogenic activity of the three PC cell lines. Combinations of nelfinavir and nitroxoline, with or without erlotinib, resulted in dose- and cell-dependent synergistic effects on cell viability. These effects were paralleled by cell cycle alterations and more consistent apoptosis induction as compared to single agents. Treatments with drug combinations induced drastic impairment of clonogenic activity in the three cell lines. Conclusions This study shows that two non-antitumor drugs, nelfinavir and nitroxoline, as single agents or in combination have antitumor effects that appear comparable, or in some case more pronounced than those of erlotinib in three PC cell lines. Our results support repurposing of these approved drugs as single agents or in combination for PC treatment.

Pancreatic cancer (PC), the fourth leading cause of cancer-related deaths, is characterized by high aggressiveness and resistance to chemotherapy. Pancreatic carcinogenesis is kept going by derangement of essential cell processes, such as proliferation, apoptosis, metabolism and autophagy, characterized by rhythmic variations with 24-h periodicity driven by the biological clock. We assessed the expression of the circadian genes ARNLT, ARNLT2, CLOCK, PER1, PER2, PER3, CRY1, CRY2 and the starvation-activated histone/protein deacetylase SIRT1 in 34 matched tumor and non-tumor tissue specimens of PC patients, and evaluated in PC derived cell lines if the modulation of SIRT1 expression through starvation could influence the temporal pattern of expression of the circadian genes. We found a significant down-regulation of ARNLT (p = 0.015), CRY1 (p = 0.013), CRY2 (p = 0.001), PER1 (p 0.0001), PER2 (p 0.001), PER3 (p = 0.001) and SIRT1 (p = 0.017) in PC specimens. PER3 and CRY2 expression levels were lower in patients with jaundice at diagnosis ( 0.05). Having adjusted for age, adjuvant therapy and tumor stage, we evidenced that patients with higher PER2 and lower SIRT1 expression levels showed lower mortality (p = 0.028). Levels and temporal patterns of expression of many circadian genes and SIRT1 significantly changed upon serum starvation in vitro, with differences among four different PC cell lines examined (BXPC3, CFPAC, MIA-PaCa-2 and PANC-1). Serum deprivation induced changes of the overall mean level of the wave and amplitude, lengthened or shortened the cycle time and phase-advanced or phase-delayed the rhythmic oscillation depending on the gene and the PC cell line examined. In conclusion, a severe deregulation of expression of SIRT1 and circadian genes was evidenced in the cancer specimens of PC patients, and starvation influenced gene expression in PC cell lines, suggesting that the altered interplay between SIRT1 and the core circadian proteins could represent a crucial player in the process of pancreatic carcinogenesis.

Summary Background There is substantial uncertainty regarding the optimal surgical treatment for chronic pancreatitis. Short-term outcomes have been found to be better after duodenum-preserving pancreatic head resection (DPPHR) than after partial pancreatoduodenectomy. Therefore, we designed the multicentre ChroPac trial to investigate the long-term outcomes of patients with chronic pancreatitis within 24 months after surgery. Methods This randomised, controlled, double-blind, parallel-group, superiority trial was done in 18 hospitals across Europe. Patients with chronic pancreatitis who were planned for elective surgical treatment were randomly assigned to DPPHR or partial pancreatoduodenectomy with a central web-based randomisation tool. The primary endpoint was mean quality of life within 24 months after surgery, measured with the physical functioning scale of the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire. Primary analysis included all patients who underwent one of the assigned procedures; safety analysis included all patients who underwent surgical intervention (categorised into groups as treated). Patients and outcome assessors were masked to group assignment. The trial was registered, ISRCTN38973832. Recruitment was completed on Sept 3, 2013. Findings Between Sept 10, 2009, and Sept 3, 2013, 250 patients were randomly assigned to DPPHR (n=125) or partial pancreatoduodenectomy (n=125), of whom 226 patients (115 in the DPPHR group and 111 in the partial pancreatoduodenectomy group) were analysed. No difference in quality of life was seen between the groups within 24 months after surgery (75·3 [SD 16·4] for partial pancreatoduodenectomy vs 73·0 [16·4] for DPPHR; mean difference −2·3, 95% CI −6·6 to 2·0; p=0·284). The incidence and severity of serious adverse events did not differ between the groups. 70 (64%) of 109 patients in the DPPHR group and 61 (52%) of 117 patients in the partial pancreatoduodenectomy group had at least one serious adverse event, with the most common being reoperations (for reasons other than chronic pancreatitis), gastrointestinal problems, and other surgical morbidity. Interpretation No differences in quality of life after surgery for chronic pancreatitis were seen between the interventions. Results from single-centre trials showing superiority for DPPHR were not confirmed in the multicentre setting. Funding German Research Foundation (DFG).

none 33 no This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms open Italian Association of Hospital Gastroenterologists and Endoscopists; Italian Association for the Study of the Pancreas; Buscarini E; Pezzilli R; Cannizzaro R; De Angelis C; Gion M; Morana G; Zamboni G; Arcidiacono P; Balzano G; Barresi L; Basso D; Bocus P; Calculli L; Capurso G; Canzonieri V; Casadei R; Crippa S; D'Onofrio M; Frulloni L; Fusaroli P; Manfredi G; Pacchioni D; Pasquali C; Rocca R; Ventrucci M; Venturini S; Villanacci V; Zerbi A; Falconi M; Cystic Pancreatic Neoplasm Study Group Italian Association of Hospital Gastroenterologists and Endoscopists; Italian Association for the Study of the Pancreas; Buscarini E; Pezzilli R; Cannizzaro R; De Angelis C; Gion M; Morana G; Zamboni G; Arcidiacono P; Balzano G; Barresi L; Basso D; Bocus P; Calculli L; Capurso G; Canzonieri V; Casadei R; Crippa S; D'Onofrio M; Frulloni L; Fusaroli P; Manfredi G; Pacchioni D; Pasquali C; Rocca R; Ventrucci M; Venturini S; Villanacci V; Zerbi A; Falconi M; Cystic Pancreatic Neoplasm Study Group

Resumen Objetivo Desarrollar una nueva clasificacion de la gravedad de la pancreatitis aguda sobre la base de un solido marco conceptual, la revision exhaustiva de la evidencia publicada, y una consulta en todo el mundo. Antecedentes Las definiciones Atlanta’92 de la gravedad de la pancreatitis aguda estan muy arraigadas entre los pancreatologos, pero con un resultado deficiente debido a que estas definiciones estan basadas en la descripcion empirica de hechos que no estan asociadas con la gravedad. Metodos Se envio una invitacion personal para contribuir al desarrollo de una nueva clasificacion de la gravedad de la pancreatitis aguda a todos los cirujanos, gastroenterologos, internistas, intensivistas, radiologos y que actualmente se encuentran activos en el campo de la pancreatitis aguda. La invitacion no se limito a los miembros de determinadas asociaciones o residentes de ciertos paises. Se llevo a cabo una encuesta basada en una web mundial y se organizo un simposio internacional para que los colaboradores de las diferentes disciplinas se dedicaran a debatir el concepto y definiciones. Resultados La nueva clasificacion se basa en los determinantes reales locales y sistemicos de gravedad, en lugar de la descripcion de los eventos que estan asociados con la causa de la gravedad. El factor determinante local se refiere a si existe necrosis (peri) pancreatica o no, y si esta presente, si es esteril o infectado. El factor determinante sistemico se refiere a si existe fracaso organico o no, y si esta presente, ya sea de forma transitoria o persistente. La presencia de un determinante puede modificar el efecto de otra, de tal manera que la presencia tanto de la necrosis (peri) pancreatica infectada y el fracaso organico persistente tienen un mayor efecto sobre la gravedad que si esas determinantes son unicas. La clasificacion basada en los resultados de los principios anteriores deriva en 4 categorias de gravedad: leve, moderada, severa y critica. Conclusiones Esta clasificacion es el resultado de un proceso de consulta entre pancreatologos de 49 paises que abarcan America del Norte, America del Sur, Europa, Asia, Oceania y Africa. Ofrece una puesta al dia de un conjunto de definiciones concisas, de todas las principales entidades necesarias para clasificar la gravedad de la pancreatitis aguda durante la practica clinica y para su uso en la investigacion. Esto asegura que en todo el mundo se pueda utilizar uniformemente la clasificacion basada en factores determinantes.

Borderline resectable pancreatic cancer is now recognized as a distinct clinical entity. In these cases, neoadjuvant treatment could maximize the potential for an R0 resection and avoid R1/R2 resections. In fact, by analyzing, the current literature is evident that approximately one-third of initially borderline resectable pancreatic tumors may undergo successful resection following neoadjuvant therapy. However, the enormous difficulties in achieving a consensus and the variability in therapeutic algorithms have delayed progress in establishing strong evidence-based practices for diagnosis and treatment. In addition, the absence of a unique definition of borderline resectable pancreatic cancer remains a great obstacle for planning a therapeutic strategy and surgical decision-making. If on the one hand, we can finally say that the presence of only few prospective trials generates no strong data to support a specific neoadjuvant therapy regimen in borderline resectable pancreatic cancer, on the other hand, there are many studies on patients with borderline resectable pancreatic cancer who receive neoadjuvant therapy that can enjoy an R0 resection with similar outcomes to up-front resectable disease.

Adenocarcinomas of Vater's papilla (PVAC) may originate from either the pancreatic duct or the intestinal epithelium. Conflicting data have been reported about the frequency of the 2 anatomical entities and their influence on patients' prognosis. To ascertain the anatomical origin of PVAC in a family member of a Lynch syndrome kindred, we searched for microRNA (miRNA) expression profiles on resected tumor specimens. The support vector machine was trained on our previous miRNAs expression data sets of pancreatic and colorectal tissue samples and used to classify the site of origin of the tumor in our patient. The support vector machine worked by contrasting the profiles of miRNAs in patients with pancreatic ductal and colorectal cancers to that of our patient, which was finally classified as pancreatic ductal adenocarcinoma accordingly to alterations of 55 miRNAs. The PVAC might be originated from ductal epithelium rather than from the intestinal mucosa of the papilla in the case at issue. Alteration of miR-548b-3p, miR-551a, miR-21, miR-92a, miR-let-7i, and miR-181a* emerged as potentially associated with cancer genetic susceptibility in PVAC.

Despite advances in clinical management of pancreatic cancer (PC), there is still room for improvement in early detection, diagnosis, and treatment strategies. The role of microRNAs (miRNAs) in tumor biology might pinpoint an alteration in expression of miRNAs as new diagnostic/prognostic biomarkers.Expression levels of miR-143 and miR-21 and correlations with clinicopathological features were analyzed in 26 matched pairs of tumor and adjacent noncancerous tissue samples collected from patients with PCs, including 18 pancreatic ductal adenocarcinomas (PDACs) and 8 adenocarcinomas of Vater's papilla (PVACs).Compared to normal tissues, miR-143 was up-regulated in both PDAC and PVAC tumor samples (P = 0.0028 and P = 0.039, respectively). Conversely, alterations in miR-21 expression were significantly different in PDAC versus PVAC samples (P = 0.0049). Tumor levels of miR-21 were associated with preoperative serum levels of CA 19-9 (r = 0.63, P = 0.0022), whereas miR-143 expression was negatively correlated to lymph node spreading (r = -0.64; P = 0.0004). Correlation between miR-143 and miR-21 expression levels in patients with PDAC was observed (r = 0.53, P = 0.023).Deregulation of miR-143 and miR-21 may reflect histological features and biological behavior of different PCs. Association data with clinical parameters might indicate a prognostic significance for miR-143 and miR-21 in PCs.

Pancreatic cancer is the result of distinctive genetic and epigenetic disturbances. This multistep process is in part well-defined and includes alterations in oncogenes and suppressor genes that control proliferation, apoptosis, angiogenesis, invasion and cell migration. Cathepsins are proteolytic enzymes and represent potential therapeutic targets in human tumors. Cathepsins predominantly function as endopeptidases within endolysosomal vesicles of normal cells and they are involved in physiological processes such as protein turnover, differentiation and apoptosis. In various types of malignancies, cathepsins have been associated with tumor progression and metastasis. Growing evidence and direct proofs suggest that cathepsins are highly up-regulated in pancreatic cancer and contribute to the development and progression of the cancer phenotype. In this review, the role of cathepsins in pancreatic cancer tumorigenesis is reported and discussed. Some critical aspects will be underlined such as specificity of cathepsin activity in pancreatic cancer and in its precursor lesions; the genetic perturbation and the intracellular signaling pathway activated by cathepsins as reported in preclinical models and in human tissues; the preliminary results and the oncological effects of cathepsin inhibitors currently tested on pancreatic cancer cells; the role of combined therapy based on chemotherapeutic agents and cathepsin inhibition. Although mounting evidences indicate that cysteine cathepsins are potential therapeutic targets in pancreatic cancer, as suggested by their functional role in controlling invasiveness and metastasis, it remains to be seen whether the promising benefits of pharmacological inhibitors observed in preclinical study might be translated to the current clinical practice.

Background and aim The neuropeptide Substance P, plays a key role in modulating neuroimmune interactions in patients with inflammatory bowel diseases. We analyzed Substance P serum levels in patients with ulcerative colitis and Crohn's disease, to detail the involvement of the neuropeptide in the pathophysiology of these disorders. Methods Serum samples were collected from 61 patients with ulcerative colitis (24 with active and 37 with inactive disease), 66 patients with Crohn's disease (29 with active and 37 with inactive disease) and 45 healthy subjects, enrolled into the study. Neuropetide serum levels were measured by means of an ELISA/EIA. Associations with disease activity and patients clinical features were also taken into account. Results Compared to controls, Substance P serum levels were significantly increased in both patients with ulcerative colitis and Crohn's disease, ( p ). In patients with ulcerative colitis, levels paralleled disease activity ( p = 0.014 ), and the amount of the neuropeptide was considerably decreased during clinical and endoscopic remission of the disease, ( p = 0.025 ). Conversely, median Substance P levels did not differ between patients with active and inactive Crohn's disease. However, levels of the neuropeptide were more often elevated in patients with inactive and stricturing/fistulizing Crohn's disease, ( p = 0.002 ). Conclusions Data underline that Substance P might exerts important immunomodulatory functions in inflammatory bowel disease. This study suggests a potential role for Substance P serum levels in monitoring intestinal inflammation in patients with inflammatory bowel disease.

Although it is recognized that neurogenic influences contribute to progression of chronic inflammatory diseases, the molecular basis of neuroimmune interactions in the pathogenesis of chronic pancreatitis (CP) is not well defined. Here we report that responsiveness of peripheral blood mononuclear cells (PBMC) to the neuropeptide pituitary adenylate cyclase-activating polypeptide (PACAP) is altered in CP. Expression of PACAP and its receptors in human CP was analyzed with quantitative RT-PCR, laser-capture microdissection, and immunohistochemistry. Regulation of PACAP expression was studied in coculture systems using macrophages and acinar cells. Responsiveness of donor and CP PBMC to PACAP was determined based on cytokine profiles and NF-kappaB activation of LPS- or LPS+PACAP-exposed cells. Although donor and CP PBMC responded equally to LPS, PACAP-mediated counteraction of LPS-induced cytokine response was switched from inhibiting TNF-alpha to decreasing IL-1beta and increasing IL-10 secretion. The change of PACAP-mediated anti-inflammatory pattern was associated with altered activation of NF-kappaB: compared with LPS alone, a combination of LPS and PACAP had no effect on NF-kappaB p65 nuclear translocation in CP PBMC, whereas NF-kappaB was significantly decreased in donor PBMC. According to laser-capture microdissection and coculture experiments, PBMC also contributed to generation of a PACAP-rich intrapancreatic environment by upregulating PACAP expression in macrophages encountering apoptotic pancreatic acini. The nociceptive status of CP patients correlated with pancreatic PACAP levels and with IL-10 bias of PACAP-exposed CP PBMC. Thus the ability of PBMC to produce and to respond to PACAP might influence neuroimmune interactions that regulate pain and inflammation in CP.

Germline genetic variability might contribute, at least partially, to the survival of pancreatic ductal adenocarcinoma (PDAC) patients. Two recently performed genome-wide association studies (GWAS) on PDAC overall survival (OS) suggested (P < 10(-5)) the association between 30 genomic regions and PDAC OS. With the aim to highlight the true associations within these regions, we analyzed 44 single-nucleotide polymorphisms (SNPs) in the 30 candidate regions in 1722 PDAC patients within the PANcreatic Disease ReseArch (PANDoRA) consortium. We observed statistically significant associations for five of the selected regions. One association in the CTNNA2 gene on chromosome 2p12 [rs1567532, hazard ratio (HR) = 1.75, 95% confidence interval (CI) 1.19-2.58, P = 0.005 for homozygotes for the minor allele] and one in the last intron of the RUNX2 gene on chromosome 6p21 (rs12209785, HR = 0.88, 95% CI 0.80-0.98, P = 0.014 for heterozygotes) are of particular relevance. These loci do not coincide with those that showed the strongest associations in the previous GWAS. In silico analysis strongly suggested a possible mechanistic link between these two SNPs and pancreatic cancer survival. Functional studies are warranted to confirm the link between these genes (or other genes mapping in those regions) and PDAC prognosis in order to understand whether these variants may have the potential to impact treatment decisions and design of clinical trials.

OBJECTIVE: Generation and maintenance of pain in chronic pancreatitis (CP) have been shown to be partially attributable to neuroimmune interactions, which involve neuropeptides such as substance P (SP). So far, expression of SP receptors NK-2R, NK-3R, the SP-encoding gene preprotachykinin A (PPT-A), and the SP degradation enzyme neutral endopeptidase (NEP) and their relation to pain in CP have not been determined. METHODS: Tissue samples from patients with CP (n = 25) and from healthy donors (n = 20) were analyzed for PPT-A, NK-2R, NK-3R, and NEP expression using quantitative RT-PCR. NEP protein levels were examined by immunoblot analysis and its localization was determined using immunohistochemistry. A scoring system was used to grade the extent of fibrosis on hematoxylin and eosin- and Masson-Trichrome-stained sections. Messenger RNA levels and the extent of pain were analyzed for correlations. RESULTS: In CP tissues, NK-2R and PPT-A expression was increased, whereas NK-3R and NEP mRNA levels were comparable with normal pancreas. Overexpression of NK-2R was related to the intensity, frequency, and duration of pain in CP patients. NK-1R and NEP expression was significantly related to the extent of fibrosis. CONCLUSIONS: Expression of NK-2R and PPT-A is increased in CP and is associated with pain. Failure to up-regulate NEP may contribute to the disruption of the neuropeptides loop balance in CP and thus may exacerbate the severe pain syndrome.

The pathophysiology of pain in pancreatic diseases is complex and multifactorial. Human data are available only for chronic pancreatitis patients and sometimes for pancreatic cancer. For acute pancreatitis, only animal data are available to date. The various hypotheses attempting to explain the genesis of pain also reflect the different therapeutical approaches to pain in these patients. The “neurogenic inflammation” hypothesis is a theory supported by various studies of all pancreatic disorders. Immunohistological reports have shown that the amount of neurotransmitters, such as substance P and its receptor calcitonin gene–related peptide and other neurotransmitters, is increased in afferent pancreatic nerves, and a correlation between pain and immune cell infiltration of the nerves has been described mainly in chronic pancreatitis patients. The most interesting finding is the existence of a spatial relationship between peptidergic neurons and inflammatory cells. Furthermore, there is the intriguing possibility of functional interaction among neuropeptides, immune cells, cytokines, and nerve growth factors.

Background Neuropeptides, such as substance P (SP), are mediators of neurogenic inflammation and play an important role in inflammatory disorders. To further investigate the role of the SP pathway in inflammatory bowel disease (IBD), we analyzed the following in normal intestinal tissue specimens and in tissue specimens from patients with Crohn's disease (CD) and ulcerative colitis (UC): neurokinin receptor-1 (NK-1R); its isoforms (NK-1R-L and NK-1R-S); its ligand SP, encoded by preprotachykinin-A (PPT-A); and the SP-degradation enzyme, neutral endopeptidase (NEP). Methods Real-time quantitative reverse transcription–polymerase chain reaction was used to simultaneously determine the expression of NK-1R-L, NK-1R-S, and PPT-A. Protein levels of NK-1R and NEP were determined by immunoblot analysis. Results In noninflamed small-bowel tissue samples of CD patients, PPT-A mRNA expression was significantly increased, whereas there was no difference between inflamed or noninflamed UC and normal intestinal tissue samples. Examining subgroups of diverse intestinal segments from CD and UC samples with various levels of inflammation revealed no differences in NK-1R-L and NK-1R-S mRNA expression, whereas there was a tendency toward overall lower NK-1R-S mRNA copy numbers. Immunoblot analysis showed upregulation of NK-1R protein levels in cases of IBD, with more pronounced enhancement in cases of CD than in UC. For NEP, there were no differences in protein levels in normal, CD, and UC intestinal tissues. Comments These observations suggest a contribution of SP and its receptor, NK-1R, in the local inflammatory reaction in IBD and particularly in ileal CD. Moreover, significant upregulation of PPT-A mRNA in the noninflamed ileum of these patients suggests an influence of inflamed intestines on their healthy counterparts.

Methods: The efficacy of pancreatic stenting in the prevention of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) was evaluated by a meta-analysis of 6 controlled studies; 12 additional uncontrolled studies were analyzed for rates of associated risk. Results: Post-ERCP pancreatitis (PEP) developed in 16.5% of controls, and in 5.1 or 9.6% of the stent group at the per-protocol (PP) or intention-to-treat (ITT) analyses. By analyzing only the 4 randomized trials, PEP developed in 24.1% of controls, and in 6.1 or 12.0% of the stented patients at the PP or ITT analyses. Risk was significantly lower in the stent group when compared with controls: OR 0.44 (95% CI 0.24–0.81). The absolute risk reduction is 12.0 (95% CI 3.0–21.0), the number needed to treat 8 (95% CI 5–34), and the publication bias 2. ORs for mild to moderate PEP were reduced in the stent group (OR = 0.537, 95% CI 0.283–1.021), as were those for severe PEP (OR = 0.123, 95% CI 0.021–0.726). Non-pancreatic complications were 4.2%, and included early stent migration (1.4%), perforations (0.4%), bleeding (1.4%), and infections (1.0%). Conclusion: Available trials show benefit for pancreatic stenting in the prophylaxis of PEP, but more randomized studies are needed before endorsing a routine use of this endoscopic procedure.

The incidence and death rate of pancreatic ductal adenocarcinoma (PDAC) have increased in recent years, therefore the identification of novel targets for treatment is extremely important. Interactions between cancer and stromal cells are critically involved in tumour formation and development of metastasis. Here we report that PDAC cells secrete BAG3, which binds and activates macrophages, inducing their activation and the secretion of PDAC supporting factors. We also identify IFITM-2 as a BAG3 receptor and show that it signals through PI3K and the p38 MAPK pathways. Finally, we show that the use of an anti-BAG3 antibody results in reduced tumour growth and prevents metastasis formation in three different mouse models. In conclusion, we identify a paracrine loop involved in PDAC growth and metastatic spreading, and show that an anti-BAG3 antibody has therapeutic potential.

Clearance of apoptotic or necrotic cells by phagocytes protects the surrounding tissue from toxic intracellular factors and reduces probable tissue damage following an inappropriate inflammatory reaction.1 Phosphatidylserine (PS) is one of the key factors in induction of phagocytosis of apoptotic cells. It is the most abundant anionic phospholipid of the plasma membrane, which is located at the inner leaflet of the cell surface.2 The loss of asymmetry and the appearance of this molecule on the outer leaflet of the cell membrane is regarded as one of the essential steps in apoptosis and subsequently in phagocytosis of apoptotic cells.3–7 If apoptotic cells are unable to express PS on their surface, it is almost impossible for them to be phagocytosed.6 However, in addition to the presentation of PS, apoptotic cells display numerous receptors on their surfaces, such as CD 36, αvβ3, αvβ5 integrins, CD14 and CD68. These are necessary in order for phagocytes to approach apoptotic cells, but only the interplay with the PS receptor enables their internalization.8 Binding of PS on the apoptotic cell surface to the PS-receptor (PSR) on phagocytes is an active noninflammatory process which is associated with the down-regulation of proinflammatory mediators such as interleukin (IL)-1β, IL-8, IL-10, granulocyte macrophage colony-stimulating factor, tumor necrosis factor-α, leukotriene C4 and thromboxane B2, while the production of anti-inflammatory mediators (transforming growth factor [TGF]-β1, prostaglandin E2, and platelet-activating factor) is increased in human monocyte-derived macrophages.9,10 Therefore, abnormalities of apoptotic cell clearance may contribute to the pathogenesis of chronic inflammatory diseases.5,9 Tissue destruction in chronic pancreatitis is histopathologically associated with a large amount of infiltrating macrophages.11 In addition, infiltrates of cytotoxic cells are localized at the border of parenchyma and fibrosis, suggesting that cell-mediated cytotoxicity is involved in cell damage in this disease.12,13 Morphologically, cell damage and apoptosis in chronic pancreatitis are associated with up-regulation of pro-apoptotic genes,14 the FAS/FAS-l system,15 caspase-116 and p75NTR17 in atrophic acinar cells, proliferating cells of ductal origin and in acinar cells redifferentiating to form tubular structures. Apoptotic mechanisms in the margin regions of the parenchyma close to stromal fibroblasts may be responsible for increased acinar cell redifferentiation, death, and phagocytosis with replacement by stromal fibroblasts.18–20 Since apoptosis is active in chronic pancreatitis and large numbers of macrophages are present in CP tissue samples, we investigated whether the presence of macrophages is PS/PSR-mediated and whether PS/PSR interaction is a major component in apoptotic cell phagocytosis in CP.

The etiopathogenesis of cholecystolithiasis is not well defined. Primary dysmotility of the organ, due to fibrosis of the gallbladder wall or muscular dysfunction, is suggested as a crucial factor. Transforming growth factor-beta (TGF-beta) and connective tissue growth factor (CTGF) are involved in several fibrotic disorders and play a critical role in fibrogenesis, thereby changing the physiological function of the organs. In the present study we analyzed the role of TGF-beta and its downstream target CTGF in patients with cholecystolithiasis.Gallbladders were obtained from 16 individuals undergoing surgery for symptomatic cholecystolithiasis. Normal human gallbladder tissue samples from five individuals without any history of gallbladder disease were obtained through an organ donor transplantation program. Northern blot analysis, in situ hybridization, and immunohistochemistry were used to analyze the expression of TGF-beta1 and CTGF in the gallbladder tissue samples.By northern blot analysis there was an enhanced TGF-beta1 mRNA expression (eightfold increase; P0.04) in the cholecystolithiasis tissue samples in comparison with normal controls. There was also a concomitant increase in CTGF (41-fold increase; P0.01). By in situ hybridization and immunohistochemistry, CTGF mRNA was localized mainly in the mucosa layer, while intensive staining of the smooth muscle cells with TGF-beta1 and CTGF was observed. In addition, TGF-beta1 immunoreactivity was also localized in the fibroblasts and inflammatory cells. TGF-beta1 m-RNA levels showed a significant relationship with the degree of fibrosis in the tissue samples (P0.04, r = 0.5).Our data indicate that TGF-beta and CTGF are involved in ultrastructural tissue changes in patients with cholecystolithiasis. Activation of the "TGF-beta pathway," predominantly in the remaining mucosa and submucosal layer, indicates that extracellular matrix (ECM) synthesis with subsequent gallbladder wall fibrosis is an important step in gallbladder dysfunction in this disorder.

Connective tissue growth factor (CTGF), which is regulated by transforming growth factor-ss (TGFss), has recently been implicated in the pathogenesis of fibrotic diseases and tumor stroma. Inasmuch as generation of desmoplastic tissue is characteristic for pancreatic cancer, it is not known whether it gives pancreatic cancer cells a growth advantage or is a reaction of the body to inhibit cancer cell progression. In the present study we analyzed the expression and localization of CTGF and evaluated whether it influences the prognosis of pancreas cancer. Tissue samples were obtained from 25 individuals (6 women, 19 men) undergoing pancreatic resection for pancreatic cancer. Tissue samples from 13 previously healthy organ donors (5 women, 8 men) served as controls. Expression of CTGF was studied by Northern blot analysis. In situ hybridization and immunohistochemistry localized the respective mRNA moieties and proteins in the tissue samples. Northern blot analysis revealed that pancreatic cancer tissue samples exhibited a 46-fold increase in CTGF mRNA expression ( p0.001) over that of normal controls. In vitro studies confirmed that pancreatic stellate cells are the major source of CTGF mRNA expression and revealed a large variance in basal and TGFss-induced CTGF expression in cultured pancreatic cancer cells. This could also be confirmed by in situ hybridization, indicating that CTGF mRNA signals were located principally in fibroblasts, with only weak signals in the cancer cells. High CTGF mRNA levels in the tissue samples correlated with better tumor differentiation ( p0.03). In addition, patients whose tumors exhibited high CTGF mRNA levels (onefold increase above normal controls) lived significantly longer than those whose tumors expressed low CTGF mRNA levels (none to onefold) ( p0.04 multivariate analysis). Our present data indicate that CTGF, as a downstream mediator of TGFss, is overexpressed in connective tissue cells and to a lesser extent in pancreatic cancer cells. Because patients with high CTGF mRNA expression levels have a better prognosis, our findings indicate that the desmoplastic reaction provides a growth disadvantage for pancreatic cancer cells.

The pathophysiology of pain in chronic pancreatitis (CP) is incompletely understood. Several hypotheses have been advanced, including pancreatic and extrapancreatic causes. The existence of different hypotheses to explain the genesis of pain in CP also reflects the different therapeutic approaches to pain in these patients. Increased intraductal pressure as a result of single or multiple strictures and/or calculi is believed to be a common cause of pain in CP patients with a dilated main pancreatic duct. Other suggested causes include pancreatic fibrosis, interstitial hypertension and pancreatic ischemia. Additionally, extrapancreatic causes like duodenal and common bile duct stenosis with scarring due to pancreatic inflammation are suggested as factors causing pain in CP. The ‘neurogenic inflammation’ hypothesis is a fascinating theory which is supported by different studies. Immunohistological reports have shown that the amount of neurotransmitters, such as substance P and its receptor, calcitonin gene-related peptide and other neurotransmitters, are increased in afferent pancreatic nerves and a correlation between pain and immune cell infiltration of the nerves has been reported in CP. In this review we will discuss the different pain hypotheses and will present the perspective that neuroimmune interaction is an important factor for pain generation in CP.

Background Pancreatic ductal adenocarcinoma (PDAC) is an extremely aggressive malignancy, characterized by largely unsatisfactory responses to the currently available therapeutic strategies. In this study we evaluated the expression of genes involved in gemcitabine uptake in a selected cohort of patients with PDAC, with well-defined clinical-pathological features. Methods mRNA levels of hENT1, CHOP, MRP1 and DCK were evaluated by means of qRT-PCR in matched pairs of tumor and adjacent normal tissue samples collected from PDAC patients treated with gemcitabine after surgical tumor resection. To detect possible interaction between gene expression levels and to identify subgroups of patients at different mortality/progression risk, the RECursive Partitioning and Amalgamation (RECPAM) method was used. Results RECPAM analysis showed that DCK and CHOP were most relevant variables for the identification of patients with different mortality risk, while hENT1 and CHOP were able to identify subgroups of patients with different disease progression risk. Conclusion: hENT1, CHOP, MRP1 and DCK appear correlated to PDAC, and this interaction might influence disease behavior.

15-25% of appendices removed from patients with suspected appendicitis appear normal on histological examination. The cause of pain in such patients is unknown. Since the content of neuropeptides seems to be altered in chronic inflammation, we investigated possible changes in peptidergic innervation for substance P (SP), vasoactive intestinal peptide (VIP), and growth-associated protein-43 (GAP-43).Appendices classified as showing acute appendicitis, non-acute appendicitis (clinical signs of acute appendicitis, but histologically not inflamed), or normal were processed for SP, VIP, and GAP-43 immunocytochemistry. The density of SP immunostaining was assessed by digitised morphometry.31 appendix specimens were studied (16 acute, 15 non-acute). 16 specimens were used as controls. Expression of GAP-43 was increased in the non-acute appendices. We observed larger amounts of SP-immunoreactive and VIP-immunoreactive nerves in the mucosal layer of the appendix in patients with non-acute appendicitis than in controls and patients with acute appendicitis (mean % area SP-immunoreactive 0.0496 [SD 0.0113] non-acute, 0.0221 [0.0049] acute, 0.0229 [0.0068] controls). In addition, a close spatial relation between SP-immunoreactive and VIP-immunoreactive nerve fibres and lymphoid cells was detected in the outer zone of lymph follicles.Neuroproliferation in the appendix, in association with an increase in neurotransmitters SP and VIP, may be involved in the pathophysiology of acute right abdominal pain in the absence of an acute inflammation of the appendix. Our data, together with increasing knowledge about the way in which the nervous system and immune cells interact, suggest that neuroimmune appendicitis is a distinct pathological entity.

A tumour score for venous invasion in patients with pancreatic adenocarcinoma was evaluated by means of computed tomography (CT), in order to improve the assessment of medical treatment and clinical outcome with special attention to borderline resectable disease.Fifty-six consecutive patients who underwent curative surgical resection for pancreatic cancer were analysed. On the basis of CT criteria, tumour involvement of the portal vein (PV) and superior mesenteric vein (SMV) was graded according to an adapted 4-point scale: score 1, definite absence of invasion; score 2, probable absence of invasion; score 3, probable presence of invasion; score 4, definite presence of invasion. Correlations between the venous infiltration scores and the patients' clinical features were also evaluated.After radiological evaluation of PV and SMV grades of infiltration, 21/56 (37 %) and 37/56 (66 %) patients, respectively, were found to have borderline resectable disease. The 4-point scale achieved a sensitivity of 80 %, a specificity of 96 % and an accuracy of 93 % in the evaluation of the PV, and a sensitivity of 100 %, a specificity of 94 % and an accuracy of 95 % in the evaluation of the SMV. Analysis of the distribution of clinical characteristics by PV and SMV infiltration showed that both scores correlated with the presence of distal metastasis (p = 0.016 and p = 0.028, respectively), and resection margins status (p = 0.015 and p = 0.006, respectively).This adapted tumour score is reliable for assessing venous invasion and might improve preoperative staging in patients with borderline resectable pancreatic cancer.