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Abstracts of Papers Submitted to the Joint 40th Anniversary Meeting of American Pancreatic Association and Japan Pancreas Society, November 4-7, 2009, Honolulu, Hawaii

doi: 10.1097/MPA.0b013e3181bc48fa
Abstracts
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Older Age and Long-Term Survival After Pancreaticoduodenectomy for Cancer

A. Abraham, E. Habermann, T. Tuttle, S. Vickers, E. Jensen, W. Al-Refaie. University of Minnesota and Minneapolis VAMC, Minneapolis, MN.

Background: Evidence to characterize the long-term survival benefits of pancreaticoduodenectomy (PD) in the elderly remains sparse. Using an NCI-sponsored dataset, we examined the association between increasing age and long-term survival after PD for cancer.

Methods: Using the 2000-2006 SEER registries, we identified 2162 persons older than 60 years treated with PD for localized non-metastatic cancer. To eliminate the effects of early operative mortality, we excluded deaths within 3 months of diagnosis. We used Cox Proportional Hazards Regression to assess the effect of older age on 3-year survival, adjusted for confounders.

Results: Over 70% of US pancreatic cancer occurred in persons older than 60 years. Only 23% received PD. Older age was associated with decreased PD rates (>80 yrs vs. 60-64 yrs, 11% vs. 27%) and receipt of adjuvant radiotherapy (>80 yrs vs. 60-64 yrs, 19% vs. 49%) (for all, p < 0.0001). Multivariate analyses showed that older age predicted increased pancreas cancer-related mortality after PD (age >80 yrs vs. 60-64 yrs, HR 1.29, 95%CI 1.05-1.59). AJCC N + stage was the strongest predictor of pancreas-cancer mortality (HR 1.80, 95%CI 1.59-2.05).

Conclusions: In this population-based experience, long term survival after PD significantly dampens with increasing age. Although poorer survivals were observed in the oldest age group, tumor-factors continue to show the strongest association with survival. Given our aging population, future evaluations should continue to assess the long-term benefits of PD in the oldest age patients.

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LHRH-Curcumin Conjugate Inhibits Pancreatic Cancer Cell Growth In Vitro and In Vivo

S. Aggarwal,1 W. Hansel,1 M.W. Ndinguri,2 R. Solipuram,1 Q. Wang,1 R.P. Hammer.2 1William Hansel Cancer Prevention Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA; 2Department of Chemistry, Louisiana State University, Baton Rouge, LA.

Targeting chemotherapeutic drugs to specific cancer cells is a major challenge in developing effective treatments that have minimal side effects. This is especially true for pancreatic ductal adenocarcinomas which are invariably lethal. In previous studies, we discovered that conjugates of lytic peptides and LHRH (for example, LHRH-Phor21) target and destroy human prostate, breast and ovarian cancer cells in xenografts and metastatic cells in the nude mouse model (Hansel et al., Mol. and Cell. Endocrinol., 260-262:183-189, 2007). All of these cell lines express LHRH receptors. The objectives of the study were to synthesize a bioconjugate of LHRH and a dietary micro-chemical (Curcumin) and test the hypothesis that LHRH-Curcumin targets and inhibits pancreatic cancer cell growth in vitro and in vivo in the nude mouse xenograft model. Unlike Curcumin itself, the LHRH-Curcumin conjugate proved to be highly soluble in water allowing its intravenous injection. In in vitro studies, LHRH-Curcumin was found to be highly cytotoxic to MIAPaCa-2, PANC-1 and BxPC-3 pancreatic cell lines, all of which express LHRH receptors. In vivo, LHRH-Curcumin caused a highly significant (P < 0.001) reduction in tumor weights and volumes in the nude mouse model. LHRH-Curcumin induces apoptosis and represents a new potential for treating pancreatic cancer.

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Controlled Release of Basic Fibroblast Growth Factor Causes Rapid Healing of Pancreaticojejunostomy With Potent Angiogenesis and Acceleration of Apoptosis Induction in Granulation Tissue

T. Aimoto,1 A. Katsuno,1 K. Yamahatsu,1 M. Hiroi,1 Y. Nakamura,1 Y. Tabata,2 M. Miyamoto,3 E. Uchida.1 1Department of Surgery, Nippon Medical School, Tokyo, Japan; 2Department of Biomaterials, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan; 3Department of Internal Medicine, Nippon Medical School, Tokyo, Japan.

Aim: We examined the healing process following the novel approach to investigate significance of administration of basic fibroblast growth factor (bFGF) incorporated in gelatin hydrogel (GH) microspheres in the anastomotic healing of the pancreaticojejunostomy (PJ).

Method: 28 dogs received a jejunal subserosal injection of 10μg bFGF-GH (n = 16) or GH alone (n = 12). Sequential analysis of the healing process was performed on day 4, 7, 21, 28.

Results: Histologic observations revealed an abundant granulation tissue at the border zone in the bFGF-GH group on day 7 and the GH alone group on day 21. Marked neovascularization and dense collagen deposition were detected in both groups on day 28. Collagen content and breaking strength showed no significant difference between both groups on day 28. A higher value of TUNEL index and a rapid decline in the number of vimentin-positive cells was detected since day 21 in the bFGF-GH group. The MVD in the bFGF-GH group was a higher value since day 7.

Conclusion: Basic FGF-GH administration can cause a rapid healing of PJ and may contribute to improvement of quality of the healing with potent angiogenesis and promotion of apoptosis induction.

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Comparison Between Contrast-Enhanced Ultrasonographic and Pathological Findings of Pancreatic Cancer

G. Akasu, H. Kinoshita, H. Ishikawa, M. Yoshitomi. Department of Surgery, Kurume University School of Medicine, Kurume City, Japan.

Contrast-enhanced ultrasonography (CE-US) with a low-acoustic-pressure contrast medium enables a continuous real-time observation of contrast enhancement. In this study, we performed CE-US with a low-sound-pressure contrast medium, Sonazoid (Daiichi-Sankyo, Tokyo, Japan), before surgery. In 9 patients who were pathologically diagnosed with pancreatic cancer after resection, we compared contrast-enhanced ultrasonographic with pathological findings.

Methods: We prepared a time-signal intensity curve of the pancreatic region. The increment in the signal intensity (ISI) before contrast enhancement to the maximum was regarded as the degree of contrast enhancement. Using a resected specimen, double immunostaining with anti-CD34 and anti-αSMA antibodies was conducted. Microvessels showing a positive reaction were counted at a 200× magnification, and regarded as the microvessel density (MVD) (pathological parameter). We compared the ISI on CE-US with MVD.

Results: The ISI was 7 to 143 dB. The MVD ranged from 1.6 to 17.7. There was a correlation between the MVD and ISI.

Discussion: MVD may be associated with metastases from many malignant tumors and their prognoses. This association is also suggested in patients with pancreatic cancer. Sonazoid is distributed only in blood vessels after infusion. Therefore, the signal intensity on CE-US may reflect micro-blood flow at the pancreatic cancer lesion site. In this study, a correlation was noted between the ISI and MVD, suggesting the usefulness of CE-US in the evaluation of pancreatic cancer MVD.

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Can Perioperative Peridural Analgesia Improve the Prognosis of Pancreatic Cancer?

A. Alexander,1 S. Unzeitig,2 W.T. Knoefel,1 A. Rehders,1 R. Riediger,1 C.F. Eisenberger,1 P. Kienbaum.2 Depts. of 1Surgery and 2Anesthesia, University of Düsseldorf, Germany.

Introduction: In patients with prostatic and breast cancer a beneficial effect on the prognosis was found after peridural anesthesia. This was explained by a reduction of narcotics and opioids as well as a lower stress level achieved by utilisation of regional analgesia. Here the influence of peridural anesthesia on the prognosis of patients with pancreatic cancer was evaluated.

Methods: In a retrospective review 100 consecutive patients with pancreatic cancer after R0 resection were analyzed. Perioperatively deceased patients where excluded. 72% received regional anesthesia with ropivacaine, and 23 of these had peridural opioids. The remaining 28% had general anesthesia, only.

Results: The median observation period was 13 months. The 5-year-survival rate was 16.5%. The majority of the patients was diagnosed at an advanced stage (90% ≥T3, 76% N1). 17% developed local tumor recurrence, 33% distant metastases. No prognostic influence of peridural anaesthesia was found. However, intraoperative peridural application of more than 30 μg of opioids resulted in a reduced overall survival in univariate analysis (p = 0.025). Further parameters that were associated with an adverse effect on prognosis were N1 status and transfusion of >3 units. Multivariate analysis confirmed the independent adverse effect of opioids.

Discussion: Peridural analgesia has its benefits perioperatively but no prognostic benefit in patients with pancreatic cancer was found. The peridural application of opioids should be critically evaluated.

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AMP-Dependent Protein Kinase Regulates Vacuolar ATPase Mediated Zymogen Activation

M. Alexandre,1 A. Diaz de Villalvilla,1 C. Shugrue,1 T. Koledecik,1 E. Thrower,1 F. Gorelick.1,2 1Dept. of Internal Medicine, Sec. of Digestive Diseases, 2Dept. of Cell Biology, Veterans Administration Connecticut Healthcare, West Haven and Yale University School of Medicine, New Haven, CT.

The pathologic activation of digestive zymogens within pancreatic acinar cells is a key step in initiating acute pancreatitis (AP). We have found that an ATP-dependent proton pump, vacuolar ATPase (vATPase), is central to zymogen activation. vATPases have 2 domains; an integral membrane domain (Vo) and a soluble cytoplasmic domain (V1). Activation of the vATPase requires translocation of the soluble V1 to the integral Vo subunit, followed by consumption of ATP leading to an increase in ADP and AMP levels. We hypothesize that increased AMP activates AMP-dependent protein kinase (AMPK) and may negatively regulate vATPase assembly. To test this hypothesis we used a cerulein model of AP in isolated rat acinar cells. Hyper-cerulein (100 nM) stimulation modified phosphorylation states of AMPK at both its activating (Thr172) and inhibitory (S485/491) sites. Hyper-cerulein stimulation after treatment with 2 mM AICAR (an AMPK activator) caused a decrease in vATPase translocation while treatment with 20 μM compound C (an AMPK inhibitor) caused an increase, as determined by immunoblot. The effects of AMPK activation and inhibition on cerulein-induced zymogen activation were investigated. AICAR decreased zymogen activation whereas compound C enhanced it. No effects on amylase secretion or cellular injury were observed. These findings suggest a protective role for AMPK in vATPase-mediated zymogen activation.

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Concurrent Inhibition of NFκB, Cyclooxygenase-2 and Epidermal Growth Factor Toward Pancreatic Cancer Therapy

S. Ali,1 S. Banerjee,2 J.M. Schaffert,2 B.F. El-Rayes,1 P.A. Philip,1 F.H. Sarkar.2 1Department Internal Medicine, 2Department of Pathology. Karmanos Cancer Institute, Wayne State University, Detroit, Michigan.

Inactivation of survival pathways such as NF-κB, cyclooxygenase (COX-2) or epidermal growth factor receptor (EGFR) signaling individually may not be sufficient for the treatment of human pancreatic cancer (PC) as suggested by recent clinical trials. 3,3′-diindolylmethane (B-DIM), is an inhibitor of NF-κB and COX-2. We hypothesized that the simultaneous inhibition of NF-κB/COX-2 by B-DIM and EGFR by erlotinib will potentiate the anti-tumor effects of gemcitabine both in vitro and in vivo. Growth inhibition in seven PC cell lines treated with B-DIM, erlotinib or gemcitabine alone or their combinations was evaluated using MTT assay. Significant growth inhibition was observed in PC cells expressing high levels of COX-2, EGFR, and NF-κB proteins. The observed inhibition was associated with an increase in apoptosis by ELISA. A significant down-regulation in the expression of COX-2, NF-κB and EGFR in BxPC-3, COLO-357 and HPAC cells was observed; suggesting that simultaneous targeting of EGFR and NF-κB/COX-2 is more effective than targeting either signaling pathway separately. Our in vitro results were further supported the in vivo showing that B-DIM in combination with erlotinib and gemcitabine is much more effective than individual agents. Our results conclude that this triple combination could be useful for the treatment of PC patients expressing high levels of COX-2, EGFR and NF-κB in their tumors, and thus further clinical studies are warranted.

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Quercetin Enhances Apoptosis and Inhibits Angiogenesis in Pancreatic Cancer Cells

E. Angst, J. Park, A. Moro, P.W.N. Lee, V.L.W. Go, H.A. Reber, G. Eibl, O.J. Hines. UCLA Center for Excellence in Pancreatic Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Flavonoids are important components of many fruits and vegetables, and may have preventive or therapeutic potential for human malignancies. We have previously shown that the flavonoid quercetin dose-dependently decreases pancreatic cancer (PaCa) growth. In this study, we hypothesize that the mechanisms of quercetin on PaCa involves enhanced apoptosis and antiangiogenesis.

Methods and Results: The cell lines MIA PaCa-2 (MP, undifferentiated) and BxPC-3 (Bx, moderately differentiated) were treated for 48 hrs with quercetin. To assess whether quercetin induces cell death, we performed annexin V and propidium iodide flow cytometry. Quercetin significantly induced apoptosis at 10 μM in both cell lines by 22% and 7.8% in MP and Bx, respectively (p < 0.05). PaCa cell expression of the pro-angiogenic chemokines was stimulated with Il-1β, and measured by ELISA and RT-PCR. CXCL5 and CXCL8 expression by PaCa cells was dose dependently decreased by quercetin. To elucidate the functional relevance of the observed decrease, HUVECs were incubated with conditioned media from quercetin treated PaCa cells. We found a 50% decrease in tube formation (p < 0.05), confirming that quercetin decreases PaCa derived angiogenesis.

Conclusion: Our data suggest that the potent inhibitory effect of quercetin is mediated in part by the induction of apoptosis and inhibition of angiogenesis in PaCa cells. Quercetin available in our daily food may be useful as an adjunct to current standard treatment for pancreatic cancer.

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Autoimmune Pancreatitis in Young Patients

H. Anjiki,1 T. Kamisawa,1 K. Takuma,1 T. Tabata,1 N. Egawa,1 M. Kurata.2 1Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan; 2Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.

Aim: Histological feature of autoimmune pancreatitis (AIP) recognized in Japan is sclerosing pancreatitis, showing rare infiltration of granulocytes. AIP has a preponderance of elderly males in Japan. Patients with AIP with granulocytic infiltration in the pancreas reported in USA and Italy showed no sexual difference, and younger. Their major initial symptom was abdominal pain, and obstructive jaundice was seen less frequently. This study aimed to examine whether there is a difference in the AIP occurred in young and elderly patients in Japan.

Methods: A total of 58 AIP patients diagnosed according to Asian diagnostic criteria for AIP in our hospital were divided into a young group (≤45 y old) and elderly group (>46 old). The clinical findings of each group were compared.

Results: The young group consisted of 7 patients (6 men, 1 woman) with an average age of 35.7 years, meanwhile, in the elderly group, there were 51 patients were 41 men, 10 women with an average age of 67.1 years. Abdominal pain as the presenting symptom was significantly more frequent in the young group than in the elderly group (86% vs. 15.7%, p < 0.05). Obstructive jaundice was detected in only 28.6% of patients in the young group compared with 68.6% of patients in the elderly group. Serum amylase elevations were detected more frequently in young group than in elderly group (p < 0.05). Although sclerosing extrapancreatic lesions were associated in 31% of elderly group, they were not associated in young group. Ulcerative colitis was associated in two patients in the young group.

Conclusion: Although rare in Japan, young patients with AIP show different clinical features from elderly patients with AIP. These clinical features were similar to those of AIP patients reported in USA and Italy.

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S100P Derived Rage Antagonistic Peptide Reduces the Pancreatic Tumor Growth and Metastasis

T. Arumugam, C.D. Logsdon. Dept. of Cancer Biology, UT MD Anderson Cancer Center, Houston, TX.

Background: We previously established that S100P increases pancreatic tumor growth and metastasis via interactions with RAGE. RAGE mediated functions are also deleterious in other diseases including diabetes, arthritis, neurodegenerative diseases and other types of tumors. Therefore, we have developed a novel antagonist for RAGE.

Methods: Several S100P derived small antagonistic peptides (10 aa) were designed and synthesized. S100P/RAGE interactions were measured by co-immunoprecipitation (Co-IP) and ELISA. In vitro and in vivo NFκB-luc reporter studies were used to examine the effects of these peptides on S100P activation of RAGE. Effects of the lead peptide were tested on In vivo tumor growth of Mpanc96 orthotopic tumors.

Results: Co-IP and ELISA studies indicated the direct interaction of S100P with its receptor RAGE and the ability of some small antagonistic peptides to block this interaction. The lead peptide successfully blocked RAGE binding as well as S100P stimulated NFκB activity. Both intratumoral and intraperitoneal delivery of this peptide blocked constitutive NFκB activity in pancreatic cancer cells implanted in vivo. Five weeks treatment with the lead peptide by i.p injection significantly reduced pancreatic cancer primary tumor growth and metastasis. In vivo, injection of the lead peptide also resulted in a dramatic reduction in glioma tumors.

Conclusions: An S100P derived small antagonistic peptide blocked tumor growth and metastasis and shows promise as a cancer treatment. Further modifications and formulations of this peptide to improve pharmacokinetics are underway.

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Notes Retroperitoneal Transvaginal Distal Pancreatectomy

M. Asakuma,1,2 P. Allemann,1 S. Perretta,1 B. Dallemagne,1 D. Mutter,1 N. Tanigawa, J. Marescaux.1 1IRCAD/EITS Institute, University Hospital, 1 place de l'hopital, Strasbourg, France; 2Department of general and gastroenterological surgery, Osaka medical college, Osaka, Japan.

Background: The retroperitoneal approach preserves the peritoneal cavity and its envelope. The benefits of laparoscopic retroperitoneal approach to the kidney and the adrenal gland are well known. The pancreas may represent another potential target. Whereas NOTES transperitoneal distal pancreatectomy has been reported, the retroperitoneal approach, which may combine the advantages of peritoneal preservation with those of no scar surgery, has never been explored. We report the feasibility of NOTES transvaginal retroperitoneal pancreatectomy in a porcine model.

Methods: With the pig supine, under general anesthesia, a 10-mm posterior colpotomy was performed with a needle-knife operated through a flexible 12-mm, double-channel endoscope. A retroperitoneal tunnel was created with blunt dissection up to the kidney with progressive visualization of the left iliac vessels, ureter, and abdominal aorta. To reach the posterior aspect of the pancreas, a space was opened medial to the upper renal pole dividing the Gerota's fascia. The tail of pancreas was mobilized with blunt and sharp dissection, using monopolar cautery. Once the distal pancreas was dissected, it was secured using a polypropylene endoscopic loop and then resected with an endoscopic snare.

Results: The procedure was successfully accomplished by a totally NOTES approach in five pigs, with a mean operative time of 118 minutes with no intraoperative complications and no injury to any retroperitoneal structure.

Conclusions: The pancreas is accessible by a transvaginal retroperitoneal NOTES approach. Human cadavers studies are necessary to confirm the validity of this model and to explore the need for specific technological developments, such as flexible stapling devices, to improve the safety of pancreatic resection.

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Surgical Management of Pancreatic Metastasis From Renal Cell Carcinoma

Y. Azumi, H. Katoh, Y. Nobuoka, M. Kishiwada, T. Hamada, S. Mizuno, M. Usui, H. Sakurai, M. Tabata, S. Isaji. Department of HepatoBiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.

Pancreatic metastatic tumors from renal cell carcinoma (RCC) are clinically rare, but most frequent cause of metastatic pancreatic tumor is RCC. The aim of this study was to define the role of surgery in their treatment.

From 1998 to 2009, 7 patients with metastatic pancreatic tumor from RCC (solitary in 3 and multiple in 4) underwent pancreatectomy: synchronous in 3 and metachronos in 4 (the median interval from nephrectomy to pancreatic metastasis was 123 months, ranging from 42 to 161 months). The locations of tumors were pancreatic head in 3, body in 3, and tail in 5. The median tumor size was 3.5 cm (1-7 cm). At the time of pancreatectomy, 6 patients had no another metastasis and one had bone metastasis. All patients belonged to favorable risk group according to the modified Memorial Sloan-Kettering prognostic factors model. Operative procedure was pancreaticoduodenectomy (PD) in 1, distal pancreatectomy (DP) in 4, and PD with DP leaving the body intact in 2. Among 7 cases, tumor relapse occurred in 6: pancreas in 2 (repeat resection in 1), lung in 2, liver in 1 and bone in 1. Only one patient died of lung metastasis at 106 months after pancreatectomy, and the median survival time was 26 months (4 to 106 months).

In conclusion, all patients who belong to a favorable risk group are candidates for pancreatectomy if the procedure is technically feasible to avoid total pancreatectomy, even in the presence of another metastatic site and multiple tumors.

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Effect of Activated Protein C on Apoptotic Expression in Experimental Acute Pancreatitis

B.I. Babu,1 S. Jamdar,1 A.K. Siriwardena,1 M. Jeziorska.2 1HPB Unit, Manchester Royal Infirmary, 2University of Manchester, UK.

Introduction: Activated protein C (APC) is known to modulate apoptosis in acute pancreatitis (AP). Utilising immunohistochemistry (IHC) and image analysis, we quantified the effect of APC on the apoptotic pathway in an L-arginine induced AP model.

Method: Under UK Home Office Licence adult Sprague Dawley rats were allocated as follows: Gp 1: control; Gp 2: AP; Gp 3; AP pre-treated with Xigris (500 μg/kg bw); Gp 4: AP with Xigris 30 minutes after induction of injury. AP was by intraperitoneal administration of L-arginine (300 mg/100 g bw). Animals were sacrificed at 48 hours. IHC and computerised image quantification was performed for Caspase 8, 9, 3.

Results: There was increased expression of Caspase 8, 3 and 9 in the AP group compared to the controls. A non-significant decrease was noted in both pre and post treatment groups for all three caspases (P = 0.41, Kruskal-Wallis).

Increased expression of Caspase 8 was noted in all the groups compared to the other caspases (P = 0.1631, Kruskal-Wallis). Caspase 9 was the least expressed. A cumulative expression of effector caspase 3 was not observed in this study. (P = 0.15, Kruskal-Wallis).

Conclusion: As apoptotic cascade proceeds, a quantitative amplification of caspase 3 compared to caspase 8 is expected. This was not demonstrated in our study supporting the possibility that APC may act prior to or at Caspase 3. No demonstrable increase was noted in the expression of caspase 9. This supports the fact that apoptosis was triggered by an extrinsic mechanism. This study provides insight in to the sub cellular basis for the potential efficacy of APC in AP.

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Human Recombinant Activated Protein C (XIGRIS) Attenuates Cerulein-Induced Experimental Acute Pancreatitis

B.I. Babu,1 T. Genovese,2 E. Mazzon,2 C. Crissafuli,2 A.K. Siriwardena,1 S. Cuzzocrea.2 1Hepatobiliary Unit, Manchester Royal Infirmary, UK, 2Experimental Pharmacology Dept, University of Messina, Italy.

Introduction: Xigris (Human recombinant activated protein C; Eli Lilly, USA) ameliorates sepsis by preserving microvascular patency. Microvascular thrombosis occurs in severe acute pancreatitis (AP). We evaluated the role of Xigris in modulating experimental AP.

Methods: This study was in accordance with EU experimentation regulations. AP was induced by 6 h injections of cerulein 50 μg/kg body weight. Male rats were allocated at random into groups: Gr 1 Control (n = 5); Gr 2 vehicle (n = 5); Gr 3: AP (n = 10); Gr 4 Cerulein + xigris at induction of AP & sacrifice at 24 h (n = 10); Gr 5 Cerulein + Xigris 24 hrs after induction & sacrifice at 48 h (n = 10). In addition to morphology, markers of apoptosis and endothelial injury were assessed by quantitative Immunohistochemistry, apoptosis by TUNEL and western blot quantified by densitometry was used to assess marker of apoptosis and endothelial injury.

Results: Cerulein administration induced acute necrotising pancreatitis. Xigris did not modify coagulation parameters. The xigris post-treatment group showed significant reductions in MPO and MDA together with reduction in histological evidence of injury. There was a significant reduction in densitometric levels of ikB, Nf-κB65, ICAm-1, P-selectin, Bax and BCL2 in this group compared to AP.

Conclusion: This study demonstrates that Xigris does not lead to pancreatic haemorrhage in AP and ameliorates the effect of cerulein induced pancreatitis through the apoptotic and NF- κβ pathways.

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Protein C Dynamics in Clinical Acute Pancreatitis

B.I. Babu, A.J. Sheen, A.K. Siriwardena. Hepatobiliary Unit, Manchester Royal Infirmary, Manchester, UK.

Introduction: Xigris (Human recombinant activated protein C; Eli Lilly, USA) ameliorates sepsis by preserving microvascular patency. Microvascular thrombosis occurs in severe acute pancreatitis (AP). Although there is experimental evidence that xigris modulates AP, there is little information on protein C levels in clinical AP. This study measures protein C levels during the course of clinical AP.

Methods: In a consecutive series of 59 patients with AP the chromogenic substrate method was used for determination of functional Protein C levels in plasma. Protein C activity was assessed at admission, 24 & 48 hours. Variables required for calculation of APACHE II scores were collected on admission, at 24 and 48 hours. The severity of the disease was based on the 1992 Atlanta Classification. Data were entered prospectively into an electronic database and analysed at completion of recruitment.

Results: The median (range) age was 41 (18-77) with 31 women. 21 (35.6%) of the patients had gallstone related AP. Median (range) Protein C levels and APACHE II Score on admission were 97.5 (44-180) and 4 (0-12). The median (range) of functional Protein C levels with mild AP was 90 (41-169) and for severe AP was 103 (24-180). The reference range for functional Protein C level was 69-154.

Discussion: There does not appear to be evidence of early depletion of functional protein C in AP. Further studies may be required to identify whether an appreciable drop occurs in the very severe form of the disease.

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Notch Signaling in Acinar Cell Reprogramming

L. Baeyens,1,2 S. Bonné,1 M. German,3 I. Rooman,1,2 H. Heimberg,1 L. Bouwens.1,2 1Diabetes Research Center, Free University Brussels, Belgium; 2Cell Differentiation Unit, Free University Brussels, Belgium; 3Hormone Research Institute, University of California San Francisco, USA.

Beta cells represent only a minor fraction of all pancreatic cells whereas exocrine acinar cells represent the bulk. These are discarded upon isolation of islets for transplantation. We investigate the potential of acinar cells for cell replacement therapy.

We have studied the possibility to generate functional beta cells by reprogramming acinar cells following primary cell culture in the presence of specific differentiation factors. Our study presents an efficient protocol for the generation of beta cells, as well as lineage tracing evidence for their acinar origin.

Isolation and in vitro culture of rodent acinar cells induces metaplasia and loss of acinar phenotype. Inductive treatment of these cells by differentiation factors increases the number of insulin positive cells.

When we actively stimulate endogenous Notch signaling, we can almost completely abrogate the responsiveness of the acinar cells to the pro-endocrine treatment. However, when we specifically silence this pathway, we can rescue the competence of these cells to respond to the differentiation stimuli. In the latter condition, more than 70% of the cells with silenced Notch signaling adopt a beta cell phenotype.

We believe that our findings draw attention to acinar cells as a possible source of beta cells and, provided it can be reproduced with human exocrine cells, could substantially improve the application of beta cell replacement therapy with currently available donor tissues.

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Combination of a Neurokinin-1 and Galanin Receptor Antagonists Ameliorates Caerulein-Induced Acute Pancreatitis in Mice

S.G. Barreto,1 C.J. Carati,2 A.C. Schloithe,1 J. Toouli,1 G.T.P. Saccone.1 1Department of General and Digestive Surgery, 2Department of Anatomy and Histology Flinders Medical Centre and Flinders University, Adelaide, South Australia, Australia.

Background: We have shown that galantide, a galanin antagonist, ameliorates acute pancreatitis (AP) in a possum and mouse model. C-96,345, a neurokinin-1 receptor antagonist (NK1RA) has been shown to ameliorate the indices of caerulein-AP in a severe model in mice.

Aim: To compare the efficacy of the combination of galantide and the NK1RA L-703,606 with that of galantide alone or L-703,606 alone in the treatment of experimental AP.

Methods: Mild AP was induced in mice with 7 hourly injections of caerulein. In separate groups of mice, galantide (30 nmol/kg) was co-administered i.p. with each injection of caerulein either coinciding with the first injection of caerulein (prophylactic) or 2 hours after the first injection (therapeutic). L-703,606 (8 mg/kg) was administered as a single dose i.p either 30 min before (prophylactic), or 2 hours after the first caerulein injection (therapeutic). The combination of the two agents was administered as indicated above. Control groups received galantide, L-703,606, or saline. Pancreata were harvested for histological examination and estimation of myeloperoxidase (MPO) activity. Plasma amylase activity was measured. Data were analysed using the Mann-Whitney U test.

Results: Prophylactic and therapeutic administration of galantide reduced the caerulein-induced plasma amylase activity by 37% and 30% (both p < 0.014 as compared to AP alone) respectively. Prophylactic but not therapeutic administration of L-703,606 reduced the caerulein-induced plasma amylase activity by 34% (p < 0.02 as compared to AP alone). Prophylactic administration of the combination of L-703,606 with galantide reduced the caerulein-induced plasma amylase activity by 44% (p < 0.005 as compared to AP alone). In contrast, therapeutic administration of both agents significantly increased plasma amylase levels by 27% (p < 0.025 as compared to AP alone). Neither agent alone nor saline altered plasma amylase activity above pre-treatment levels. Prophylactic and therapeutic galantide treatment significantly reduced pancreatic MPO activity (p < 0.003). Similarly, prophylactic and therapeutic L-703,606, alone as well as in combination with galantide, significantly reduced pancreatic MPO activity (p < 0.05). Galantide and L-703,606 individually, and in combination, significantly reduced the AP-induced necrosis score compared to the AP alone group (p < 0.05).

Conclusion: Prophylactic treatment with NK1RA or galanin receptor antagonist alone, and in combination, ameliorates mild caerulein-induced AP. While therapeutic administration of galantide ameliorates all the indices of AP, therapeutically administered L-703,606 reduces only pancreatic MPO activity and pancreatic damage. The prophylactic administration of the combination of both antagonists does not appear to offer any further benefit as compared to galantide alone. The effects of the therapeutic administration of both agents together suggests an interaction between NK1R and galanin receptors may occur.

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Galanin Stimulates Caerulein-Stimulated Pancreatic Amylase Secretion Via Its Action on Somatostatin Secretion

S.G. Barreto,1 C.J. Carati,2 A.C. Schloithe,1 J. Toouli,1 G.T.P. Saccone.1 1Department of General and Digestive Surgery, 2Department of Anatomy and Histology Flinders Medical Centre and Flinders University, Adelaide, South Australia, Australia.

Background: Galanin inhibits pancreatic amylase secretion induced by physiological concentrations of caerulein by an insulin-dependent mechanism.

Aim: To determine the effect and elucidate the mechanism of action of exogenous galanin on pancreatic amylase secretion induced by supramaximal concentrations of caerulein from lobules in-vitro.

Methods: Amylase secretion from isolated murine pancreatic lobules was measured. Lobules were co-incubated with galanin (10−12M-10−7M) and caerulein (10−7M). Lobules were pre-incubated with atropine (10−5M), tetrodotoxin (10−5M), diazoxide (10−7M), or galantide (10−12M-10−7M) for 30 mins followed by incubation with caerulein (10−7M) alone, or combined with galanin (10−12M). Lobules were also co-incubated with galanin (10−12M), caerulein (10−7M), and octreotide (10−12M-10−7M) or cyclo-(7-aminoheptanoyl-Phe-D-Trp-Lys-Thr[BZL]), a somatostatin antagonist (10−9M). Amylase secretion was expressed as percent of total lobular amylase.

Results: Caerulein (10−7M) stimulated amylase secretion 1.2 fold compared with control secretion. Galanin (10−12M-10−7M) potentiated caerulein-stimulated amylase secretion. Diazoxide pre-treatment abolished the caerulein-stimulated amylase secretion while atropine and tetrodotoxin caused a partial inhibition. Preincubation of lobules with a combination of atropine and diazoxide abolished galanin's potentiation of caerulein-stimulated amylase secretion. Preincubation of lobules with galantide or co-incubation with octreotide significantly reduced, and at some concentrations even abolished, galanin's potentiation of caerulein- stimulated amylase secretion. The somatostatin antagonist, alone or in combination with galanin, produced an effect that was not significantly different from galanin's effect on caerulein-stimulated amylase release.

Conclusions: These data suggest that at supramaximal caerulein concentrations, galanin acts via its receptors to further increases caerulein-stimulated amylase secretion by inhibiting the release of somatostatin caused by supramaximal caerulein.

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High Incidence of Elevated Lipase and Amylase in Type 2 Diabetes Patients (T2DM)

E.J. Bastyr,1,2 J. Barkin,3 F.T. Botros,1 J. Shu.4 1Lilly Research Laboratories, Indianapolis, IN; 2Indiana University School of Medicine, Indianapolis, IN, 3University of Miami, Miami FL; 4i3 statprobe, Ann Arbor, MI, United States.

Serum lipase and amylase elevations are critical for the diagnosis of pancreatitis yet little is known of the elevations in T2DM. We analyzed lipase and amylase levels in a cohort of 440 T2DM patients who were screened for the EGO study (clinicaltrials.gov ID:NCT00630825) of the long-acting, glucagon-like peptide1 analog LY2189265 (LY). EGO was a double-blind, randomized phase 2 clinical trial comparing LY versus placebo in overweight/obese patients with suboptimal control of T2DM despite therapy with 2 oral antihyperglycemic agents. Patients (n = 262) with normal history and physical examinations were randomized to once-weekly titrated or non-titrated subcutaneous injections for 16 weeks of placebo, LY 0.5 mg, LY 1.0 mg, or LY 2.0 mg. Of the 440 screened patients (48% female, 57 ± 11 years; HbA1c 8.3 ± 1.6% [mean ± SD]), 13% had elevated lipase (≥60 IU/dL), and 5% had elevated amylase (≥112 IU/dL);16% had either elevated lipase or amylase. At study endpoint in the 262 randomized patients, increases in both amylase and lipase were observed, however, there were no significant differences between placebo and LY treatment groups (p > 0.05). Multiple regression analysis evaluating 29 possible factors exploring both linear and logistic models identified 2 common factors, higher baseline lipase and lower A1c, as significantly associated with increase in lipase and abnormal lipase at endpoint. Prospective studies investigating A1c lowering and the clinical importance of elevations in lipase in T2DM are warranted.

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Granulocyte MMP-9 Is a VEGF Independent Component of the Angiogenic Switch in PDAC

D. Bausch,1 T. Pausch,2 U.T. Hopt,2 C. Fernandez-del-Castillo,1 A.L. Warshaw,1 S.P. Thayer,1 T. Keck.2 Dpts of Surgery 1MGH & HMS, Boston, MA; 2Universitätsklinik Freiburg, Germany.

Introduction: Vascular endothelial growth factor (VEGF) secreted by tumor cells plays a key role in angiogenesis. Matrix metalloproteinases (MMP) remodel the extracellular matrix. MMP-9, secreted by stromal granulocytes (PMN), promotes angiogenesis indirectly via VEGF. Our aim was to determine the role of PMN-derived MMP-9, its interaction with VEGF, and the efficacy of anti-angiogenic therapy targeting MMP-9 and VEGF in pancreatic cancer (PDAC).

Methods: Inhibitors to MMP-9 (Doxycycline) and VEGF (Bevacizumab) were used alone or in combination in an in vitro angiogenesis assay to test their effect on angiogenesis caused by MMP-9/PMN and VEGF/PDAC cells. In an in vivo model of xenografted PDAC, treatment effects after 14 days under monotherapy with Doxycycline or Bevacizumab and a combination of both were evaluated.

Results: In vitro, PMN-derived MMP-9 had a direct and strong angiogenic effect and was independent and additive to PDAC-derived VEGF. Complete inhibition of angiogenesis required the inhibition of VEGF and MMP-9. In vivo, co-localization of MMP-9, PMN and vasculature was observed. MMP inhibition with oral Doxycycline alone resulted in a significant decrease in PDAC growth and weight and mean vascular density comparable to VEGF inhibition alone.

Conclusion: PMN-derived MMP-9 is a potent, direct and VEGF-independent angiogenic factor in PDAC. MMP-9 inhibition is as effective as VEGF inhibition in vivo. Together, MMP and VEGF inhibition may prevent tumor recurrence and metastasis induced by VEGF inhibition.

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Notch Pathway Activation in the Ectatic Ducts of Chronic Pancreatitis

U.K. Bhanot,1,2 R. Köhntop,1 C. Hasel,1 P. Möller.1 1Department of Pathology, University of Ulm, Ulm, Germany; 2Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.

Ductal obstruction during the course of in chronic pancreatitis (CP) leads to pancreatic ductal hypertension (PDH) and duct ectasia. Consequently, ductal epithelium subjected to chronic stress due to PDH may undergo molecular alterations, thereby not only initiating and sustaining the inflammatory process but also activating molecules that have transforming potential. Acino-ductal metaplasia and pancreatic intraepithelial neoplasia (PanIN) are frequently observed in CP. Using laser capture microdissection, cDNA microarrays and Ingenuity Pathways Analysis, we found an altered Notch pathway in the ectatic ducts of CP. The microarray data was validated by real-time PCR. We also found elevated transcripts of Notch receptors, Notch1 and Notch3 in microdissected ectatic ducts of CP. The Notch pathway ligands, Jagged/Delta-like and a Notch target - HES-related repressor protein (HERP), were up-regulated in ectatic compared to normal pancreatic ducts, while another target of Notch, hairy/enhancer of split (HES) was down-regulated. The transcripts of Delta-like1 and Jagged1 were increased 3.7-fold and 1.3-fold, respectively, while those of HERP1 were elevated 2.4-fold in the ectatic ducts of CP, compared to normal ducts. By immunohistochemistry, Jagged1 was not expressed in normal pancreatic ducts, while it was highly expressed in ectatic ducts. This pattern of Notch component alteration in ectatic ducts was mimicked to some extent in vitro in a human pancreatic duct epithelial (HPDE) cell line subjected to a pressure of 200 mmHg for 24 h. Therefore, we conclude that in the ectatic ducts of CP, PDH activates signalling pathways such as Notch, which have transforming potential.

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Lactate Enhances Cerulein Induced Protease Activation in Rats

M. Bhoomagoud,1 J. Atladottir,3 E. Thrower,1 J. Darlak,4 R. Patton,4 F. Gorelick.1,2 1Department of Internal Medicine, Section of Digestive Diseases, 2Department of Cell Biology, 3Department of Surgery, Veterans Administration Connecticut Healthcare, West Haven and Yale University School of Medicine, New Haven, Connecticut, 4College of Charleston, S. Carolina.

Fluid resuscitation may be the most important part of treatment for pancreatitis. Ringers lactate is a commonly used resuscitation solution. Lactate is an important metabolite and can have distinct pathophysiological effects. Our earlier studies demonstrated that lactic acid sensitizes acinar cells to cerulein induced protease activation. We hypothesized that exposure to lactate might sensitize the acinar cell to secretagogue-induced pancreatitis.

Methods: Cerulein (100 nM) can induce protease activation in acinar cells. The effects of lactate in cerulein-induced pancreatitis (zymogen activation and injury) were examined in rats: 1) in vitro with isolated acini; 2) in vivo with Ringers lactate infusion.

Results: In acini, lactate (10-20 mM) enhanced zymogen activation and secretion, both in presence of cerulein as well as alone. Pretreating rats with Ringers lactate in vivo enhanced cerulein (50 μg/kg) induced trypsinogen activation and pancreatic edema compared to normal saline infusion.

Conclusion: Lactate causes protease activation in acinar cells. These studies for the first time suggest that Ringers lactate might be deleterious in patients with pancreatitis and normal saline resuscitation could be a better choice.

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A Novel Explant Outgrowth Culture Model With Long-Term Survival and Preserved Secretory Phenotype of Mouse Pancreatic Acinar Cells

M. Bläuer, I. Nordback, J. Sand, J. Laukkarinen. Dept. of Gastroenterology and Alimentary Tract Surgery, and Pancreas Laboratory, Tampere University Hospital, Tampere, Finland.

Introduction and Aim: Despite many earlier attempts, no good long-term (over 48 hr) acinar cell culture model, with a preserved amylase secretion, exists. For many mechanistic studies such a model would be of great advantage. Our aim was to develop a culture model with long-term survival and maintained secretory capacity of mouse acinar cells.

Materials and Methods: Explants of mouse pancreata were cultured in a serum-free medium on tissue culture inserts. Outgrowth of acinar cells was seen from day 4 onwards. On day 8, the outgrown primary cells were detached for secondary culture. The cellular composition of the cultured explants and the identity of the outgrown cells in primary and secondary cultures were assessed by immunohistochemical means. Cell viability and caerulein-stimulated (10−12-10−8M) amylase release were studied in primary and secondary cultures.

Results: Immunohistochemical analysis revealed that the outgrown cells both in primary and secondary cultures were predominantly acinar, whereas other cell types remained within the explants. Cell viability remained high during the follow-up. Basal and caerulein-stimulated amylase release was sustained up to 10 days in the primary culture, and for a minimum of 6 days in the secondary culture.

Conclusions: We have developed a mouse acinar cell culture model with long-term cell survival and preserved secretory function.

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Immunotherapeutic and Epigenetic Approaches Targeting Cancer-Testis Antigens in the Treatment of Pancreatic Cancer

A. Boni, S.P. Thayer, C. Ferrone, D. Bausch, N. Neyhard, A. Cogdill, C.F. Fernandez-del-Castillo, A.L. Warshaw, J.A. Wargo. Department of Surgery, Massachusetts General Hospital, Boston MA.

Objectives: To determine the expression profile of cancer-testis antigens in resected specimens of pancreatic cancer, and to develop immunotherapeutic and epigenetic approaches targeting these antigens for treatment.

Methods: RNA was isolated from 19 specimens of resected pancreatic adenocarcinoma and expression levels of NY-ESO-1, MAGE-1, MAGE-3 and MAGE-6 were assayed by quantitative RT-PCR. Expression levels of these antigens were also assayed in pancreatic cancer cell lines before or after treatment with chromatin remodeling agents (Decitabine and Valproate). Untreated and treated lines were then cultured with T lymphocytes specific for either NY-ESO-1 or MAGE-3 to assess for an immune response against these tumors.

Results: NY-ESO-1 is expressed in a minority of pancreatic cancer specimens (10%) whereas MAGE-1, MAGE-3, and MAGE-6 are expressed in the majority (100%, 42%, 31%, respectively). Expression of cancer-testis antigens in pancreatic cancer cell lines increased significantly (p < 0.02) after treatment with chromatin remodeling agents, rendering them sensitive to treatment with antigen-specific T cells.

Conclusions: Expression of cancer-testis antigens is high in resected specimens of pancreatic cancer, and can be further induced by treatment with chromatin remodeling agents. These studies provide the basis for combination of chromatin remodeling agents and immunotherapeutic approaches (such as vaccines or adoptive T cell transfer) in the treatment of pancreatic cancer.

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Role of Ethanol Metabolism in Pancreatic Acinar Cell Death

D. Booth,1 O.H. Petersen,1 R. Sutton,2 D.N. Criddle.1 1The Physiological Laboratory, University of Liverpool, UK and 2Liverpool NIHR Pancreatic Biomedical Research Unit, Royal Liverpool University Hospital, UK.

Background: Non-oxidative alcohol metabolites are implicated in the pathogenesis of acute pancreatitis. We have now examined effects of manipulation of ethanol metabolism on pancreatic acinar cytosolic Ca2+ ([Ca2+]C) and cell fate.

Methods: Confocal microscopy was used to assess changes in [Ca2+]C, mitochondrial function (NAD(P)H), ΔΨm) and cell death induced by ethanol and its metabolites in murine pancreatic acinar cells.

Results: Low concentrations of ethanol (10 mM) with palmitoleic acid (POA; 20 μM) produced oscillatory [Ca2+]C rises (61.5% of cells). When oxidative metabolism was inhibited with 4-methylpyrazole (4-MP, 100 μM), sustained [Ca2+]C elevations predominated, associated with (ΔΨm) decreases (34%). Necrosis and apoptosis levels induced by the ethanol/POA combination were similar to controls, but were significantly increased in the presence of 4-MP (4.3 and 3.7-fold, respectively). Concomitant inhibition of hydrolase activity with bis-(4-nitrophenyl) phosphate (BNPP; 200 μM) produced a 2-fold reduction in necrosis induced by the ethanol/POA/4-MP combination, indicating the importance of fatty acids to cell death. Palmitoleic acid ethyl ester (POAEE) or POA (100-200 μM) induced concentration-dependent increases of cell death whereas the oxidative metabolite acetaldehyde (100-200 μM) was without effect.

Conclusions: Inhibition of oxidative metabolism increased [Ca2+]-dependent toxicity induced by a low concentration of ethanol with fatty acid, by promoting non-oxidative metabolism to form fatty acid ethyl esters. The data suggest that ethanol and fatty acids may exert important effects on the pancreas at low levels when oxidative metabolism is compromised.

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Laparoscopic Distal Pancreatectomy: A Systematic Review of the Current Literature

D. Borja-Cacho, W. Al-Refaie, S. Vickers, T. Tuttle, E. Jensen. Department of Surgery, University of Minnesota, Minneapolis, MN.

Background: Current evidence of laparoscopic distal pancreatectomy (LDP) is based mainly on short-term outcomes from cohorts too small to make strong arguments for or against it. Our aim is to conduct a systematic review of the available literature regarding the safety and efficacy of LDP.

Methods: We searched MEDLINE for studies describing the demographic data, intra-operative factors, short-term outcomes and tumor characteristics of patients undergoing LDP. Data is reported as mean ± SD.

Results: We reviewed 24 studies that included 806 patients. The mean age was 55 ± 4.4 years. The mean operative time and estimated blood loss were 199 ± 83 min and 284 ± 94 ml, respectively. Spleen preservation and splenectomy were performed in 49.6% and 49.8% of the patients, respectively. The morbidity and mortality rate were 38% and 0.3%, respectively. The main complications were pancreatic fistula (PF) (17%), intra-abdominal collections (3%) and pulmonary/pleural complications (3%). PF definition was not uniform among authors; 14 different definitions were used. The most common postoperative diagnoses were MCN (20%), serous cystadenomas (17%), neuroendocrine tumors (16%), IPMN (11%), and pancreatic adenocarcinoma (10%). Although LDP was used for malignant tumors, the margin status was not reported in 57.7% of the patients; the final lymph node status was reported only in 17% of the patients.

Conclusions: LDP is a safe procedure; the morbidity rate is comparable to open procedures. Although LDP should be considered in patients with benign diseases, the role of LDP in the setting of malignancy is yet to be determined.

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Triptolide Sensitizes Pancreatic Cancer Cells to Death Receptor Therapy by Increasing the Membrane Expression of Death Receptor 5

D. Borja-Cacho, Y. Yokoyama, R. Chugh, N. Mujumdar, V. Dudeja, S. Vickers, A. Saluja. Department of Surgery, University of Minnesota, Minneapolis, MN.

Background: Pancreatic cancer is highly resistant to death-receptor therapy. Our group has described that triptolide increases apoptosis in pancreatic cancer cells. We hypothesized that triptolide decreases resistance to death-receptor therapy in pancreatic cancer. The aims of this study were to evaluate the effects of combined therapy with triptolide and anti-Death Receptor 5 Antibody (antiDR5Ab) on a) cell viability and apoptosis, b) expression of anti-apoptotic proteins, and c) the membrane expression of Death Receptor-5.

Methods: Five pancreatic cancer cell lines were exposed to vehicle, triptolide (0-200 nM), antiDR5Ab (0-100 ng/ml), or a combination of both drugs. We assessed the effects of both agents on cell viability, apoptosis, caspase-3, -8 and -9 activity, PARP and BID cleavage. The protein expression of XIAP and DR5 was measured after 24 hours of triptolide therapy.

Results: Pancreatic cancer cells were resistant to antiDR5Ab, but combined therapy with triptolide and antiDR5Ab significantly decreased cell viability, triggered apoptosis and induced caspase -3, -8 and -9 activation in all cell lines tested. PARP and BID cleavage were only seen when both drugs were co-administered. After 24 hours of treatment triptolide decreased the protein expression of XIAP. The flow cytometry analysis revealed an increase in the membrane expression of DR5 after 24 hours of triptolide treatment.

Conclusions: Triptolide decreases the intrinsic resistance that pancreatic cancer cells have to antiDR5Ab; this effect is the result of decreased expression of anti-apoptotic proteins (XIAP) and the increased expression of DR5 in the membrane of cancer cells.

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Symptoms and Signs in Patients With Ductal Adenocarcinoma of the Pancreas

B. Brinkmann, A. Holle, J. Emmrich. Division of Gastroenterology, Department of Internal Medicine, University of Rostock, Germany.

Background and Aims: Most patients with pancreatic ductal adenocarcinoma develop symptoms late in the course of disease. Less patients present with resectable disease. Because the lack of early symptomatology leads to delays in diagnosis retrospective analysis of symptoms and signs is important. Here, we aimed to identify percentages of symptoms and signs related to the diagnosis pancreatic adenocarcinoma in this time.

Material and Methods: Data were analyzed from 138 patients with pancreatic ductal adenocarcinoma. In all patients tissue diagnosis was fixed after surgical resection or by aspiration cytology. Gender, age, tumour localization, surgery, abdominal pain, nausea, vomiting, diarrhea, obstipation, weight loss (>3 kg in 3 months), tiredness, drop in performance, fatigue, jaundice, diabetes mellitus were analyzed in the included patients.

Results: There was no difference in gender of patients (48% female, 52% male). 73% of the patients were between 60 and 80 years old. Localization of carcinoma was in 75% of the cases in the caput of pancreas. Surgery was done in 25% of the patients. Abdominal pain was reported by 81% of the patients, localized in abdomen in 91%. Only 9% of the patients had back pain. Time with pain was lower than 3 months in 63% of the patients. Other symptoms were inappetence (68%), nausea (40%), vomiting (22%), diarrhea (33%), obstipation (17%), weight loss (67%), fatigue (32%), drop in performance (70%), jaundice (46%), Diabetes mellitus (36%).

Conclusion: The most important symptoms of pancreatic adenocarcinoma are abdominal pain, poor performance, inappetence, and weight loss. In case of these uncharacteristic symptoms and signs in patients between 60 and 80 years old diagnostic procedures including pancreas are recommended.

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Ritonavir Mediated Induction of Apoptosis in Pancreatic Cancer: Involvement of RB/E2F-1 and AKT Pathways

C.S. Bryant,2,3 S. Kumar,2,3 A. Qazi,3 S. Chamala,1 J. Pal,1 J. Shah,1 S. Seward,2,3 M.A. Shammas,1,3 M. Prasad,1,3,4 R.B. Batchu.1,3 1Laboratory of Surgical Oncology & Developmental Therapeutics, Department of Surgery, Wayne State University, Detroit, MI., 2Dept of Ob/Gyn, 3Karmanos Cancer Institute, Detroit, MI, and 4Providence Hospital, Southfield, MI.

Recent observations suggest a lower incidence of malignancy in patients infected with HIV during treatment with Highly Active Anti-Retroviral Therapy (HAART) utilizing protease inhibitors. In the current study, we investigated the effects of the FDA-approved HIV protease inhibitor ritonavir on proliferation of pancreatic adeno-carcinoma (PAC) cell lines.

Methods: Human PAC cell lines BxPC-3, MiaPaca-2 and PANC-1 propagated under standard conditions were treated with serial dilutions of ritonavir. Cell viability was assayed utilizing Cell Counting Kit-8. Apoptotic fractions of cells were determined by Annexin V and propidium iodide staining by Immunofluorescence and flow cytometry. Signal transduction was studied using western blotting and immunoprecipitation.

Results: Ritonavir induced apoptosis in pancreatic cancer cell lines BxPC-3, MiaPaca-2 and PANC-1 in a dose-dependent manner with IC50 over a 3-day period of 7.5 μM for BxPC-3, 8.2 μM for MiaPaca-2 and 15.5 μM for PANC-1. Ritonavir also amplified cell-killing induced by gemcitabine. Inhibition of the AKT pathway, G0/G1 cell cycle arrest, modulation of cell cycle regulatory proteins, enhanced interaction of retinoblastoma protein with E2F-1 transcription factor, and decreased interaction of E2F-1 protein with its consensus binding sites were also observed. Dose-dependent cleavage of Poly (ADP-ribose) polymerase (PARP) and caspases 9, 3 and 7 were present in cells treated with ritonavir, indicating activation of the intrinsic apoptotic pathway.

Conclusions: Our results demonstrate that ritonavir may be effective as a single agent in the treatment of PAC at concentrations well within the range achieved in patients with HIV. Ritonavir enhancement of gemcitabine-induced cell death suggests that this agent may prove efficacious in combination with the currently used clinical standard for treatment of PAC. Because ritonavir is already approved for human use, repositioning it for PAC may reduce the costs, decrease the risks, and markedly accelerate its implementation into the clinical arena for treatment of this usually fatal disease.

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Resume of Work After Distal Pancreatectomy: Laparoscopic Approach Is Better. A Single Institution Comparative Study on 114 Patients

G. Butturini,1 S. Partelli,1 S. Crippa,1 G. Malleo,1 L. Casetti,1 G.L. Melotti,2 M. Piccoli,2 C. Bassi,1 P. Pederzoli.1 1Pancreatic Unit, Verona University, 2General Surgery, Ospedale Baggiovara Modena, Italy.

Aim: To compare perioperative and long-term outcomes of laparoscopic distal pancreatectomy (LDP) with open distal pancreatectomy (ODP).

Methods: Between 2000 and 2006, all patients with benign neoplasms of the pancreatic body/tail were addressed to LDP or ODP according to the choice of two surgeons (CB and PP). The procedures were performed at Pancreatic Unit of Verona. The laparoscopic resections were executed by two surgeons (GLM and GB). All perioperative data were prospectively collected and patients were followed up. Multivariate analysis was performed using binary logistic regression.

Results: Seventy-one (62.3%) patients underwent ODP and 43 (37.7%) LDP. Overall mortality was nil. In the comparison there were no differences in median operative time (180 vs 180 minutes), overall complications (46.5% vs 48.8%), pancreatic fistula rates (14.1% vs 27.9%), re-explorations (9.9% vs 9.3%), length of hospital stay (9 vs 8 days), postoperative diabetes (30.9% vs 22.5%) and incisional hernia (17.6% vs 5%). LDP patients had a shorter median time to resume work (3 versus 6 weeks, p < 0.0001). By multivariate analysis, LDP was an independent factor for shorter resume to work (odds ratio 0.03, 95% confidence interval 0.05-0.20).

Conclusions: LDP is associated with a shorter time to resume work and this should be considered in the cost effectiveness analyses in future clinical trials.

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Pancreatic Excretory Function in Patients With Chronic Pancreatitis and Obesity

N.V. Byelyayeva. Department of Internal Medicine No 1, Donetsk State Medical University, Ukraine.

Introduction: In case of obesity as adipose dystrophy of the pancreas, as chronic pancreatitis (CP) on the background of adipose dystrophy could be an option for development.

Aim: To assess pancreas excretory function in obese patients.

Methods: 110 CP patients on the background of obesity and 30 healthy were examined. 68 patients (61.8%) had I degree, 37 patients (33.6%) - II degree, 5 patients (4.6%) - III degree obesity. Patients underwent fecal elastase-1 and probe (aminophylline-calcium) tests of pancreas excretory function.

Results: Index of pancreatic elastase-1 was normal in 58 of the patients (52.7%). Mild pancreatic insufficiency as by results of elastase test was determined in 32 patients (28.2%), moderate insufficiency - in 21 patients (19.1%). By results of probe test volume of duodenal contents, debit-hour of bicarbonates, α-amylase, pancreatic isoamylase and tripsin insignificantly tended to decrease in comparison with normal indices. Lipase debit-hour was reliably decreased. Lower obturative type of pancreas secretion was most frequent - in 52 patients (47.3%) (probably it is connected with high incidence of concomitant biliary pathology). 42 patients (38.2%) had upper obturative type of pancreatic secretion, 10 patients (9.1%) - hyposecretory type, 6 patients (5.4%) - hypersecretory type.

Conclusion: In patients with CP on the background of obesity reduction of pancreas excretory function does not reach severe degree, although lipase production is decreased reliably. This should be taken into account for dose selection of enzyme preparation.

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TM4SF1 Stimulates Pancreatic Cancer Cell Migration and Invasion

J. Cao,1,2 V. Ramachandran,2 T. Arumugam,2 F. Nast,2 C. Logsdon.2,3 1Dept of Gastroenterology, Changhai Hospital, the Second Military Medical University, Shanghai, China; 2Depts of Cancer Biology and 3Medical Oncology, UT M.D. Anderson Cancer Center, Houston, TX.

Introduction: TM4SF1 is a member of the four-transmembrane-domain family of cell surface molecules. TM4SF1 is a highly expressed and has been implicated in the regulation of metastasis in several human epithelial cell carcinomas. However, little is known about the TM4SF family of proteins in pancreatic cancer. Therefore, in the current study we examined the expression and function of TM4SF1 pancreatic cancer cells.

Methods: TM4SF1 was detected in human pancreatic tumors by immunohistochemistry (IHC). The expression of TM4SF1 mRNA in pancreatic cell lines and pancreatic cancer tissues, adjacent normal pancreatic tissues and chronic pancreatitis tissues were also quantitated (qRT-PCR). SiRNA and shRNA approaches were used to silence TM4SF1 in pancreatic cancer cell lines and the effects on cell migration and invasion were analyzed (Boyden Chamber).

Results: TM4SF1 was highly expressed in pancreatic cancer tissues as assessed by both qRT-PCR and IHC. Pancreatic cancer cell lines also highly expressed TM4SF1 compared to non-cancer cell controls (HPDE). The migration and invasion of pancreatic cancer cell lines Mpanc96 and HPAC was significantly decreased when TM4SF1 was silenced by either siRNA or shRNA. In contrast, TM4SF1 silencing had no effect on cell proliferation.

Conclusions: These findings suggest that TM4SF1 is a surface membrane antigen in pancreatic cancer that is involved in the migration and invasion of the cancer cells.

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What Is the Right Outcome Measure? Defining Mortality After Pancreatic Cancer Surgery

J.E. Carroll, J.P. Simons, M.M. Murphy, S.C. Ng, T.P. McDade, Z. Zhou, S.A. Shah, J.F. Tseng. Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA.

Objective: Outcomes after resection for pancreatic cancer have used varying measures including in-hospital and 30-day mortality, making comparisons difficult. We hypothesized that national data could be used to assess incremental postoperative mortality to determine the relationships between these measures. We further hypothesized that deaths following resection might be classified as early (from complications) and late (cancer-related) deaths.

Design: We queried the linked SEER-Medicare databases for patients resected for pancreatic adenocarcinoma 1991-2002. The chronology of post-resection deaths was analyzed. The Cochran-Armitage trend test evaluated risk for death from: A) ≤60 days of resection and B) 60 days to 2 years.

Results: Of 1904 patients, 7.4 % (n = 140) died within the first 30 days, 83.6% of whom were inpatients. In-hospital mortality was 8.0% (n = 153), 76% of which was within 30 and 96% within 60 days. Risk decreased significantly over the first 60 days (P < 0.0001). After 60 days, the risk was did not decrease through 2 years (P = 0.8858).

Conclusions: In a large national database, in-hospital and 30-day mortality after resection for pancreatic adenocarcinoma are similar, making comparisons between these outcomes reasonable. After a 60-day post-resection window of increased mortality, mortality risk does not decrease through two years, suggesting that risk of death is not confined to discrete early (postoperative) and late (cancer-related) periods.

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The Microenvironment in Pancreatic Cancer Induces Neuronal Plasticity

G.O. Ceyhan, I.E. Demir, H. Friess. Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.

Introduction: Pancreatic neuropathy in pancreatic cancer (PCa) is characterized by intrapancreatic neuropathy such as increased neural density and hypertrophy, which are associated with pancreatic neuropathic pain. To better understand the mechanisms of these neuropathic alterations, we aimed at achieving an in-vitro simulation of the pancreatic neuroplasticity and to identify responsible molecular targets.

Methods: Isolated myenteric plexus (MP) and dorsal root ganglia (DRG) from newborn rats were treated with normal pancreas (NP) or PCa tissue extracts. MP were cultured with 8 pancreatic cancer cell lines (PCC), and also with nerve growth factor (NGF)- and Artemin-depleted PCa tissue extracts and PCC supernatants. For analysis, neurite density, outgrowth, neuronal branching and perikaryonal size were quantified and compared.

Results: DRG neurons grown in PCa tissue extracts built much denser networks than in NP extracts. Similarly, MP exposed to PCa extracts showed a much stronger neurite outgrowth, more complex branching pattern and a somatic hypertrophy. PCC supernatants induced a prominent neurite outgrowth, increased neurite density and perikaryonal hypertrophy in MP. Furthermore, neurite density of MP neurons was noticeably attenuated by depletion of NGF and Artemin from the extracts and PCC supernatants.

Conclusion: The neurotrophic characteristics of PCa microenvironment induce neuronal plasticity under in-vitro conditions, as known in in-vivo conditions. In this scenario, NGF and Artemin seem to be potential key players in the generation of pancreatic neuropathy.

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Comprehensive Approach Towards Analysis of Complex Disorders: Tropical Calcific Pancreatitis as a Model

G.R. Chandak,1 S. Bhaskar,1 S. Paliwal,1 D.N. Reddy,2 G.V. Rao.2 1Genome Research Group, Centre for Cellular and Molecular Biology, Hyderabad, India; 2Asian Institute of Gastroenterology. Hyderabad, India.

Chronic pancreatitis (CP) is an established complex disorder with evidence of genetic heterogeneity and pleiotropy, irrespective of various etiological subtypes. However, cationic trypsinogen gene mutations explain the genetic basis of all types of chronic pancreatitis with variable strength. We have shown absence of trypsinogen gene variants and provided further evidence of genetic heterogeneity in tropical calcific pancreatitis (TCP), a distinct non-alcoholic type of juvenile and severe CP with uncertain etiology prevalent in tropics such as India. To understand the etiopathology of TCP, we have undertaken comprehensive analysis including the genomic, transcriptomic and proteomic approaches. TCP was dissected into various sub-phenotypes such as exocrine and endocrine damage, fibrosis, stones, etc. and several candidate genes were screened for associated variants. Variants in the signal peptide region of cathepsin B were found to be associated with TCP, while no association was observed with other genes including transcription factor 7 like 2, regenerating islet-derived protein 1α, etc.

Microarray analysis on pancreatic tissue samples identified several differentially regulated genes belonging to calcium signalling, insulin signalling and MAPKinase signalling pathways, based on Gene Ontology descriptions. Proteomic profile of pancreatic tissues from these patients identified 15 differentially regulated proteins. Finally, through systems biology approach, we have attempted to network various genetic and non-genetic factors in the pathogenesis of TCP and proposed a model for chronic pancreatitis in tropical countries.

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Prevalence of Pancreatic Polypeptide (PP)-Deficient (Type 3) Diabetes in U.S.

D. Chang,1,2 A. Rabiee,1 D. Elahi,1 D. Andersen.1 1Department of Surgery School of Medicine, and 2Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.

Introduction: Chronic pancreatitis (CP), total or proximal pancreatic resection (Res) are frequently associated with PP deficiency. The morbidity of DM due to Res or Pancreas disease (T3DM) has been shown to be equivalent to T1DM in terms of retinal and renal disease.

Methods: We sought to determine the prevalence of T3DM in US by analysis of discharge coding of CP, Res, and diabetes from the Nationwide Inpatient Sample (NIS), for the yrs 2001-2005. We assumed that each CP patient (pt) was admitted only once/yr, that only severe CP was associated with hospital admission, that each of these pts with severe CP is PP deficient, and further assumed that all PP-deficient CP pts are diabetic.

Results: The database recorded 7348 Res pts, with 763 hospital deaths. Correcting for the various expected durations of survival based on diagnostic codes, the annual prevalence of pts surviving after pancreatic resection is 47,897 (95%CI 38,895-56,934). Assuming that 50% of all proximal pancreatectomy pts (91% of Res) and 100% of all total pancreatectomy pts (9% of Res) are diabetic, we estimated the prevalence of T3DM after Res as 26,000. For CP, the NIS extrapolation yielded an expected annual prevalence of 94,933. Assuming all of these CP pts have severe disease, we estimate the combined prevalence of T3DM due to pancreatic disease or Res as 121,000.

Conclusions: T3DM pts may benefit from PP therapy to reduce the diabetes-related morbidity. Strategies for clinical trials and drug availability may be guided by this estimate.

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Biomarkers of Gemcitabine Response in Pancreatic Cancer

D.K. Chang, E.K. Colvin, C.J. Scarlett, M. Pinese, D. Goldstein, N.D. Merrett, E.A. Musgrove, S.M. Henshall, R.L. Sutherland, J.G. Kench, A.V. Biankin. Cancer Research Program, Garvan Institute of Medical Research, Sydney, Australia.

Purpose: Selection of therapy based on cancer stage and molecular phenotype is the basis of modern clinical oncology practice. This ensures delivery of optimal therapy and minimises unnecessary side effects. Gemcitabine (GEM) is the predominant first-line agent used for adjuvant therapy in pancreatic cancer (PC). Although recent trials have shown equivalent outcome for GEM and 5-FU, they may benefit different patients.

Methods: We examined the expression of S100A4 and hENT1, both play a role in GEM action using immunohistochemistry and their relationship with survival and response to adjuvant GEM in a cohort of 294 patients with resected PC.

Results: High S100A4 expression was an independent poor prognostic factor (HR = 1.78, 95% CI = 1.29-2.46; P = 0.0004) and a predictor of GEM response that survival advantage was only observed in S100A4 negative group (median survival 50.4 Vs 23.9 months, P = 0.0404), but not S100A4 positive group (17.1 Vs 15.1 months, P = 0.3722). hENT1 expression was also found to be a predictor of GEM response that survival advantage was only observed in hENT1 high group (31.3 Vs 15.5 months, P = 0.0059), but not hENT1 low or negative group (22.3 Vs 18.9 months, P = 0.2357).

Discussion: Stratification of adjuvant chemotherapy based on S100A4 and hENT1 expression has the potential to improve outcomes for patients with PC and focus future clinical trials of novel therapeutic strategies. A proposed prospective randomised trial design using biomarker stratification will be presented.

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Margin Clearance and Outcome in Resected Pancreatic Cancer

D.K. Chang, A.L. Johns, N.D. Merrett, A.J. Gill, E.K. Colvin, C.J. Scarlett, R.L. Sutherland, S.M. Henshall, J.G. Kench, A.V. Biankin. Cancer Research Program, Garvan Institute of Medical Research, Sydney, Australia.

Purpose: Current adjuvant therapies for pancreatic cancer (PC) are inconsistently used and only modestly effective. Because a high proportion of patients who undergo resection for PC likely harbour occult metastatic disease, any adjuvant trials assessing therapies such as radiotherapy (RTX) directed at locoregional disease are significantly underpowered. Stratification based on the probability (and volume) of residual locoregional disease could play an important role in the design of future clinical trials assessing adjuvant RTX.

Methods: We assessed the relationships between margin involvement, the proximity to operative resection margins and outcome in a cohort of 365 patients who underwent operative resection for PC.

Results: Microscopic involvement of resection margin by tumor was associated with poor prognosis. Stratifying the minimum clearance of resection margins by 0.5 mm increments demonstrated that although median survival was no different to clear margins based on these definitions, it was not until the resection margin was clear by >1.5 mm that optimal long-term survival was achieved.

Conclusion: These data demonstrate that a margin clearance of >1.5 mm is important for long-term survival in a subgroup of patients. More aggressive therapeutic approaches that target locoregional disease such as RTX may be beneficial in patients with close surgical margins. Stratification of patients for entry into future trials based on this criterion may identify those patients who benefit from adjuvant RTX.

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Long-Term Follow-Up of Intraductal Papillary Mucinous Neoplasms and Prediction for Malignany

J.H. Chang, I.S. Lee, Y.K. Cho, J.M. Park, S.W. Kim, M.G. Choi, K.Y. Choi, I.S. Chung. Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Background/Aim: Surgical operation has been recommended in main duct intraductal papillary mucinous neoplasms (MD-IPMNs) and close observation in branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) smaller than 30 mm without symptoms or mural nodules. We investigated these recommendations and elucidated the natural history of IPMNs.

Methods: The patients with radiological imaging or histological findings consistent with IPMN were enrolled between 2003 and 2008. Thirty-one patients were followed up more than 6 months and 11 patients immediately underwent surgical treatment after diagnosis.

Results: Fifteen patients had MD-IPMNs and 27 patients had BD-IPMNs. Median follow-up period was 608 days (180−2044). In BD-IPMNs, cystic lesions smaller than 30 mm without suspicious features were 21 (4 adenoma, 2 borderline malignancy, and 15 follow-up). The mean changes of cyst size were 0.2 mm (−18−19) in MD-IPMN and 4.4 mm (0−49) in BD-IPMN (P = 0.355). Cystic lesions of BD-IPMNs smaller than 30 mm without suspicious features showed minimal change of cyst size as mean 0.8 mm (0−2) and no development of suspicious features for median 233 days (180−1832) follow-up.

Conclusion: BD-IPMNs smaller than 30 mm without mural nodule or wall thickening grew slowly and did not progress to invasive carcinoma during follow-up. They could be carefully monitored without operation.

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The Role of PGE2 and EP Receptors on Human Pancreatic Stellate Cells

C. Charo,1 V. Ramachandran,1 R.F. Hwang,2 C.D. Logsdon.1 Depts. of 1Cancer Biology, and 2Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX.

Background: A hallmark of pancreatic ductal adenocarcinoma (PDAC) is it's extensive desmoplastic reaction. Pancreatic fibrosis is associated with high levels of COX-2 activity, which produces the prostaglandin PGE2. The current study examines the effects of PGE2 on Human Pancreatic Stellate Cells (HPSCs).

Methods: COX-2 expression was measured by immunohistochemistry (IHC). HPSCs isolated from PDAC patients were immortalized (SV40LT, hTert). HPSCs were treated with PGE2 in vitro followed by measurements of proliferation (MTS), migration (Boyden chamber) and invasion (invasion chamber). Expression of extra cellular matrix (ECM) genes (collagen IA, fibronectin and vimentin) and matrix metalloproteinase genes (MMP 2&9) were measured by QRT-PCR. The presence of EP receptors was determined by RT-PCR. EP receptors were silenced using validated siRNAs (Qiagen) and effects on proliferation, migration, invasion and ECM and MMP gene expression were analyzed.

Results: COX-2 was highly expressed in cancer epithelial cells but not in stromal cells. PGE2 stimulated HPSC proliferation by 18 ± 0.44% (p < 0.05), migration by 93 ± 0.53% (p < 0.05) and invasion by 92 ± 0.62% (p < 0.05) and stimulated expression of ECM and MMP genes. All four EP receptors were present in HPSCs. Silencing EP4 resulted in a decrease in migration by 82 ± 0.75% (p < 0.05) and invasion by 79 ± 1.1% (p < 0.05) and also decreased ECM and MMP gene expression.

Conclusion: EP4 receptors on HPSCs mediate PGE2 stimulation of stromal development, suggesting that EP4 may be a useful target for pancreatic cancer treatment.

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Identification and Functional Characterization of Corticotropin Releasing Hormone (CRH) Receptors in Human Pancreatic Cancer Cells

M.C. Chen,1 V.L.W. Go,1 G. Eibl,1 S.V. Wu.2 Departments of 1Surgery and Medicine, Center for Excellence in Pancreatic Diseases, David Geffen School of Medicine at UCLA, 2VAGLA Healthcare System, Los Angeles, CA.

Background: Stress-sensing and coping CRH system contributes the ability of pancreas to adapt to various stress that can be a risk factor for pancreatic cancer and other stress-related metabolic diseases.

Aims: The present study was to investigate the expression and function of CRH receptors in pancreatic cancer cell lines.

Methods: RT-qPCR was measured to determine the expression levels of CRHR in Panc1, MiaPaCa-2, BxPC-3 and HPAF-II. Intracellular cell signaling, growth and apoptosis assays were performed on cells following treatment with CRH and urocortin 2 (UCN2) to activate CRHR1 and/or CRHR2.

Results: In all cancer cell lines analyzed, CRHR2A wild type receptors were abundantly present, while additional CRHR2 splice variants were differentially expressed. In contrast, CRHR1 wild type and splice variants were expressed at relatively lower levels in each cell line. CRH and UCN2 elicited time- and dose-dependent AKT responses in conjunction with inversed ERK1/2 phosphorylation in cell type-specific manner. Both CRH and UCN2 had little to moderate effects on cell growth (10-20%) and apoptosis (2-3 fold) in different pancreatic cancer cell line.

Conclusion: Functional CRH receptor isoforms are identified in various human pancreatic cancer cell lines. Differentially regulated CRHR receptors and an altered CRH system in pancreatic cancer cells may affect normal functions of CRH/UCN to maintain stress homeostasis in the pancreas.

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Can Intraductal Ultrasonography (IDUS) Predicting the Longitudinal Extension of Intraductal Papillary Mucinous Tumor (IPMT) of the Pancreas?

Y.K. Cheon, Y.D. Cho, J.H. Moon, K.Y. Hur, J.S. Lee. Institute for Digestive Research, Digestive Disease Center, Soon Chun Hyang University College of Medicine, Seoul, Korea.

Objectives: Successful treatment requires reliable preoperative assessment of the highly variable extension of IPMN. The aim of study was to determine the role of intraductal ultrasonography (IDUS) in predicting the extension of IPMN and in selecting the method of pancreatic resection.

Methods: Twenty-three consecutive patients who underwent IPMN resection were prospectively analyzed. The primary outcome is the accuracy of IDUS for the assessment of tumor extension in the pancreatic duct. According to the preoperative localization of IPMN by IDUS and a comparison with the topography of IPMN established by the pathological examination of frozen sections, various types of limited pancreatic resection were planned.

Results: In 10 of 12 patients with invasive carcinoma or carcinoma in situ, the tumor was located in the pancreatic head, and eight had a main-duct-type tumor. Preoperative assessment by IDUS had an 87.5% diagnostic accuracy for tumor extension of IPMN compared to 28.6% in cases assessed by other imaging methods without IDUS. Of the 16 patients examined with IDUS, a positive tumor margin was observed at the cut surface in 2 patients. Of 14 patients with negative margins upon IDUS and frozen sections, 1 was shown to be margin-positive by final pathology.

Conclusions: IDUS is a useful diagnostic method for preoperative localization and prediction of the extension of IPMN. IDUS is a reliable diagnostic method for selecting pancreatic resection methods in patients with IPMN.

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Dissecting the Actions of Alcohol Metabolites Mediating Pathologic Exocytosis That Underly Alcoholic Pancreatitis

S. Chidambaram, N. Fernandez, H.Y. Gaisano. Department of Medicine, University of Toronto. Toronto, Ontario, Canada.

Pancreatitis is a life-threatening inflammatory disorder of the exocrine pancreas with limited therapeutic options. The molecular mechanism of clinical alcohol-mediated pancreatitis, so far, remains elusive. We had recently reported that alcohol induced Munc18c on the acinar basolateral plasma membrane (BPM) to become receptive to postprandial cholecystokinin (CCK)-induced displacement into the cytosol, causing activation of syntaxin (Syn)-4 to complex with SNAP-23 on plasma membrane (PM) and VAMP8 on granule membrane, forming the SNARE complex that mediates basolateral exocytosis. Subsequently, the restricted BPM sites become available for aberrant exocytosis into the interstitial space, where zymogen activation occurs, leading to pancreatitis. It is not alcohol per se that mediates the above observed effect, but rather, alcohol metabolites, including acetaldehyde and fatty acid ethyl ester (FAEE) produced by oxidative and nonoxidative pathways respectively, might exert these actions. To study the effects of alcohol metabolites on pathological exocytosis, acini were preincubated with ethanol, acetaldehyde and/or FAEE followed by low dose CCK-8 stimulation which actually resulted in an inhibition of maximal secretion. Amylase secretion assay showed that acetaldehyde and FAEE (ethyl palmitate and ethyl oleate) exhibited the same effect as ethanol, and in fact, acetaldehyde showed stronger inhibition of secretion. And remarkably, under these conditions of acetaldehyde and FAEE treatment, Munc18c was displaced from the BPM. These results indicate that acetaldehyde and FAEE are the putative cellular metabolites by which alcohol induces perturbation in CCK-stimulated amylase secretion and Munc18c activation of SNARE complex in acinar cells.

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Endoplasmic Reticulum Stress-Dependent Repression of Cyclin D1 Is Dysregulated in Pancreatic Cancer Cells

J.H. Choe,1 D.J. McConkey,1 C.D. Logsdon.1,2 1Department of Cancer Biology and 2Department of GI Medical Oncology, UT MD Anderson Cancer Center / UT-Houston Graduate School of Biomedical Sciences, Houston, TX.

Protein misfolding causes accumulation of proteins in the endoplasmic reticulum (ER) and activation of an ER stress response pathway, called the unfolded protein response (UPR). Activation of the UPR leads to global repression of protein translation through phosphorylation of eukaryotic translation initiation factor-2α (eIF2α). UPR-induced attenuation of cyclin D1 expression has previously been reported to cause G1 phase cell cycle arrest in immortalized mouse embryonic fibroblasts (MEFs) through an eIF2α-dependent mechanism. Cyclin D1 is frequently over-expressed in pancreatic cancer and has been implicated as a poor prognostic indicator and a mechanism of chemoresistance in the disease. We report that the ER stressor tunicamycin (TM) induces immortalized non-tumorigenic pancreatic ductal cell lines to undergo a reduction in cyclin D1 expression similar to that observed in MEFs. In contrast, pancreatic cancer cells (Panc-1, Hs766T, Su86.86) do not repress cyclin D1 protein expression and show a delayed induction of cell cycle arrest. Our data indicates that reduced repression of cyclin D1 in the pancreatic cancer cell lines is a result of reduced phosphorylation of eIF2α and a subsequent diminished ability to attenuate protein translation in response to TM. Therefore, cancer cells appear to display a defective translational control in response to certain ER stresses, suggesting that these mechanisms may be targeted to circumvent chemoresistance.

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Usefulness of HCL-Induced Magnetic Resonance Cholangiopancreatography

Y.W. Choi, Jung Kyung Yang, Y.S. Kim, T.H. Lee, E.H. Im, K.C. Huh, Y.W. Kang. Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea.

Background: MRCP is not available to put some pressure through pancreatic duct.Thus intravenous secretin was introduced to dilate and investigate stenotic pancreatic duct during MRCP.

Objective: To assess the efficacy of HCl-induced secretin MRCP in investigating pancreatic duct.

Methods: From January to October 2006, HCl-induced secretin MRCP was performed in twenty-one patients with acute pancreatitis (group 1, n = 6), chronic pancreatitis (group 2, n = 11) and other pancreatobiliary diseases (group 3, n = 4). We obtained MR images before and during 0.1N HCl administration via ENBD tube at the speed of 2.2 ml/min every 2 minutes for total of 20 minutes. Images were assessed as follows; "major improvement" as main pancreatic ductal dilatation and visualization of side branch; "slightly improvement" as only main ductal dilatation; "no improvement" as no interval change.

Results: The proportion of "major improvement", "slightly improvement", and "no improvement" were 38% (n = 8), 33% (n = 7) and 28% (n = 6). In gourp 1, the proportion of "major improvement", "slightly improvement", and "no improvement" were 66% (n = 4), 16% (n = 1) and 16% (n = 1). In group 2, the proportion of "major improvement", "slightly improvement", and "no improvement" were 18% (n = 2), 45% (n = 5) and 36% (n = 4). In group 3, the proportion of "major improvement", "slightly improvement", and "no improvement" were 50% (n = 2), 25% (n = 1) and 25% (n = 1).

Conclusions: HCl-induced Secretin MRCP improved visualization of the pancreatic ducts especially in patients with chronic pancreatitis.

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Minnelide: A Novel Therapeutic Strategy Against Pancreatic Cancer

R. Chugh, S. Patil, V. Dudeja, D. Borja-Cacho, R. Dawra, Y. Yokoyama, N. Mujumdar, M. Antonoff, K. Clawson, S. Vickers, G. Georg, A. Saluja. Division of Basic and Translational Research, Department of Surgery and Department of Medicinal chemistry, University of Minnesota, Minneapolis, MN.

Background: Pancreatic adeoncarcinoma is the fourth leading cause of death in the United States. We have previously shown that inhibiting HSP70 expression by triptolide - a Chinese herb extract - leads to apoptotic cell death in pancreatic cancer cells and reduces the growth as well as locoregional spread of pancreatic tumors in an orthotopic model. Since triptolide is soluble only in organic solvents like DMSO, which makes it unfavorable for use in clinical trials, we have developed a prodrug of triptolide named Minnelide which is water soluble and converts to the parent molecule when it is acted upon by enzyme phosphatase either in vitro or in vivo. The aim of this study is to evaluate the efficacy of Minnelide and its therapeutic potential for human trials owing to its higher water solubility.

Methods: Pancreatic cancer cells (Mia-Paca-2/S2VP10) were incubated with minnelide (100-200 nM) or vehicle (Control, C) for 48 hr. Cell viability and apoptosis (annexin V staining, caspase 3 and 9) was assessed at different time intervals. HSP70 expression was measured in whole cell lysates by western blot. For in vivo experiments, tumor cells were implanted in the pancreas of nude mice and treated with either vehicle or Minnelide for 60 days.

Results: Minnelide inhibited HSP70 protein expression in a dose-dependent manner starting at 100 nM. Further, Minnelide decreased the cell viability of two different human pancreatic cancer cell lines in a dose- and time-dependent manner (viability values expressed as % of control. 48 h: MiaPaca-2 22.73+/−1.55, S2VP10 57.3 +/−8.8). Cell death was associated with annexin V positivity and activation of caspase 3. Minnelide also significantly decreased tumor size and loco-regional spread to other organs and mortality in the orthotopic model.

Conclusion: Minnelide is very effective at killing pancreatic cancer cells by apoptosis and inhibiting tumor growth in-vivo. It holds a great promise as a novel therapeutic strategy against pancreatic cancer. We are initiating a Phase I trial for Minnelide.

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Positive Peritoneal Lavage Cytology Is a Predictor of Worse Survival in Locally-Advanced Pancreatic Cancer

C.J. Clark, F. Bahiraei, L.W. Traverso. Department of General Surgery, Virginia Mason Medical Center, Seattle, WA, USA.

Background: The poor prognostic significance of positive peritoneal cytology in pancreatic cancer is recognized by the American Joint Committee on Cancer. With the emergence of more accurate staging modalities such as pancreas protocol computed tomography (CT), peritoneal lavage cytology has not been widely accepted. The aim of this study was to determine the utility of peritoneal lavage cytology in predicting survival in locally-advanced pancreatic cancer.

Methods: Between 2000 and 2008, 202 patients with locally-advanced unresectable pancreatic cancer determined by CT underwent diagnostic laparoscopy and peritoneal lavage for cytology (DL-PLC). Kaplan-Meier and Cox proportional-hazards regression analyses were used to determine significance of this staging procedure on survival.

Results: DL-PLC upstaged 58 of 202 patients (29%). Patients upstaged by DL-PLC had a significantly worse median survival (p = 0.003). Patients with positive peritoneal lavage cytology alone also had significantly worse median survival of 12 versus 17 months (p < 0.001). However, occult hepatic metastases discovered during laparoscopy did not significantly alter survival. Worse survival for patients with positive peritoneal cytology was independent of CA 19-9, performance status, co-morbidities, tumor size, and location of tumor (p = 0.001, HR 1.97, 95% CI 1.3 - 3.0).

Discussion: The use of diagnostic laparoscopy and peritoneal lavage cytology in selected patients provides for additional accuracy by upstaging 29% of patients with unresectable, locally-advanced pancreatic cancer. Positive peritoneal cytology identifies a specific sub-group of patients with locally-advanced pancreatic cancer who have worse survival. This study supports the current recommendations of the AJCC to consider positive peritoneal cytology as stage IV disease. This study also suggests that staging that includes peritoneal lavage for cytology should be incorporated into future clinical trials especially for patients with locally-advanced disease.

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Assessment of Retinoic Acid Signaling in the Normal Adult Pancreas, Pancreatic Injury and Regeneration and Pancreatic Cancer

E.K. Colvin, C.J. Scarlett, M. Pinese, A.V. Biankin. Cancer Research Program, Garvan Institute of Medical Research, Darlinghurst NSW, Australia.

Background: Retinoic Acid (RA) signaling regulates Pdx1 expression and is essential for pancreatic development. Aberrations in signaling pathways regulating embryonic development also play a role in pancreatic cancer (PC). We have previously demonstrated aberrant expression of key components of RA signaling in PC.

Aim: To assess RA signaling in the normal adult pancreas, chronic pancreatitis, pancreatic regeneration following injury and PC.

Methods: RARE-LacZ reporter mice mark cells undergoing active retinoic acid signaling. Pancreata from these mice were assessed in the normal adult pancreas, caerulein induced chronic pancreatitis, regeneration and PC. RARE-LacZ mice were crossed with LSL-KrasG12D/+; LSL-Trp53R172H/+;Pdx-1-Cre mice to produce LSL-KrasG12D/+; LSL-Trp53R172H/+; Pdx-1-Cre; RARE-LacZ offspring. Transgenic mice aged until pancreatic tumors formed and were assessed for RA signaling.

Results: Examination of normal adult RARE-LacZ pancreata revealed RA signaling activation in islets, intercalated ductal epithelium and rare acinar cells. Enhanced activation of RA signaling in acinar cells was observed during injury and regeneration of the exocrine pancreas, and in the desmoplastic stroma, while active RA signaling was not observed in the invasive tissue within pancreatic tumors.

Conclusion: In the normal adult pancreas, RA signaling is rarely active in a small proportion of the pancreas and is not active in PC. RA signaling is re-activated, however, to aide in regeneration of the exocrine pancreas.

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Allopurinol and 3-Amino Benzamide in Experimental Acute Necrotizing Pancreatitis

B. Comert,1 A. Turan Isik,1 S. Aydın,2 M. Ozyurt,3 S. Deveci,4 N. Mas,5 I. Tasci,1 L. Yamanel,1 E. Cinar,6 M. Tahir Ünal,1 M. Refik Mas.1 Departments of 1Internal Medicine, 3Microbiology, 4Pathology, 6Infectious Diseases, 2Güven Hospital, Afyon Kocatepe Medical Faculty; 5Department of Anatomy, Ankara, Turkey.

Introduction: Acute pancreatitis (AP) continues to be an untreatable condition with high morbidity and mortality. It is frequently complicated with infections of the pancreatic and peripancreatic tissues when necrosis develops. We aimed to evaluate the effect of 3-Amino Benzamide and Allopurinol combination, on bacterial translocation and oxidative stress.

Materials and Methods: Seventy-five Sprague-Dawley rats were randomly divided into five groups. Group I (sham) rats were controls. AP was induced by intraductal taurocholate infusion in the remaining four groups. Group II was treated with saline, Group III with ALPL, Group IV with ALPL plus 3-AB, and Group V with 3-AB alone. 3-AB was started right after the induction of AP. ALPL treatment began six hours after AP induction. All the rats were killed 48 hours after the induction of pancreatitis. Blood and tissue samples were obtained.

Results: Serum amylase levels decreased significantly in Groups III, IV and V when compared to Group II (p < 0.002, for all). Histopathological recovery was significantly better in 3-AB treated rats (Group V) (p < 0.001). Combination of ALPL and 3-AB revealed significantly better histopathological recovery when compared to ALPL alone (p < 0.03). Additionally, in the treatment groups, serum and pancreatic OS parameters improved (p < 0.001), and BT decreased (p < 0.05).

Discussion: Xanthine oxidase is involved in the pathogenic events especially in establishment of bacterial translocation in intraabdominal pathologies. Inhibition of this enzyme cause not only biochemical and histological recovery but also decrease the rate of translocation of intestinal bacteria to pancreatic tissue and mesenteric lymph nodes. It has significant antioxidant property which explains much of its effects at histological level. PARS is involved in the process of oxidative injury. In this study, we have found significant decrease with individual treatments in pancreatic injury, oxidative stress and bacterial translocation, but combination of these two agents did not yield more efficiency.

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Gender Specific Reference Standards and Classification of Secretory Function for the Endoscopic Pancreatic Function Test

D. Conwell,1 B.U. Wu,1 L. Lee,1 E. Purich,3 G. Zuccaro,2 P. Banks.1 1Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA; 2Cleveland Clinic Foundation, Cleveland, OH, USA; 3ChiRhoClin, Inc., Burtonsville, MD, USA.

Purpose: 1) Establish reference values for pancreatic function based on the ePFT collection method in healthy subjects, 2) Determine the correlation of a single collection timepoint with peak [HC03] for diagnostic screening of pancreas exocrine insufficiency (PEI) during EGD, 3) Describe a standardization method based on z-score for classification of pancreas function, 4) Report the correlation and agreement of the single collection time point z-score to peak z-score in a separate cohort of pts undergoing evaluation for PEI.

Methods: Separate cohorts of pts were studied at Cleveland Clinic (CCF) and Brigham and Women's Hospital (BWH). At CCF, healthy volunteers (non-PEI), underwent ePFT for 1 hour (t0 - t60). Pancreas fluid analyzed for: [Na], [HC03], [Cl] and [K]. Correlation between a single t30 timepoint [HC03] and peak [HC03] was determined. The t30 [HC03] and peak [HC03] was transformed to a z distribution. Pancreatic Function Classification: Normal Function (+/− 1 sd), Secretory Dysfunction (−2 to −1 sd), Abnormal Function (<−2 sd). At BWH, the newly derived system was applied to pts referred for evaluation of PEI. Statistics: SAS v 9.1 (Cary, NC).

Results: At CCF, 28 subjects (14M/14F) underwent a 1 hour ePFT. The mean age for males and females was 35 and 40 yr respectively. Differences in median peak [HC03] were observed when males [median 114 (IQR 110, 120)] and females [median 99 (IQR 93, 105)] were compared. (p = 0.0008, male vs. female, Wilcoxon). Correlation coefficient between the 30 minute (t30) and peak [HC03] was R2 = 0.80, p < 0.0001. At BWH, 57 referral pts were evaluated with ePFT to evalute for PEI. Correlation of t30 timepoint to peak [HC03] was R2 = 0.93, p < 0.0001. Agreement between t30 and peak [HC03] timepoints were significant (p = 0.0009) and the overall kappa coefficient was 0.6275 [0.44 - 0.81]. Validity of the t30 timepoint was determined using gender-specific peak [HC03] as reference standard to maximize diagnostic accuracy. A t30 [HC03] cutpoint of 80 meq/L (women) and 95 meq/L (men) provided a sens and spec of 100% and 73% respectively for PEI (85% PPV, 100% NPV). Overall, t30 [HC03] AUC = 0.93 (95% CI: 0.87-0.99) for predicting PEI (<−2 sd below mean).

Conclusion: 1. There are gender-specific differences in normal pancreatic function. 2. A single t30 minute [HC03]timepoint has excellent correlation to peak [HC03] in healthy subjects. 3. A standardization (z-score) has been calculated for both peak and t30 minute [HC03] to more properly classify pancreatic function. 4. The correlation and agreement of the single t30 [HC03]is excellent in both non-PEI and PEI subjects. Clinical Application: A single gender-specific t30 [HC03] cutpoint has been determined to screen for PEI.

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Are Multifocal Pancreatic Cysts an Indolent Condition?

C. Correa-Gallego, C. Ferrone, S.P. Thayer, J.A. Wargo, A.L. Warshaw, C. Fernández-del Castillo. Department of Surgery, Massachusetts General Hospital, Boston, MA.

Multifocal pancreatic cysts (MPC) are being identified with increasing frequency. Most are felt to be branch-duct IPMNs, but little is known about them. We retrospectively reviewed our latest experience to identify and characterize these lesions.

Between 2004 and 2008, 401 patients were evaluated for pancreatic cystic lesions, and 16% (65/401) were found to have multifocal pancreatic cysts (MPC). These patients were older (72 vs. 62 yrs; P < 0.001) and 5 times less likely to be symptomatic (8 vs. 40%; P < 0.001) than patients with single cysts; median number of cysts was 4 (2 - 10), and 60% were female. Compared to asymptomatic patients with MPC, those who were symptomatic had larger cysts (dominant cyst 31 vs. 17 mm; P < 0.001), with no significant difference in age.

80% of symptomatic and 15% of incidentally-discovered patients with MPC underwent surgery; one third of the latter (3/9) had been followed for a median of 23 m and experienced a median growth of 11 mm. Final diagnoses were: 5 Branch-duct IPMNs (1 invasive cancer), 5 combined main and branch-duct IPMNs (2 invasive cancer and 1 CIS), and 3 non-mucinous cysts. Invasive malignancy was more frequent in symptomatic patients with multifocal vs. single cysts (75 vs. 17%; P = 0.02).

Conclusions: MPC occur in older individuals and are mostly asymptomatic. The majority of those resected are IPMNs, but 22% are non-neoplastic. While patients with symptomatic MPC have a higher likelihood of invasive cancer than the ones with single cysts, patients without symptoms should have continued surveillance.

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Non-Neoplastic Cysts Comprise 8% of Resected Pancreatic Cysts Presumed to Be Neoplastic

C. Correa-Gallego,1 M. Mino-Kenudson,2 C. Ferrone,1 S.P. Thayer,1 J.A. Wargo,1 A.L. Warshaw,1 C. Fernández-del Castillo.1 Department of 1Surgery and 2Pathology, Massachusetts General Hospital, Boston, MA.

The main driving force behind resection of incidentally-discovered pancreatic cysts is timely removal of cancer. Although cancer is ultimately found in < 10% of cases, cystic lesions of the pancreas, except for pseudocysts, are felt to be neoplastic and potentially malignant. Non-neoplastic pancreatic cysts are not well recognized, and are the focus of this report.

Between 2004 and 2008, 256 patients underwent resection for a cystic lesion of the pancreas (CLP) presumed to be neoplastic. The majority (60%) were incidentally-discovered. 8 % of all resected cysts (20 cases), were non-neoplastic: 3 lymphoepithelial cysts, 3 enteric duplication cysts, 2 pseudocysts, 1 retention cyst, and 11 unclassified "benign", non-mucinous cysts.

These non-neoplastic cysts occurred more frequently in women (13/20). The mean age was 47 yrs, and 5 were symptomatic. By CT and/or MRI, most were diagnosed preoperatively as branch-duct IPMNs or MCNs. Median cyst size was 25 mm and 4 were multifocal. Symptomatic cysts were larger (median 41 mm) and none were multifocal. 14 patients were evaluated by endoscopic ultrasound; cytology was non-diagnostic in 4/8 cases; 3 were reported as non-malignant and one as 'atypical mucinous cells'; CEA was elevated (≥192 ng/dL) in 5/6 cases. Upon pathological examination, only 4 showed communication with the ductal system (2 pseudocysts, 1 retention cyst and 1 unclassified cyst).

Conclusion: Non-neoplastic cysts, many of which defy existing classifications, represented 10% of incidentally-discovered and 5% of symptomatic resected CLPs. They often contain high levels of CEA. These cystic lesions should be considered in the differential diagnosis of pancreatic cysts, although the means to diagnose them are uncertain without resection.

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Inhibition of Pancreas Growth in Raptor-Deficient Mice

S.J. Crozier,1 S.A. Ernst,2 K. Inoki,3 M.N. Hall,4 J.A. Williams.1 Departments of 1Molecular & Integrative Physiology, 2Cell & Developmental Biology, and 3Life Sciences Institute, University of Michigan, Ann Arbor, Michigan; 4Biozentrum, Universität Basel, Basel, Switzerland.

Pharmacological inhibition of the protein kinase mTOR prevents pancreatic growth in response to hormonal and nutrient stimulation. Recently it has been demonstrated that the protein Raptor facilitates mTOR signalling. The purpose of this study was to develop a transgenic mouse whose pancreatic acinar cells are Raptor-deficient (Rd). Floxed Raptor mice were bred with tamoxifen-inducible Elastase Cre mice. Offspring were genotyped at 4 weeks of age and injected with tamoxifen. When these mice were refed after an overnight fast, phosphorylation of the mTOR target protein, ribosomal protein S6 (S6) was increased in wildtype mice. In contrast, there was no increase in S6 phosphorylation in Rd mice, although phosphorylation of a protein upstream of mTOR, Akt, was increased. The weight of the pancreas was decreased by 31% in Rd mice and was associated with a 53% decrease in pancreatic protein, but no change in pancreatic DNA. In another experimental protocol, 10 week old mice were fed chow containing trypsin inhibitor (TI) for 1 week. TI feeding resulted in a 180% increase in pancreatic weight in wildtype mice that was associated with parallel increases in DNA and protein. In Rd mice there was no increase in weight, protein, or DNA following TI feeding. These results show that mTOR signalling is significantly decreased in the pancreas of Rd mice and that mTOR activation is required for both basal and hormone-induced acinar cell growth.

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Transgenic Imaging Model to Monitor Pancreatic Changes In Vivo

Z. Cruz-Monserrate, S. Gaiser, B. Ji, C.D. Logsdon. Dept. of Cancer Biology, UT M.D. Anderson Cancer Center, Houston, TX.

Background: A variety of genetic mouse models are being used to study pancreatic diseases. However, the development and extent of disease in these models are extremely difficult to assess before the animals are sacrificed. The aim of this study was to develop an inducible mouse model of pancreatic disease that could be imaged non-invasively to assess pancreatic disease progression in real-time.

Methods: We developed triple transgenic mice with Cre regulated mutant K-RasG12D and luciferase as well as acinar cell specific tamoxifen regulated Cre (Ela-CreER). Animals were then treated with tamoxifen over 3 consecutive days and imaged using an IVIS imaging system after 3, 6, 12 and 30 days. At the indicated times, animals were sacrificed and analyzed histologically.

Results: Tamoxifen fed animals produced a significant increase in luciferase signal associated with the exocrine pancreas compared to controls. Repeated imaging displayed a decrease of luciferase signal indicating K-Ras mediated disruption of pancreatic tissue and our ability to monitor pancreatic changes over time. Upon sacrifice we observed a correlation between reduced luciferase signal and histological changes, including development of intense fibrosis, inflammatory cell infiltration and loss of acinar cells.

Conclusions: Our results show that our animal model is a useful tool for future studies because it can be used to track changes in the pancreas in vivo via imaging of luciferase. In particular it should serve as a useful preclinical model to test for drugs against inflammatory response pathways induced by activated K-Ras.

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Floating Fibroblasts Promote Invasiveness of Pancreatic Cancer Cells

L. Cui, K. Ohuchida, K. Mizumoto, M. Onimaru, M. Tanaka. Departments of Surgery and Oncology Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Backgrounds: Cancer-stromal interaction plays a critical role in tumor invasion and metastasis. Recently, bone-marrow derived mesenchymal cells were reported to initiate the pre-metastatic niche. It has been also reported that orthotopically co-transplanted stromal cells were observed in the metastatic site. Furthermore, cancer-related fibroblasts were reported to exist in the blood of patients with lung cancer. These data suggest that floating fibroblasts may be involved in initiation of metastasis.

Aims & Methods: To elucidate the implication of floating fibroblasts in caner-stromal interaction, we used two pancreatic cancer cell lines and primary fibroblasts from 3 patients with pancreatic cancer and compared biological characteristics between floating- and adherent-cultured fibroblasts using qRT-PCR, migration and invasion assay, and gelatin zymography.

Results: Floating-cultured fibroblasts significantly enhanced migration and invasion of pancreatic cancer cells compared with adherent-cultured fibroblasts (P < 0.05). Floating-cultured fibroblasts expressed significantly higher levels of CD10 mRNA (> 7.5-fold), MMP3 (> 21.5-fold) and MMP9 (> 81.2-fold) mRNA, and lower level of α-SMA mRNA (< 100-fold) than those of adherent cultured fibroblasts. Also, floating-cultured fibroblasts showed higher levels of MMP9 activity than adherent-cultured fibroblasts.

Conclusion: Floating-cultured fibroblasts may enhance malignant behavior of pancreatic cancer cells.

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Semi-Quantitative Evaluation of Stellate Cell Activation in Tropical Calcific Pancreatitis Compared to Alcoholic Pancreatitis, Adenocarcinoma of Pancreas and Normal Pancreas

J. Cyriac,1 P. Mahadevan,3 A. Koshy,1 H. Ramesh,2 P. Augustine.1 Departments of 1Gastroenterologyy, 2Gastrointestinal Surgery and 3Pathology, Lakeshore hospital and research centre, Kochi, Kerala, India.

Background and Aims: Pancreatic stellate cell (PaSC) is known to be the source of fibrosis in pancreatic pathology of various etiologies. However, there is no published data on activation of PaSCs in tropical calcific pancreatitis. The present study was undertaken to estimate the proportion of activated stellate cells, in a semi-quantitative manner, in normal pancreas and pancreatic fibrosis due to, tropical calcific pancreatitis (TCP), alcoholic chronic pancreatitis (ACP) and pancreatic adenocarcinoma (CaP).

Methods: Expression of CD34, and alpha-smooth muscle actin (α-SMA) was assessed by immunohistochemistry. Morphometry was performed by a point counting procedure and CD34 positive areas were excluded from α-SMA positive areas for counting activated stellate cells. Student's T-test was used to compare the proportion of activated stellate cells among the four categories.

Results and Discussion: In all the disease conditions studied, namely, TCP (17 ± 14, %, M ± SD), ACP (14 ± 12) and CaP (24 ± 13), there was highly significant increased percentage of activated PaSCs compared to normal (2 ± 4) pancreas (p < 0.0002). The proportion of activated PaSCs in TCP was similar to that in cases of ACP and CaP. Such activation has been documented for the first time in case of TCP while it is already known for the other causes.

Conclusion: The present study suggests that a final common pathway of pancreatic stellate cell activation leads to fibrogenesis in Tropical Calcific Pancreatitis just as in other pancreatic pathologies.

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Body Mass Index on Survival Outcomes in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Carcinoma

M.A. Dandona,1 D.C. Linehan,2 W.G. Hawkins,2 S.M. Strasberg,2 F. Gao,3 A. Wang-Gillam.1 1Department of Internal Medicine, 2Surgery, 3Division of Biostatistics, Washington University, St. Louis, MO.

Background: Obesity is associated with an increased risk of pancreatic cancer. The association between obesity on survival in patients with pancreatic adenocarcinoma after pancreaticoduodenectomy, however, has not been well examined.

Methods: A retrospective analysis of 373 patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy between 1995 and 2008 was conducted using a prospectively maintained database at Washington University in St. Louis. Body mass index (BMI) was calculated based on body weight and height at time of surgery. Patients with a BMI of less than 18.5 kg/m2 were excluded from the study. Patients were stratified as normal (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥30 kg/m2). The impact of BMI on overall survival was assessed using the Kaplan-Meier and log rank test.

Results: Of 354 patients evaluated, 147 (41.5%) had normal body weight, 132 (37.2%) were overweight, and 75 (21.3%) were obese. The median survival for each group was 17.3 months (normal), 20.0 months (overweight), and 22.1 months (obese). No statistically significant association was found between BMI and overall survival among the three groups (p = 0.58).

Conclusions: BMI at the time of surgery has no impact on overall survival in patients with resected pancreatic cancer. Prior studies have reported that obesity is associated with poorer outcomes in pancreatic cancer. Thus, further investigation into this association is warranted.

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K-Ras Mutation Promotes Caerulein Induction of Chronic Pancreatitis in Mice

J. Daniluk, S. Gaiser, Y. Liu, L. Tsou, B. Ji, C.D. Logsdon. Dept. of Cancer Biology, UT M.D. Anderson Cancer Center, Houston, TX.

Background: K-Ras mutations are frequently found in chronic pancreatitis (CP) patients, although the significance is not understood. Generally it is thought that K-Ras mutations are the result of chronic inflammation. However, we have observed that Ras activity at high levels can cause CP. Thus, we hypothesized that K-Ras mutations may be a cause as well as a result of inflammation in CP.

Methods: Control mice or LSL-KRasG12D/Ela-CreER (LSL) double transgenic mice which express endogenous levels of KRasG12D in pancreatic acinar cells were treated with caerulein (50 ug/kg/injection X 9, i.p.), the injections were repeated two weeks after initial injection, and the mice were sacrificed in another two weeks. Histology, Ras activity and pancreatitis parameters were evaluated.

Results: Ras activity was moderately elevated in LSL mice compared to control mice. LSL mice developed infrequent (∼1 or 2 per section) mPanIN-1 lesions surrounded by limited focal fibrosis. Caerulein treatment induced high and sustained Ras activity in LSL mice compared to control mice. Caerulein treatments caused fibrosis, inflammatory cell infiltration and loss of acinar cells mimicking the histological features of human CP in LSL mice but not in control mice.

Conclusions: Our results indicate that concomitant interactions between intrinsic (spontaneous K-Ras mutation) and extrinsic (inflammatory stimuli) pathways lead to elevated Ras activity and CP. These data support that K-Ras mutations may predispose to CP and may be a direct link between CP and pancreatic cancer.

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Infectivity-Enhanced Oncolytic Adenoviral Vectors Expressing Syngeneic IFNα for Pancreatic Cancer

J. Davydova, E. Brown, S. Vickers, M. Yamamoto. Department of Surgery, University of Minnesota, Minneapolis, MN.

Although interferon (IFN)-α shows great promise for combination therapy in various cancers, its clinical utilization has been impeded by its systemic toxicity and poor biodistribution. To enhance its efficacy without increasing toxicity, it is logical to express the IFNα locally in the tumors. In this work, we applied IFNα-expressing conditionally replicative adenovirus (CRAd) for pancreatic cancer. Host specific human and hamster IFNα expressing Ads were used for the experiments, respectively. In vitro, IFNα-expressing oncolytic Ads killed hamster and human pancreatic cancer cell lines at significantly lower dose compare to non-replicative IFNα expressing vectors and oncolytic Ad without IFNα. To study in vivo effect, we established subcutaneous human MiaPaca2 xenografts in nude mice and hamster HP1 tumors in immunocompetent Syrian hamsters, which permit human Ad replication. After single intratumoral injection of infectivity-enhanced vectors expressing hamster IFNα, both replciative and non-replicative vectors showed anti-tumor effect in early time points, but the tumor re-grew in non-replicative vector group after day 12. After day 20, oncolytic Ad IFNα significantly outperformed the non-replicative vector. Importantly, the hamsters treated with oncolytic IFNα vector exhibited significant tumor shrinkage (and some disappearance). Such shrinkage was not evident in immunodeficient mice, suggesting immunomodulatory effect. These data indicate that infectivity-enhanced CRAd expressing syngeneic IFNα is a powerful therapeutic modality for pancreatic cancer.

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Deletion of T7 Trypsinogen Gene Significantly Decreases Trypsin Activation and Pancreatic Necrosis in Caerulein Induced Pancreatitis

R.K. Dawra, V. Dudeja, A.K. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Background and Aims: Intra-acinar trypsin activation occurs early during the induction of pancreatitis. While trypsin activation is probably an important initiator of cell injury, the direct evidence for its role is still lacking. Although trypsin inhibitors decrease severity in experimental models of pancreatitis they have other nonspecific effects as well. Mice whose trypsinogen genes are deleted would be invaluable for deciphering the role of intra-acinar trypsin activation in acinar cell injury during pancreatitis.

Mouse pancreas expresses multiple isoforms of trypsinogen. T7 is the cationic isoform of trypsinogen and is most abundant. It is also more susceptible to cathepsin B-mediated activation. We have already generated T7 gene deleted mice. This study aims to evaluate the effect of this gene deletion on trypsin activation and pancreatic necrosis, using caerulein induced model of pancreatitis.

Methods: Pancreatitis was induced in T7-gene-deleted and wild-type litter mate mice using supramaximal doses of caerulein. Trypsinogen activation in the pancreatic homogenates and pancreatic necrosis were quantitated.

Results: Intra-peritoneal caeruelin (50 μg/kg) significantly increased trypsin activity in the pancreas of wild-type mice, as compared with saline administered controls. No such increase in trypsin activity was observed in mice in which the trypsinogen T7 gene was deleted. After caerulein -induced pancreatitis, pancreatic necrosis decreased significantly in trypsinogen T7 deleted mice, as compared with wild type litter mates (4.29 ± 0.67 T7 vs 15.7 ± 3.73 WT).

Conclusions: Our data suggest that T7 isoform is activated within acinar cells early on during pancreatitis. Deletion of this isoform of trypsinogen significantly decreases necrosis of acinar cells, which suggests that that trypsin activation is an important initiator of pancreatitis.

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Development of Pancreatic Cancer Specific Promoters: ATDC and CEACAM5

D. Deng, B. Ji, C.D. Logsdon. Cancer Biology Department, University of Texas, M D Anderson Cancer Center, Houston, TX.

Background: One approach to cancer targeting is through the use of promoters that express specifically in cancer cells. Previous promoters based on the insulin or CCK1 receptors previously described by others face the obstacle that these genes are widely expressed and therefore not cancer specific. In the current study we evaluated promoters developed from two highly cancer specific genes, ATDC and Ceacam5.

Methods: We analyzed the gene profiles of pancreatic ductal adenocarcinoma (PDAC) samples and compared them to profiles of chronic pancreatitis and normal pancreas samples. RNAs for CEACAM5 and ATDC were especially highly and specifically expressed. To examine these genes further, a series of luciferase constructs that contain various fragments within the first 2.0 kb of the 5'-genomic region of CEACAM5 and ATDC were developed and transfected into pancreatic cancer (Mpanc96, Bxpc3, Panc1, HPAC, Aspc1 and Panc02) or normal (HPDE, HPNE, 293T) cells.

Results: For CEACAM5 and ATDC, 852-bp and 660-bp fragments provided maximal cancer specific promoter activity, respectively. Both promoters were highly active in cancer cells compared to non-cancer cells. I.P injection of the liposome encapsulated luciferase reporters based on these promoters successfully localized orthotopic pancreatic cancer cells (Mpanc96) in nude mice.

Conclusions: Promoters with high specificity and activity in pancreatic cancer cells have been developed. These promoters may be used to direct expression of genes to pancreatic cancer for future development of diagnostic imaging and therapeutic applications.

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The Association of Binge Drinking and the Outcomes of Severe Acute Pancreatitis

L.H. Deng, P. Xue, L. Huang, X.N. Yang, M.H. Wan, Q. Xia. Pancreatic Research Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China.

Aim: To study the association of binge drinking and the outcomes of severe acute pancreatitis (SAP).

Methods: This retrospective study included 347 patients with first-attack SAP from January 2001 to February 2004. The international definition was adopted that one standard drink (180 ml [6 oz] of wine, 360 ml [12 oz] of beer, or 45 ml [1.5 oz] of 90-proof spirits) contained 12 g of alcohol. Binge drinking was defined as the consumption of five or more standard drinks by men, and four or more alcoholic beverages by women, in the past 48 hours of SAP (a shorthand description was the "5/4 definition"). Based on the history of binge drinking or not, the patients were divided into the alcohol group (n = 77) and the control group (n = 270). Clinical data of the two groups were compared.

Results: Patients age and comorbidity were similar between the two groups. There were more males (64, 83.1%) than females (13, 16.9%; P < 0.05) in the alcohol group as well as males in the control group (111, 41.1%; P < 0.05). The two groups had significant differences in admission serum triglyceride (5.0 ± 5.0 vs 3.0 ± 3.5, P < 0.05), Balthazar's CT score (6.3 ± 5.4 vs 4.2 ± 4.5, P < 0.05), and APACHE II score (19.1 ± 5.1 vs 16.2 ± 6.0, P < 0.05). Total mortality and the incidences of complications were higher in the alcohol group than the control group (P < 0.05).

Conclusions: Binge drinking might be a contributor to the aggravation of first-attack SAP.

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Myristoleic Acid Inhibits Pancreatic Cancer Growth Via 5-Lipoxygenase Inhibition

X.-Z. Ding, P. Collin, T.E. Adrian. Department of Physiology, Faculty of Medicine, United Arab Emirates University, Al Ain, UAE and Coastside Research, Stonington, ME.

No effective treatment for pancreatic cancer is available, so identification of effective drugs is extremely important. We have previously shown that lipoxygenase inhibitors have potent anti-pancreatic cancer effects and that extracts of the Atlantic Sea Cucumber, cucumaria frondosa inhibit pancreatic cancer growth and induce apoptosis. We identified myristoleic acid as a major component of these extracts. The effects of myristoleic acid on cancer cell growth, induction of apoptosis and effects on LOX activity were determined.

Myristoleic acid concentration-dependently inhibited thymidine incorporation in AsPC-1, Panc-1 and HPAC cells (IC50 ∼2 μg/ml). Myristoleic acid induced massive apoptosis evidenced by marked morphological changes, annexin V binding at 2 hours and TUNEL assay. The fatty acid inhibited production of 5-HETE by 94% and Leukotriene B4 by 92% in arachadonic acid-treated human PBMC's. Myristoleic acid markedly inhibited growth of HPAC cell xenografts in athymic mice and totally abolished growth of AsPC-1 xenografts at a dose of 250 mg/kg/day i.p. The fatty acid was well-tolerated and the animals gained weight.

In summary, the echinoderm-derived myristoleic acid has potent anti-cancer effects in vitro and in vivo. The inhibition of growth induced by myristoleic acid is accompanied by marked apoptosis and appears to be mediated, at least in part, by inhibition of lipoxygenases that are up-regulated in pancreatic cancer. Myristoleic acid may be valuable in the prevention or treatment of pancreatic cancer.

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Inhibition of SIRT1 as a Novel Therapeutic Strategy for Pancreatic Cancer

V. Dudeja, R. Chugh, S. Skube, H.M. Bezek, N. Majumdar, Y. Yokoyama, D. Borja-Cacho, R. Dawra, S. Vickers, A. Saluja. Department of Surgery, University of Minnesota, Minneapolis, MN, USA.

Transcription factor Heat Shock Factor 1 (HSF1) is critical for the survival of pancreatic cancer cells. We have previously shown that HSF1 is overexpressed in pancreatic cancer cells and its downregulation leads to apoptotic cell death in pancreatic cancer cells. Deacetylation of HSF1 by SIRT1 promotes its function by maintaining it in a DNA bound active state. We hypothesize that SIRT1 contributes to the pathogenesis of pancreatic cancer by promoting HSF1 dependent pro-survival pathways. Thus inhibition of SIRT1 would lead to apoptotic cell death in pancreatic cancer cells.

Methods: SIRT1 expression was reduced in pancreatic cancer cell lines (MiaPaCa-2 & S2VP10) by SIRT1 siRNA. Two unique sequences of SIRT1 siRNA were used to rule out any off-target effects of siRNA. Cell viability (MTT assay) and apoptosis (annexin V staining, caspase 3) were measured.

Results: Inhibition of SIRT1 expression by SIRT1 siRNA markedly reduced the viability of both the pancreatic cancer cell lines at 96 h. Viability (% of control) expressed as mean ± SEM: MiaPaCa-2: 22.6 ± 3.2, S2VP10 42.3 ± 7.61. Inhibition of SIRT1 expresion also led to marked increased annexin V staining in both pancreatic cancer cell lines (data not shown). Further, inhibition of SIRT1 expression also led to activation of caspase-3 in both pancreatic cancer cell lines. Caspase 3 levels at 72 h (% of control) expressed as mean ± SEM: MiaPaCa-2: 482.6 ± 23.3; S2VP10-729.2 ± 32.68. Similar results were observed when the SIRT1 expression was inhibited by the other SIRT1siRNA sequence.

Conclusion: Silencing of SIRT1 expression activates caspase dependent apoptotic cell death in pancreatobiliary cancer cells. Thus SIRT1 holds a great promise as a potential candidate for the drug development.

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Synergistic Effects of Embelin and Ellagic Acid on Pancreatic Cancer

M. Edderkaoui, H. Hui, J. Markus, G. Li, V.L.W. Go, A.S. Gukovskaya, S.J. Pandol. Department of Veterans Affairs & University of California, Los Angeles, CA.

Background: Pancreatic cancer (PaCa) is an aggressive malignancy that is resistant to all therapies. Evidence from population studies indicates a protective effect of fruits and vegetables in the diet on cancer including PaCa. Ellagic acid (EA), a polyphenol found in berries has antioxidative and anticarcinogenic properties. Embelin, a quinone phytochemical has proapoptotic effects in different cancers.

Methods: Human pancreatic cancer cells MIA PaCa-2 were cultured for 72 h in the presence of different doses of embelin and EA. Molecular signaling was assessed by Western. Apoptosis was assessed by measuring DNA fragmentation and AnV staining. Proliferation was assessed by measuring H3-thymidine incorporation.

Results: Embelin and EA dose-dependently (0.5 μM to 30 μM) stimulated apoptosis and decreased proliferation in PaCa cells. Combinations of both compounds at low doses (0.5-3 μM) had synergistic effects on both apoptosis and proliferation. An investigation of molecular signaling revealed that embelin decreased the protein level of the inhibitors of apoptosis (IAPs), XIAP and survivin through a proteasomal pathway. On the other hand, EA decreased NF-kB binding activity and mitochondrial cytochrome c release, without effects on the levels of the IAPs.

Conclusion: These results show that phytochemicals in combinations have synergistic and beneficial effects on pancreatic cancer cells by simultaneously inhibiting key molecular pathways necessary for survival and proliferation of cancer.

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Our Experience of Duodenal Distrophy Treatment

V. Egorov,1 V. Vishnevsky,1 A. Shastny,2 A. Schegolev,1 G. Karmazanovsky,1 N. Yashina,1 H. Dubova,1 T. Shevchenko,1 O. Zhavoronkova,1 R. Petrov.1 1Vishnevsky Institute of Surgery, Moscow, Russia; 2Vitebsk State Medical University, Vitebsk, Belarus.

Background: Duodenal dystrophy (DD) is an uncommon sequence of chronic pancreatitis developing in pancreatic heterotopia in the duodenal wall and causing serious complications.

Methods: The clinical, imaging, pathologic findings and follow-up of 12 patients operated for DD in our institutions between 2005 and 2008 were retrospectively analyzed. All the patients were examined by B-US, CT, MRI and endoUS. The main criteria of the disease was histological confirmation of ectopic pancreas (EP) in the duodenal wall, fully separated from the orthotopic gland.

Results: Ten patients were male alcoholics (mean age, 46 (30-65) years. There were one male and one female among non-drinkers. DD was diagnosed preoperatively in 9 cases. The most accurate diagnostic methods were CT and endo US. Reasons for operation were abdominal pain(10), tumor suspicion(2) and duodenal stenosis(8) associated with vomiting and weight loss. Pancreaticoduodenectomy had been done in 11 cases (7 pyloruspreserving) and duodenumpreserving pancreatic head resection (DPPHR) - 1. There were no deaths and all the patients are alive. One complication - coagulation trauma of the right ureter in heavy retroperitoneal fibrosis. During follow-up all the patients were pain-free and 9 (75%) of them had gained weight.

Conclusion: DD can be and have to be diagnosed before surgery by CT and endoUS. Pancreaticoduodenectomy is a method of choice after failure of medical treatment. The effectiveness of DPPHR for treatment of DD has to be studied.

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Treatment of Primary and Metastatic Solid-Pseudopapillary Tumors

V. Egorov, V. Vishnevsky, A. Schegolev, G. Karmazanovsky, N. Yashina, H. Dubova, T. Shevchenko, O. Melehina. Vishnevsky Institute of Surgery, Moscow, Russia.

Background: Solid-pseudopapillary tumor (SPT) of the pancreas is a rare pancreatic tumor with positive prognosis but uncertain malignant potential.

Methods: The clinical, demographic, imaging, and pathologic findings of 17 patients operated for SPT between 2006 and May, 2009 were analyzed. Positive immunohistochemical staining for vimentin, nuclear β-cathenin, α -1-antitrypsin and α -1-antichemotrypsin with negative reaction for sinaptophisin and chromogranin A were the diagnostic signs.

Results: The mean age was 39,6 (15-70) years, 16 were female. The duration of follow-up after the first tumor detection varied from 0.5 to 14 years. The main symptoms were nausea, vomiting and vague abdominal pain. Blood tumor markers were normal in all cases. On B-US, CT and MRI tumor were solid in 4 cases. Tumors with the mean diameter of 7.2 cm (3-15 cm) were located at the head(8), body(8), and tail(1) of the pancreas. Surgical procedures included pancreaticoduodenectomy(8), combined and extended distal pancreatectomy(8) and segmental resection(1). One patient has had at presentation and 2 patients (17,6%) developed liver and retroperitoneal metastases in 14 and 60 months after the initial operation, which required staged hepatectomies, removal of tumor nodules and arterial liver chemoembolisation. All patients are alive.

Conclusions: In spite of strong believe in low grade malignant potential of SPT 17.6% of patient developed distal metastases. Complete surgical resection of the primary SPT and metastases gives chance for long survival even in disseminated tumors.

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Acute Pancreatitis Should No Longer Be Treated in Low Volume Hospitals

M.P. Ellis, J.J. French, R.M. Charnley. Freeman Hospital, Newcastle upon Tyne, UK.

Background: We have previously shown that high hospital caseload confers a survival benefit for patients with acute pancreatitis (AP). We now aim to identify those risk factors affecting early mortality.

Methods: In a prospective multi-centre observational study all patients with AP were recruited from 18 hospitals over a six month period. Clinical data was gathered and independent risk factors for mortality were identified using information known at admission. Multivariate reverse stepwise multivariate regression analysis identified risk factors for mortality at 48 hours, 7 days and overall. Covariates analysed were age, gender, comorbidity, chronic pancreatitis, aetiology, socioeconomic status and hospital caseload.

Results: Significant independent risk factors for mortality at 48 hours were advancing age (OR = 9.153, p = 0.009), miscellaneous aetiology (OR = 7.165, p = 0.012) and hospital caseload below 90 cases per annum (OR = 3.815, p = 0.044). Similar trends were observed for mortality at 7 days and overall hospital mortality. No differences were identified between high and low caseload hospitals for severe AP (p = 0.740) or patients with severe AP admitted to critical care units (p = 0.497) or intervals from admission until diagnosis (p = 0.834) or from diagnosis until critical care admission (p = 0.205).

Conclusion: Low hospital caseload is an independent risk factor for mortality. This trend is observed as soon as 48 hours after admission and this has important implications for patient management and service planning.

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Appropriate Extent of Lymph Node Dissection for Pancreatic Adenocarcinoma From the Viewpoint of the Number of Positive Nodes

I. Endo, M. Ueda, R. Matsuyama, K. Taniguchi, Y. Minami, Y. Honma, Y. Ohta, Y. Nagano, K. Tanaka, H. Shimada. Dept of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan.

Introduction: Although extended lymph node dissection for pancreatic adenocarcinoma (PA) was denied its effect on patient's prognosis, appropriate lymph node dissection is still controvertial.

Material and Methods: From 1992 to 2007, 142 patients with PA underwent surgical resection. 15 patients with R2 resection and 3 hospital death were excluded. Out of 124 patients, 85 patients underwent extended lymph node dissection including paraaortic nodes. Lymph node mapping based on the histological examination were made in each patients. Number of lymph node metastasis, relationship between other clinicopathological factors, and long-term survival, were retrospectively analyzed.

Results: 72% of the patients had lymph node metastasis. Number of positive lymph node was one in 24 patients, two in 14, three or more in 21 patients. Four of 24 (6.6%) patients had single nodal metastasis in the paraaortic region. 3-year, 5-year survival, and MST of the patients according to the number of lymph node metastasis were (49.2, 25.3, 29) in N0 patients, (28.6, 22.9, 17) in Num1 patients, (19.8, 0, 15) in Num2 patients, (0, 0, 10) in Num3 or more patients. 3-year, 5-year survival, and MST of the patients with paraaortic node metastasis were (0, 0, 15).

Conclusion: Only patients with up to 2 nodal metastasis showed long-term survival. These stations were existed around the pancreas and SMA. Paraaortic node dissection showed no prognostic improvement but may have a role to avoid stage migration.

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Diagnosis of Acute Necrotizing Pancreatitis by Perfusion CT in the Early Phase of Acute Pancreatitis

A. Endou, H. Shimamura, K. Takeda. Department of Surgery, Sendai Medical Center, Sendai, Japan.

Aim: Perfusion imaging by MDCT (perfusion CT) is a new modality to measure tissue perfusion of the pancreas in acute pancreatitis. We examined whether perfusion CT in the early phase of acute pancreatitis can detect ischemic area in the pancreas leading to pancreatic necrosis.

Methods: We investigated pancreatic perfusion measurement using MDCT in 12 patients with acute pancreatitis within the first 72 hr after the onset and two weeks after the admission. Perfusion, peak enhancement intensity (PEI), time to peak (TTP) and blood volume (BV) was measured and sequentially observed.

Results: Perfusion, PEI, TTP and BV was all significantly lower in poorly perfused area of the pancreas in acute necrotizing pancreatitis (ANP) than those in acute edematous pancreatitis (AEP) and those in perfused area of the pancreas in ANP on admission. When the parameters were measured two weeks later, perfusion in AEP and perfused area of ANP was recovered to almost normal range, whereas perfusion in poorly perfused area (ischemic area) of the pancreas in ANP was decreased. Pancreatic necrosis was confirmed by surgical operation.

Conclusion: Perfusion CT in the early phase of acute pancreatitis is useful for detection of ischemic change in the pancreas leading to pancreatic necrosis.

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Opposite Effects of Two BH3-Only Pro-Apoptotic Bcl-2 Members in Pancreatic Cancer

M. Erkan, S. Streit, T. Samkharadze, C. Reiser-Erkan, H. Friess, J. Kleeff. Department of General Surgery, Technische Universität München, Munich, Germany.

Background: BNIP3 and BNIP3L are BH3-only pro-apoptotic Bcl-2 proteins. While loss of BNIP3 leads to apoptosis resistance and worsened prognosis in pancreatic cancer, the role of BNIP3L in pancreatic cancer is unknown.

Methods: cDNA-microarray, QRT-PCR, and immunoblot analyses were used to evaluate BNIP3L expression. Correlation of BNIP3L positivity with p53-status of tumors and patient survival was analyzed by immunohistochemistry using PanIN tissue-microarrays (n = 188) and tissues of normal pancreas (n = 20), chronic pancreatitis (n = 20) and pancreatic cancer (n = 75). Modulation of BNIP3L expression was achieved using siRNA molecules and by hypoxia.

Results: Independent of the disease, linear regression analysis revealed a reciprocal expression of BNIP3 and BNIP3L mRNAs in pancreatic tissues of 69 patients (p < 0.0001, F = 27.74). Compared with the normal pancreas, the expression of BNIP3 mRNA decreased 80% in pancreatic cancer while BNIP3L expression increased 14-fold (p < 0.001). There was a significant reduced expression of BNIP3 in p53-mutated tumors (p = 0.004). Median survival of BNIP3L positive patients was significantly shorter than BNIP3L negative patients (17 months, vs. 34 months, p = 0.009). In pancreatic cancer cell lines, BNIP3L was induced by hypoxia up to 9-fold. Silencing of BNIP3L did not influence apoptosis resistance in these cells.

Conclusion: Expression of BNIP3 and BNIP3L is inversely correlated in pancreatic tissues. Unlike BNIP3, higher expression of BNIP3L in pancreatic tumors is a significant negative prognostic factor.

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Organ-, Inflammation- and Cancer Specific Transcriptional Fingerprints of Pancreatic and Hepatic Stellate Cells

M. Erkan,1 N. Weis,2 C. Schwager,2 U. Wirkner,2 W. Ansorge,2 J. Debus,2 P.E. Huber,2 H. Friess,1 A. Abdollahi,2 J. Kleeff.1 1Department of General Surgery, Technische Universität München, Munich, Germany. 2Department of Radiation Oncology, German Cancer Research Center.

Background: Stellate cells (SC) play a key role in fibrogenesis, impacting significantly on the outcome of patients, thus targeting them is a novel therapy approach.

Methods: To identify organ- and disease-specific SC transcriptional fingerprints, we employed genome-wide transcriptional analysis of primary human pancreatic- and hepatic-SC isolated from 22 patients with chronic inflammation or cancer. Transcriptional profiles of SC were generated using our 51K human cDNA microarray platform. The identified genes were validated by quantitative RT-PCR, immunoblot, ELISA, immunocytochemistry and immunohistochemistry.

Results: Expression profiling identified 160 organ- and 89 disease- specific SC transcripts. Collagen type 11a1 was discovered as a novel pancreas specific marker with up to 65-fold higher expression levels in pancreatic- compared to hepatic-SC. Likewise, the expression of the cytokine CCL2 and the cell adhesion molecule VCAM1 were confined to hepatic-SC. PBX1 expression levels tend to be increased in inflammatory- vs. tumor-SC. Intriguingly, tyrosine kinase JAK2 and a member of cell contact-mediated communication CELSR3 were found to be selectively up-regulated in tumor SC.

Conclusions: Our data may be instrumental in developing new tailored organ- or disease-specific therapies targeting the stroma.

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Fifteen Years of the Warshaw Technique

C.R. Ferrone, I.T. Konstantinidis, C. Fernandez-del Castillo, J. Wargo, S.P. Thayer, A.L. Warshaw. Department of Surgery, Massachusetts General Hospital, Boston, MA.

Background/Aim: The Warshaw technique for spleen preservation during distal pancreatectomy (DP) was first described in 1988. The splenic vessels are ligated and the spleen survives on the short gastric vessels. In this report we describe our series with attention to failures resulting in splenectomy and to clinical or radiologic evidence of portal hypertension.

Methods: Retrospective review of 533 patients who underwent DP between 2/1994-2/2009.

Results: The spleen was preserved via the Warshaw technique in 117/533 patients (22%). Median age was 55 years (range 11-85) and 87 were women (74%). Pathology was: MCN 31 (23 adenoma, 8 borderline), IPMN 20 (cancer 3, borderline 9, adenoma 8), serous cystadenoma 17, pancreatic endocrine tumor 18, chronic pancreatitis 8, ductal adenocarcinoma 4 and other 19. The incidence of pancreatic leak was 26% (30/117). Only 3 (2.6%) patients required reoperation due to splenic infarction. These patients presented at 3, 14 and 100 days after DP with abdominal pain and/or fever. All 3 underwent an uneventful open splenectomy. Median follow up for the cohort was 2.2 years. None of the patients had clinical evidence of left-sided portal hypertension. Of the 69 patients who had a follow up CT/MRI at a median of 3.2 years only 2 had dilated venous collaterals.

Conclusions: Spleen preservation during a DP has a low failure rate of 2.6%. Patients who develop significant abdominal pain or fever should be evaluated for splenic infarction. Clinically relevant sinistral portal hypertension was not observed.

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Analysis of Observed Cases of Intraductal Papillary Mucinous Neoplasms (IPMNs) of the Pancreas: When Is the Best Timing of Surgery?

T. Fujii, S. Yamada, A. Kanzaki, M. Kanda, H. Sugimoto, H. Kasuya, S. Nomoto, S. Takeda, A. Nakao. Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Background/Aims: The best approach to the treatment for IPMNs remains controversial. Our objective was to elucidate predictors of malignancy, to define the appropriate management, and to uncover a more accurate natural history and behavior of IPMNs.

Method: We reviewed the clinicopathological features of 126 patients who underwent surgical resection and of 75 patients who were initially observed at Nagoya University Hospital between 1981 and 2008.

Results: 1. Patients with invasive carcinomas (n = 37) had significantly shorter survival rates than patients with non-invasive IPMN (adenoma (n = 71), borderline (n = 3), CIS (n = 15)) (p < 0.0001). Multivariate analyses revealed that the main duct or the combined type was significantly predictive of both malignancy and invasive carcinoma. 2. Observed IPMNs included 66 cases of branch duct type and 9 cases of main duct type, and the average observation period was 33 months. Twenty-two cases were indicated for surgical management based on the International Consensus Guidelines for Management of IPMNs, and 15 of them underwent surgery after 2-4 years of observation. Pathologically, only two of them were invasive carcinomas.

Conclusions: Our results suggest that the long-term follow-up was possible, and almost of the resected cases after observation were non-invasive IPMNs. Careful observation and aggressive resection before the occurrence of invasion are required.

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Reactive Oxygen Species Production in Pancreatic Acinar Cells Is Associated With Pancreatic Injury

N. Fujimori, T. Nakamura, T. Oono, H. Igarashi, T. Ito, R. Takayanagi. Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan.

Background: There is increasing evidence of oxidative stress occurring in the course of acute pancreatitis (AP), however, it remains unclear how oxidative stress modulate the effect on acinar cells. We evaluated the effect of hydrogen peroxide (H2O2) in rat pancreatic acinar cells.

Methods: In vitro, pancreatic acinar cells were isolated from normal male Lewis rats, and these cells were incubated with various concentrations of H2O2. Intracellular reactive oxygen species (ROS) production was visualized and measured using CM-H2DCFDA as fluorescent dye. Next, viability of acinar cells was evaluated by MTS assay. The culture supernatants were assayed for MCP-1 production by ELISA. In vivo, AP was induced in rat by 3 intraperitoneal injections of cerulein with LPS. Immunohistochemically, pancreatic expression of 8-OHdG was evaluated.

Results: H2O2-induced intracellular ROS were increasing in acinar cells time- and dose-dependently. In cell viability assay, H2O2 above 100 μM was markedly cytotoxic to acinar cells. The treatment of acinar cells with H2O2 increased MCP-1 production, but a high dose of H2O2 (500 M) significantly decreased MCP-1 production through cytotoxicity. In vivo, the histologic damage of the pancreas was identified, in that pancreatic expression of 8-OHdG, especially in the destroyed acinar cells, was markedly increased in AP compared with control group.

Conclusion: Pancreatic injury is associated with intracellular ROS, and adequate ROS may play a key role by promoting inflammation via MCP-1 production.

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Alpha-Smooth Muscle Actin Expressing Stroma Promotes an Aggressive Tumor-Biology in Pancreatic Cancer

H. Fujita,1 K. Ohuchida,1 K. Mizumoto,1,2 K. Nakata,1 J. Yu,1 T. Kayashima,1 L. Cui,1 K. Miyoshi,1 N. Ikenaga,1 T. Egami,1 T. Manabe,1 T. Ohtsuka,1 M. Tanaka.1 1Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; 2Kyushu University Hospital Cancer Center, Fukuoka, Japan.

Background: Pancreatic ductal adenocarcinoma (PDAC) is often characterized by a prominent desmoplastic stroma that is partially induced by activated pancreatic stellate cells (PSCs). Activated PSCs are characterized by the expression of α-smooth muscle actin (SMA) and an increased synthesis of several connective tissue components. In the current study, we investigated the significance of α-SMA expression in PDAC.

Methods: We obtained formalin-fixed paraffin embedded (FFPE) tissue samples from 109 patients with PDAC who underwent pancreatectomy at our institution from 1992 to 2007. We measured α-SMA mRNA levels by quantitative real-time RT-PCR, and investigated the association with clinicopathological parameters and survival time. We also assessed the effect of PSCs on pancreatic cancer cells using in vitro experiments.

Results: The high α-SMA expression group had a significantly shorter survival as shown by univariate analysis (P = 0.005) and multivariate analysis (P < 0.0001). Activated PSCs enhanced the invasiveness, proliferation and colony formation of pancreatic cancer cells.

Conclusions: Quantitative analysis of α-SMA mRNA expression using FFPE tissue samples was useful to predict the prognosis of patients with PDAC. Activated PSCs may regulate the malignant behavior of pancreatic cancer cells.

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Clinicopatoholical Analysis of Invasive Carcinoma Derived From Intraductal Papillary Mucinous Neoplasm

I. Fujita,1 T. Hatori,1 A. Kimijima,1 T. Furukawa,2 M. Yamamoto.1 1Department of Surgery, Institute of Gastroenterology, 2International Research and Educational Institute for Integrated Medical Sciences, Tokyo Women's Medical University, Tokyo, Japan.

Introduction: The patients with invasive carcinoma derived from intraductal papillary mucinous neoplasm (IPMN) die sometimes by a tumor recurrence. It is known that there are two type of the invasive carcinoma derived from IPMN, tubular adenocarcinoma and mucinous carcinoma. The aim of this study is to evaluate the clinical features of the invasive carcinoma derived from IPMN in terms of the difference of the invasive carcinoma type, retrospectively.

Mehods: Sixty-seven patients who underwent pancreatic resection for invasive carcinoma derived from IPMN between 1989 and 2008 were chosen in this study. The patients were divided into two groups according to the type of the invasive carcinoma; 48 patients were tubular carcinoma group, 19 patients were mucinous carcinoma group.

Results: The rates of lymph node metastasis were 65% (31) in the tubular carcinoma group, 26% (5) in the mucinous carcinoma group. The rates of extrapancreatic tumor extension were 83% (40) in the tubular carcinoma group, 53% (10) in the mucinous carcinoma group. 5-year survival rates were 42% in the tubular carcinoma group, 89% in the mucinous carcinoma group, respectively (p < 0.01).

Conclusions: The prognosis of the invasive carcinoma derived from IPMN is depended on the difference of the invasive carcinoma type. A good prognosis is expected in the patients with mucinous carcinoma even if IPMN is an invasive carcinoma.

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Endosonography-Guided Biliary Drainage (ESBD): An Excellent Alternative to Percutaneous Transhepatic Biliary Drainage

N. Fujita, Y. Noda, G. Kobayashi, K. Ito, J. Horaguchi, S. Koshita, Y. Kanno. Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan.

Background: Recently, reports on a new endoscopic biliary internal drainage technique utilizing endosonographic guidance (endosonography-guided biliary drainage, ESBD) have been increasing.

Aim: To evaluate the efficacy of ESBD for malignant biliary obstruction in cases with difficult transpapillary endoscopic biliary drainage (EBD).

Methods: Nineteen patients with obstructive jaundice who underwent ESBD because of difficult EBD between January 2007 and June 2009 were included. ESBD was performed by using a curved linear array echoendoscope and a puncture needle under endosonographic and radiographic guidance. The technical success, complications, and clinical efficacy of ESBD were prospectively evaluated.

Results: ESBD was performed via the duodenum, stomach, and esophagus in 10, 7, and 2 patients, respectively. Stent placement was successful in all cases and excellent biliary decompression was achieved in all but one patient. One patient developed localized peritonitis following guidewire migration and successful ESBD after re-puncture of the bile duct. In another patient, stent migration was observed one week after ESBD, which was treated with re-ESBD. Three patients underwent surgery for their primary diseases, and stent exchange was carried out in 11 patients during the course electively or at the time of stent occlusion.

Conclusions: ESBD is an effective treatment for obstructive jaundice that will replace PTBD in cases of difficult EBD and is a possible alternative to EBD in selected cases.

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Successful Endoscopic Dilation of Severe Pancreaticojejunostomy (PJ) Stricture Presented as Recurrent Pancreatitis After Pancreaticoduodenectomy for Isolated Insulinoma

N. Fukami, D. Ringold, Y. Chen. Division of Gastroenterology and Hepatology, University of Colorado, Denver.

PJ stricture is a rare complication after pancreaticoduodenectomy. Evaluation of anastomosis is difficult due to altered anatomy. Treatment of the stricture is surgical or endoscopic where accessible. We experienced successful dilation of PJ stricture only by rendezvous EUS-ERP procedure after ERP access failed.

Case: 56 yr-old female underwent pancreaticoduodenectomy for symptomatic insulinoma in the head of pancreas. Patient had acute pancreatitis within 1 year of surgery and continued to have recurrent attacks. CT identified post surgical change but failed to reveal any cause. MRCP showed dilated pancreas duct (PD) in the remaining pancreas suggesting anastomotic stricture. ERP was attempted but the site of PJ was not located. EUS-guided PD injection of contrast confirmed severe PJ stricture. Attempt of 0.018 in guide wire antegrade passage via 22 G needle failed. After surgical consultation, patient decided for non-surgical approach rather than re-operation. PD was punctured using 19 G needle under EUS and 0.025 in guide wire was successfully passed across the anastomosis. ERP was performed subsequently and retrograde dilation and the stent placement were successful. Patient improved clinically with resolution of post-prandial abdominal pain after the procedure.

Conclusions: EUS-ERP access of the PJ anastomosis can be attempted when conventional ERP via jejunal loop failed. Complication and long term outcome are to be determined to establish this technique as viable alternative to surgical approach.

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Introduction of the Critical Path for Pancreaticoduodenectomy Taking in the Concept of Probiotics

M. Fukase, H. Shimamura, K. Takeda. Department of Surgery, Sendai Medical Center, Sendai, Japan.

Aim: There have been recently a lot of reports that taking in the concept of probiotics and prebiotics to the perioperative nutrition management of a gastrointestinal surgical op leads to reduction of postoperative surgical site infection. Then, we made the critical path for pancreaticoduodenectomy (PD) taking in the concept of probiotics, and examined its effectiveness.

Patients and Methods: We performed 161 PD in our hospital between Jul 1998 and Sept 2008. In these pts, we defined the 18 cases introduced PD path since Oct 2007 as "path group", and the other 143 cases as historical "control group". Between the two groups, comparison was carried out including operative morbidity or length of hospital stay. Pts in the path group should take a drink containing Lactobacillus acidophilus for a couple of days before op, and start water intake with Clostridium butyricum tablets from 3POD. Both groups were permitted to take liquid meal from 4POD, and start rice porridge from 6POD. All pts were also applied central venous parenteral nutrition.

Result: In the path group, pancreatic fistula (PF) and cholangitis were observed in 4 and 2 pts, respectively. The morbidity rate in the path group was relatively lower than the control group, though not significant: all complication, 33.3% vs. 43.4%; PF, 22.2% vs. 25.2%. However, length of hospital stay was significantly shorter in the path group: 35.5 vs. 42.7.

Conclusion: Introduced PD path taking in the concept of probiotics may be beneficial for perioperative nutrition management.

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Is it Appropriate Performing Pancreatectomy for Chronic Pancreatitis? From Considerations of the 18 Cases

S. Fukazawa, H. Shimamura, K. Takeda. Department of Surgery, Sendai Medical Center, Sendai, Japan.

Aim: Surgical treatments for chronic pancreatitis (CP) can generally be categorized into two procedures; drainage of the main pancreatic duct (MPD) and pancreatectomy. To preserve the pancreatic function, it is more advisable performing MPD drainage than pancreatectomy, though we often select the latter. The aim of this study is to consider the appropriateness of the pancreatectomy for CP.

Patients and Methods: We conducted a retrospective study of pts with CP who underwent surgical ops between Jul 1998 and Dec 2008 in our hospital.

Results: Eighteen patients underwent surgical ops for CP. Their procedures were pancreaticoduodenectomy (PD; n = 9), distal pancreatectomy (DP; n = 3), Frey's op (n = 5) and other MPD drainage (n = 1). Thus, two thirds of the pts underwent pancreatic resection. Since more than a half of the pts who underwent PD had jaundice at preoperative term, bile duct stenosis could be a primary reason for choosing PD. For these pts with jaundice, we should consider differential diagnoses including pancreatic cancer (PC). In spite of using a variety of modalities, we could not exclude the possibility of PC in some patients until the pathological exams revealed no malignancy. One of the pts had positive uptake in FDG-PET, so that we diagnosed as PC and performed PD with lymph node dissection. Meanwhile, in all the pts who were complicated with the collapse of distal MPD, we resigned preserving distal pancreas, and underwent DP.

Conclusion: In cases of CP complicated with bile duct stenosis or distal MPD collapse, pancreatectomy might be appropriate.

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The Experiences of Internal Drainage of Pancreatic Pseudocysts Accomplished by Minimally Invasive Laparoscopic Approaches

S. Fukuyama,1 K. Takeda,3 S. Egawa,2 H. Tokumura,1 M. Unno,2 S. Matsuno.4 1Department of Surgery, Tohoku Rosai Hospital, Sendai; 2Department of Hepato-Pancreato-Biliary Surgery, Tohoku University Graduate School of Medicine, Sendai; 3Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai; 4Department of Surgery, Tohoku Koseinenkin Hospital, Sendai, Japan.

Background: One of the late complications of acute pancreatitis is pseudocyst. Drainage needs to be considered if the cyst is not decreased or disappeared in the clinical course. Since indications of laparoscopic surgery have been spreading for various kinds of diseases, laparoscopic approach can be considered to be one option for drainage. We report a summary of 7 cases of laparoscopic approaches that we experienced.

Patient: From May 1998 to May 2008, a total of 7 patients underwent laparoscopic approaches. Information regarding patient characteristics, operative technique, operational time, complications and clinical follow-up were collected and analyzed.

Results: We performed 5 laparoscopic cystojejunostomies (LCJ) and 2 laparoscopic cystogastrostomies (LCG). 2 cases were converted to be open procedures. The mean operation time was 208 minutes for LCJ and 322 minutes for LCG. No complication was recognized. Mean hospital stay was 18 days for LCJ and 20 days for LCG.

Conclusion: Even though the operation time for LCG with complicated procedure tends to be longer compared to that of LCJ, it seems feasible to perform these 2 operations. We will continue to perform laparoscopic approach in order to confirm the safety and validity of these operations.

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Giardia Lamblia Infection Accompanied With Pancreatic Cancer Diagnosed By Endoscopic Ultrasound-Guided Fine-Needle Aspiration

M. Furukawa, L. Lee, A. Funakoshi, K. Nishiyama, S. Itaba. Division of Pancreatology, Department of Gastroenterology, National Kyushu Cancer Center.

Giardia lamblia is a common protozoal pathogen residing in the upper intestine and biliary tract, but not in the pancreas. We report the case of a 69-yr-old male who was admitted to our hospital for the treatment of pancreatic tail mass.

He had been diagnosed originally by a private doctor for hypertension and angina pectoris. Recently he had upper abdominal discomfort. Although he had no abnormality in the upper GI tract, on ultrasonography he had small cyst and mass lesion in the body to tail of the pancreas. The imaging multidetector CT scan also showed pancreatic tail cystic and mass lesion that was suspected of pancreas cancer. On endoscopic ultrasonography the mass consisted of cystic part and solid part and its size was 22 mm by 19 mm. There were quite different cystic pattern seen in intraductal papillary mucinous neoplasm (IPMN). Hot spot was confirmed in accordance with the mass in FDG PET-CT (SUV 3.8). Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the mass showed adenocarcinoma; moreover numerous pear-shaped, binucleated, flagellated organisms that is morphologically consistent with trophozoites of Giardia lamblia were also identified in the specimen. Endoscopic retrograde cholangio-pancreaticoography (ERCP) showed occlusion of the main pancreatic duct in the tail. The similar trophozoites were recognized in the cytology of the pancreatic juice. The patient subsequently underwent distal pancreatectomy for the treatment of the pancreas cancer. Resected tumor histology indicated invasive ductal carcinoma showing well to moderately differentiated adenocarcinoma. To our knowledge there have been few previous reports of pancreatic infection with giardiasis and no case of the infection with the cancer, but the carcinogenesis of this giardiasis is unknown.

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The Indication of Operative Management Against Intraductal Papillary Mucinous Neoplasm (IPMN) of the Pancreas in 7 Experienced Cases

M. Furukawa, L. Lee, K. Nishiyama, A. Funakoshi. Division of Pancreatology, Department of Gastroenterology, National Kyushu Cancer Center, Fukuoka 811-1395, Japan.

Background: The evidenced based management of intraductal papillary mucinous neoplasm of pancreas (IPMN) is a clinical challenge because of its pre-malignant state, although we have an international guideline for the treatment.

Methods: We reviewed our experience with 7 IPMN patients who underwent pancreas resection according to the international guideline for the treatment of IPMN. Each of the type of the IPMN (main ductal type or branch type), the history of pancreatitis, maximum diameter of the pancreas duct, the existence of hot area in FDG PET-CT, and the cytology of the pancreatic juice in the endoscopic retrograde pancreatology was evaluated before the surgical management. Data on neoplasm characteristics were analyzed in the context of pathologic findings and of the type of k-ras codon 12 point mutation after resection.

Results: Among 7 patients, there were 3 (43%) females; median age 65 years. 6 patients (86%) had a main ductal type. The existences of hot area in the PET were found in 4 patients (57%). One patient had a Class V in preoperative pancreatic juice cytology. Malignant lesions (adenocarcinoma) were found in 3 patients (43%). Among these three patients, an invasive ductal carcinoma derived from IPMN was identified in one case. All cases revealed k-ras codon 12 point mutation (GGT to GAT) in both neoplastic and normal appearance tissues.

Conclusion: The accurate diagnosis for malignancy and operative indication of IPMN is so tough; therefore further clinical studies should be done to determine the operative indication against IPMN.

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Prognostic Relevance of Morphologic Types of Intraductal Papillary Mucinous Neoplasms of the Pancreas

T. Furukawa,1,4 T. Hatori,2 I. Fujita,2 M. Yamamoto,2 M. Kobayashi,3,4 N. Ohike,5 T. Morohoshi,5 S. Egawa,6 M. Unno,6 S. Takao,7 M. Osako,8 S. Yonezawa,9 M. Mino-Kenudson,10 G.Y. Lauwers,10 H. Yamaguchi,11 S. Ban,11 M. Shimizu.11 1Int. Res. Edu. Inst. Integ. Med. Sci., 2Dept. Surg., Inst. Gastroenterol. 3Dept. Path., 4Dept. Surg. Path., Tokyo Women's Med. Univ.; 5First Dept. Path., Showa Univ. Sch. Med., Tokyo; 6Div. Hep.-Bil.-Panc. Surg., Grad. Sch. Med., Tohoku Univ., Sendai; 7Front. Sci. Res. Ctr., Kagoshima Univ.; 8Dept. Surg., Kagoshima-shi Med. Assoc. Hosp.; 9Dept. Hum. Path., Fld. Onc., Kagoshima Univ. Grad. Sch. Med. Dent. Sci., Kagoshima, Japan; 10Dept. Path., Massachusetts Gen. Hosp., Boston, MA; 11Dept. Path., Saitama Med. Univ. Int. Med. Ctr., Hidaka, Japan.

Background and aim: We assessed the clinicopathologic significance of 4 distinct types-the gastric, intestinal, pancreatobiliary, and oncocytic-of intraductal papillary mucinous neoplasm (IPMN) of the pancreas.

Methods: We retrospectively analyzed the data from 224 patients with IPMNs.

Results: Our series included 107 gastric-type, 79 intestinal-type, 15 pancreatobiliary-type, and 23 oncocytic-type IPMNs. These IPMN types were significantly associated with sex, histologic grade/diagnosis, the macroscopic types, invasive phenotypes, and prognosis. Gastric-type IPMNs were associated with the male gender, low grade/adenoma, the branch duct type, noninvasive neoplasm, and fair survivals (93% at 5 and 10 years (Ys)). Intestinal-type IPMNs were associated with high grade/carcinoma, the main duct type, noninvasive neoplasm but colloid carcinoma when invasive, and less favorable survivals (83.4% at 5 Ys and 59.6% at 10 Ys). Pancreatobiliary-type IPMNs were associated with the female gender, high grade/carcinoma, tubular adenocarcinoma, and poor survivals (39.3% at 5 Ys and not determined at 10 Ys). Oncocytic-type IPMNs were associated with high grade/carcinoma, noninvasive neoplasm but oncocytic carcinoma when invasive, and less favorable survivals (82.3% at 5 Ys and 70.5% at 10 Ys). Analysis by Cox proportional hazards models indicated that histologic grade/diagnosis was the most significant predictor of prognosis; however, the morphologic type was also found to contribute to the prognosis.

Conclusion: The morphologic type is a useful prognostic predictor in patients with IPMNs.

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A Case of Pancreatoduodenectomy for Intraductal Papillary Mucinous Neoplasm in the Branch Pancreatic Duct of Pancreas Head in a Patient With Pancreas Divisum

K. Furusawa, A. Horiguchi, S. Ishihara, M. Ito, Y. Asano, T. Shimizu, T. Yamamoto, K. Tuda, S. Morigaki, C. Yamada, S. Miyakawa. Department of Surgery, Fujita-health University, Toyoake, Aichi, Japan.

A 43-years-old Japanese man was admitted to our hospital because of acute abdominal pain and elevating of serum amylase level and pancreas swelling using abdominal US. His medical history was chronic pancreatitis. Abdominal Computed Tomography (CT) scanning revealed diffuse dilatation of main pancreatic duct, and there were pancreas head tumor size of 2.3 cm ≥ 1.4 cm ≥ 1.4 cm, which wall was contrasted, and the multiple partition cyst, the expansion of the ramification pancreatic duct. Endoscopic Retrograde Cholangiopancreatography (ERCP) revealed that did not open size of a main and the accessory pancreatic duct, and the mutin discharge did not drainage it. And the papilla of vater was revealed from main bile duct, accessory papilla was revealed from the main pancreatic duct independently each. However, there were no views the main bile duct contrasting from the papilla. And the contrasting inspection of accessory papilla, a ventral pancreatic duct didn't depiction, but the multiple depictions. There was shadow deficit by the mutin in santorini duct and branch pancreatic duct.

The preoperative diagnosis was intraductal papillary mutinous neoplasm (IPMN) in the branch pancreatic duct of pancreas head with pancreas divisum. A sub gastric preserving pancreaticoduodenectomy was performed.

Fluorography of pancreas duct performed on the resected specimen inserting from the edge of pancreas duct. The main pancreatic duct which opened to an accessory papilla and the ramification which commuted to a cyst was recognized by ventral pancreatic duct. The main bile duct contrasting from the papilla.

We diagnosis divisum type of II of Warshaw's classification.

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Transgenic Expression of Intracellular Active Trypsin Causes Acute Pancreatitis

S. Gaiser, J. Daniluk, Y. Liu, L. Tsou, B. Ji, C.D. Logsdon. Dept of Cancer Biology, UT MD Anderson Cancer Center, Houston, TX, USA.

Introduction: Premature intracellular activation of trypsinogen (TRYP) is widely believed to be the initiating event in pancreatitis. Since its biological consequences have not been directly tested yet our aim was to develop a transgenic mouse model expressing intracellular active TRYP.

Methods: Mutant TRYP, which can be activated by the endogenous protease PACE (PACE-TRYP) was utilized. Mutant mice containing a loxp-stop-loxp-PACE-TRYP cassette were bred with elastase I promotor driven, tamoxifen regulated Cre-recombinase mice. Activation of PACE-TRYP expression by tamoxifen administration in double transgenic mice was documented by Western blot. Acinar cell morphology was monitored by light and electron microscopy. Pancreatitis parameters, levels of cell death and pancreatic inflammation were examined.

Results: PACE-TRYP was expressed and activated in acinar cells after induction with tamoxifen. In homozygous animals the active TRYP mutant caused massive acinar cell death, edema and abundant infiltration of inflammatory cells. Heterozygous animals, however, displayed only temporary loss of zymogen granules and did not show relevant inflammation but rather limited levels of apoptosis.

Conclusion: Sufficient levels of intracellular active trypsin are capable of causing severe acinar cell damage leading to the onset of acute pancreatitis. This new model presents the first direct evidence that intracellular trypsin activity is indeed a potential initiator of pancreatitis. It provides an important tool to improve our understanding of pancreatitis.

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Glucose Tolerance, Insulin Sensitivity, Subclinical Inflammation and Endothelial Dysfunction in Subjects With Newly Diagnosed Pancreatic Cancer

A. Gasiorowska,1 R. Talar-Wojnarowska,1 L. Czupryniak,2 A. Borkowska,2 J. Loba,2 E. Malecka-Panas.1 1Department of Digestive Tract Diseases, 2Diabetology and Metabolic Diseases Department, Medical University of Lodz, Lodz, Poland.

Introduction: Glucose intolerance or diabetes is often the first sign of pancreatic cancer.

Aims and Methods: We studied glucose tolerance in patients with newly diagnosed pancreatic cancer (PC) aiming at identifying factors suggestive of cancer etiology of glucose metabolism disturbances. The additional aim of the study was to assess endothelial dysfunction and subclinical inflammation. The study group was 18 non-diabetes individuals with newly diagnosed PC (mean age 69.6 ± 8.9 years, BMI 23.0 ± 4.7 kg/m2), 13 age- and body weight-matched healthy subjects served as controls. All subjects underwent OGTT with plasma glucose and insulin measurements. HOMA index and fasting plasma adiponectin, TNF-alfa, interleukin-6 (IL-6), interleukin-1beta (IL-1b), E-selectin, thrombomodulin, adhesion molecules ICAM and VCAM, and high-sensitive CRP were assessed.

Results: PC and control subjects plasma glucose values in OGTT were at 0 min 98 ± 21 and 90 ± 17, 60 min - 166 ± 43 and 103 ± 36 (p < 0.01), 120 min - 173 ± 39 and 90 ± 28 (p < 0.001) mg/dl, and plasma insulin at 0 min 3.6 ± 1.8 and 10.2 ± 7.9 (p < 0.01), 60 min - 22.3 ± 17.4 and 33.1 ± 21.4, 120 min - 31.9 ± 19.3 and 34.1 ± 44.7 mIU/l. PC patients presented also with significantly greater insulin sensitivity as measured with HOMA than controls (0.83 ± 0.39 vs 2.34 ± 1.87; p < 0.01). Moreover, PC subjects as compared with controls had significantly greater plasma adiponectin (16132 ± 8165 vs 6681 ± 4329 ng/ml; p < 0.001), IL-6 (8.6 ± 4.9 vs 3.9 ± 1.4 pg/ml; p < 0.01), thrombomodulin (2.0 ± 0.8 vs 1.1 ± 0.5 ng/ml; p < 0.01), ICAM (929 ± 417 vs 318 ± 85 ng/ml; p < 0.001) and VCAM (1669 ± 489 vs 857 ± 312 ng/ml; p < 0.001).

Conclusion: In conclusion, individuals with newly diagnosed pancreatic cancer present with elevated post-challenge plasma glucose associated with significant insulin sensitivity. Diagnosing glucose metabolism disturbances in lean subjects with high insulin sensitivity should point at the possibility of pancreatic cancer as an underlying condition. Moreover, despite absence of insulin resistance, newly diagnosed PC subjects present with clinical markers of subclinical inflammation and endothelial dysfunction.

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Small Intestine Changes in Patients With Chronic Pancreatitis (CP)

N.B. Gubergrits, Y.V. Linevsky. Department of Internal Medicine No 1, Donetsk State Medical University, Ukraine.

Introduction: Pancreatic excretory insufficiency in CP patients leads to development of intestine dysbiosis and secondary enteritis. Atrophy of small intestine mucosa is a cause of reduced efficacy of substitution therapy.

Aim: To study enzymatic indices of small intestine digestive function in CP patients.

Methods: We examined 32 CP patients. Aspiration biopsy of mucosa of small intestine was taken. Amylolytic and lipolytic enzyme activity, the activity of lactase, saccharase, maltase, glycine-L-leucinedipeptidase, monoglyceridlipase and alkaline phosphatase were examined in mucosa homogenates. An absorptive function of small intestine was evaluated by D-xylose test. Patients underwent relaxation duodenography.

Results: X-ray examination of duodenum showed smooth internal outlines of pars descendence and "snow storm" symptom on a residual contrast enhancement. Histology of jejunal bioptates revealed dystrophy of villi epithelium, its marked leucopedesis and different grades of atrophy. Amylolytic and lipolytic activity of membrane and cavitary digestion was increased, also a reduced production of monoglyceridlipase was determined. An increased production of saccharase, reduced level of glycine-L-leucinedipeptidase in mucosa, growth of alkaline phosphatase contents were obtained. Insufficiency of small intestine absorptive function and bacterial proliferation were revealed in small intestine.

Conclusion: Secondary disorders of small intestine enzyme production are developing in patients with CP as far, as reduction of intestinal mucosa absorptive function.

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Surgical Gastrostomy for Complex Pancreatobiliary Endoscopy After Roux en Y Gastric Bypass

J.M. Gutierrez,1 H. Lederer,1 J.C. Krook,1 O.W. Cass,1 T.P. Kinney,2 M.L. Freeman,2 E.H. Jensen.1 Departments of 1Surgery and 2Gastroenterology, Hennepin County Medical Center and University of Minnesota Medical Center, Minneapolis, Minnesota.

Background: Pancreatobiliary endoscopy following Roux en Y Gastric Bypass (RYGBP) is challenging. We review 32 cases of surgical gastrostomy for complex transgastric upper gastrointestinal endoscopy.

Methods: Retrospective review of prospectively collected database of patients with history of RYGBP that had surgical gastrostomy for pancreatobiliary and duodenal access at a single institution from 2004-2008. Indication for procedure, surgical findings, successful cannulation and complications are reported.

Results: Thirty patients (25 female) with age ranging from 27 to 72, underwent 32 procedures. The indications to access the gastric remnant were sphincter of Oddi dysfunction (13), pancreatitis (6), common bile duct stone/obstruction (5), cholangitis (3), pancreatic mass evaluation (2), gastrointestinal bleed (2), and cystic duct leak after cholecystectomy (1). Mean operative time was 200 minutes (987-338), estimated blood loss, mean 85 cc (10-500). Laparoscopic gastrostomy was attempted in 28 cases with 1 conversion to open (3.6%). Four planned open procedures were also performed. All 30 patients underwent successful endoscopy; 28 had an ERCP, all with successful cannulation of the pancreatobiliary tree (100%).

Conclusions: Surgical gastrostomy is an effective means to gain access to the upper GI tract and pancreatobiliary tree following roux-en-Y gastric bypass. This technique should be considered when traditional endoscopic approaches are impossible.

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Surgical Ampullectomy - Indications, Technique and Outcome in 51 Consecutive Patients

T. Hackert, W. Hartwig, U. Hinz, L. Schneider, O. Strobel, M.W. Büchler, J. Werner. Department of Surgery, University of Heidelberg, Germany.

Background: Ampullectomy of the duodenal papilla represents a surgical therapy especially for benign tumors and stenosis of the papilla. However, in tumors with dysplasia or large adenomas, decision between ampullectomy as a rather small operation and more aggressive approaches such as pancreatico-duodenectomy may be difficult. Aim of the study was to define indications, surgical approaches and outcome for ampullectomy compared with pancreatico-duodenectomy.

Methods: Data analysis of 51 patients undergoing open ampullectomy was performed with regard to epidemiology, indication, endoscopic pre-treatment, preoperative diagnostic findings, surgical intervention, histology and outcome. Data were compared to pancreaticoduodenectomy in a matched-pair analysis (n = 51/102) with regard to operative parameters, morbidity and mortality.

Results: 51 patients (18 male, 33 female, 60 ± 14 y) underwent ampullectomy. Indications included benign tumors in 75%, high grade dysplasia or malignant tumors in 11% and inflammatory stenosis in 14%. Overall morbidity was 28% including fistula, intraabdominal abscess and need for reoperation due to bleeding. No deaths occurred. Compared to Whipple resections morbidity (41%), reoperation rate (9,3%) and mortality (3,6%) were reduced, while fistula rate (7% vs. 5,6%) was comparable. Mostly, type A fistulas occurred that did not require invasive therapy. Regarding surgical parameters, blood loss and operation time were significantly reduced in ampullectomy as well as occurrence of major perioperative complications.

Conclusion: Surgical ampullectomy is a feasible procedure of limited extent for the treatment of inflammatory stenosis and adenomas of the papilla, especially for suspected high-grade dysplasia and intraductally extending lesions. Severe surgical complications as well as mortality are reduced in comparison to pancreatico-duodenectomy.

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hENT 1 Expression Might Be a Useful Biomarker to Predict Prognosis in Patients With Resected Pancreatic Cancer

A. Hagihara,1 S. Hiraoka,2 M. Ikeda,4 H. Ueno,1 J.R. Machey,5 T. Okusaka,1 C. Morizane,1 S. Kondo,1 Y. Sakamoto,3 K. Shimada,3 M. Esaki,3 S. Nara,3 T. Kosuge.3 1Hepatobiliary and Pancreatic Oncology Division, 2Pathology Division, 3Hepatobiliary Pancreatic Surgery Division, National Cancer Center Hospital, Japan. 4Division of Hepatobiliary and Pancreatic Oncology, National Cancer Center East Hospital, Japan. 5Department of Medical Oncology, Cross Cancer Institute, Canada.

Context: Gemcitabine (GEM) is a promising adjuvant chemotherapy for patients with resected pancreatic cancer. GEM is transported into cells mainly by the human equilibrative nucleoside transporter 1 (hENT1).

Aim: We investigated the relationship between the expression of hENT1 in tumor cells and prognosis of pancreatic cancer patients who underwent surgery with or without adjuvant GEM.

Methods: Among 119 patients (pts) who were enrolled in the multicenter randomized controlled trial of adjuvant gemcitabine (JASP-02), 59 pts who underwent surgery at National Cancer Center Hospital were examined in this study. Macroscopically curative resection was performed in all 59 pts, and 30 pts received adjuvant GEM (29 pts surgery only). The hENT1 expression was assessed by immunohistochemistry.

Results: Analysis of all pts showed that pts with high hENT1 expression (n = 24) had significantly longer overall survival (OS) than pts with lower or no hENT1 expression (n = 35) (median, 28.5 vs. 13.6 months, P = 0.02). Longer OS was regardless of adjuvant GEM.

Conclusions: Our findings suggest that hENT1 expression might be a useful biomarker to predict prognosis in pts with resected pancreatic cancer.

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Gemcitabine Affects Drug Transporter Expression in Pancreatic Carcinoma Cells

W. Hagmann,1 R. Jesnowski,1 J.M. Löhr.1,2 1CCU Molecular Gastroenterology, DKFZ, Heidelberg, Germany, 2Department of Surgical Gastroenterology, CLINTEC, Karolinska Institute, Stockholm, Sweden.

Gemcitabine is widely used as first line chemotherapeutic drug in treatment of pancreatic cancer. Our previous studies have shown, that treatment of human pancreatic carcinoma cells with 5-FU alters their transporter expression profile, and that altering the expression levels of MRP5 (ABCC5) influences chemoresistance of these tumor cells (Hagmann et al., 2009). Here we checked by RT-QPCR and immunoblot analyses the influence of acute and chronic gemcitabine treatment on the RNA and protein expression of uptake and export transporters in pancreatic carcinoma cells. Exposure to gemcitabine (12 nM, 3 d) did not alter MRP1, MRP3, MRP5 and ENT1 mRNA expression, while high doses of the drug (20 μM, 1 h) elicited upregulation of these transporters in most cell lines studied. In cells with acquired gemcitabine resistance (up to 160 nM gemcitabine), MRP5 and ENT1 mRNA or protein expression were upregulated in several cell lines. Combined treatment with 5-FU and gemcitabine caused a 5-40 fold increase in MRP5 and ENT1 expression which are relevant for gemcitabine transport. Our studies suggest that the efficiency of chemotherapy using gemcitabine and/or 5-FU may benefit from taking into account the observed alterations of relevant transporter expression levels induced by these drugs. In addition, the observed varying degree of responsiveness of different human pancreatic cancer cells to gemcitabine treatment argues for an individualized screening test prior to chemotherapy in patients.

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Trypsin (OGEN) 4 Represents an Inhibitor-Insensitive Isoform in the Mouse Pancreas and Is Upregulated and Activated During Experimental Pancreatitis

W. Halangk,1 M. Butueva,1 M.M. Lerch,2 M. Sahin-Tóth,3 T. Wartmann.1 1Department of Surgery, Otto-von-Guericke University, Magdeburg, Germany; 2Department of Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany; 3Department of Molecular and Cell Biology, Boston University, Boston, MA.

We have recently demonstrated that the trypsin activity generated during pancreatitis (AP) is largely insensitive towards trypsin inhibitors - generally a feature of mesotrypsin. In order to identify the mouse equivalent of mesotrypsin we determined trypsinogen (TG) expression in pancreatitis by RT-PCR and biochemically characterized recombinant TGs.

In NMRI mice AP was induced by 7 injections of caerulein (50 μg/h, i.p.). Control mice received i. p. saline. Trypsin was fluorometrically measured. TG isoforms 4, 5, 7, 8, 9, 11, 12, 16, and 20, as well as SPINK3 were expressed in E. coli. Expression of TG 4 or 5 mRNA during AP was determined by RT-PCR and subsequent sequencing of resulting cDNAs.

Only between 10 and 20% of the trypsin activity that is generated in response to caerulein hyperstimulation could be inhibited using SBTI or SPINK3. Inhibitor titration of trypsins 7, 8, 9, 10, 11, 16, and 20 indicated a strong sensitivity for SBTI or SPINK3, whereas trypsins 4 and 5 were barely inhibited. RT-PCR indicated the expression of both isoforms and only the expression of TG 4 increased during pancreatitis.

Mouse TG 4 and 5 share the biochemistry of mesotrypsin, are both expressed in the pancreas, and isoform 4 is upregulated in pancreatitis. The pathophysiological role of this mesotrypsinogen-(PRSS3)-equivalents in the mouse needs to be further explored and may, in view of its minimal proteolytic potency, not include the triggering of the protease cascade that leads to acinar cell injury.

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The Homebox Gene MSX2 REGULATES the Transporter Gene ABCG2 Expression in Pancreatic Cancer Cells

S. Hamada, K. Satoh, M. Hirota, A. Kanno, H. Ito, T. Shimosegawa. Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai city, Miyagi, Japan.

Background: Recent researches have reported several markers to isolate the cancer-stem cells. Among them, the transporter gene ABCG2 is highly expressed in the cancer stem cells. In this study, we found the correlation between the ABCG2 and the homeobox gene MSX2 expression levels in pancreatic cancer cell lines, and further investigated the role of MSX2 in the regulation of the ABCG2 expression.

Methods: The expression levels of ABCG2 were assessed by the real-time RT-PCR and flow cytometry. The role of the MSX2 was assessed by over-expression or knock-down of MSX2 in the pancreatic cancer cell line. The gemcitabine sensitivity was measured by MTT assay. The promoter analysis of the ABCG2 was done by the luciferase assay.

Results: In the human pancreatic cancer cell lines, the expression levels of the MSX2 were correlated with the ABCG2 expression levels. Over-expression of the MSX2 resulted in the up-regulation of the ABCG2 and the gemcitabine resistance in BxPC3 cells. In contrast, Knock-down of MSX2 in Panc-1 cells resulted in the down-regulation of the ABCG2 and sensitized cells to the gemcitabine treatment. The promoter analysis suggested that the three MSX2 consensus binding elements in the -400 to -600 bp of the ABCG2 gene have regulatory role.

Discussion: The regulatory mechanism of the ABCG2 expression by MSX2 was identified for the first time. This transcriptional regulation of the ABCG2 could be a novel therapeutic target in the pancreatic cancer.

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Ductal Carcinoma of the Pancreas During Prospective Follow-Up of the Branch Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas

K. Hanada,1 T. Iiboshi,1 Y. Ishii,1 N. Hirano,1 H. Amano,2 F. Hino,2 T. Fukuda,3 Y. Kuroda,3 S. Yonehara.4 1Center for Gastroendoscopy, 2Department of Gastroenterology, 3Department of Surgery, 4Department of Pathology, Onomichi General Hospital, Onomichi, Japan.

Introduction: Recently, there have been some reports about cases with synchronous ductal carcinoma of the pancreas and intraductal papillary mucinous neoplasm (IPMN). In this prospective study, the development of ductal carcinoma of the pancreas during follow-up in patients with branch duct (BD) type of IPMNs was investigated.

Methods: Consecutive 83 patients diagnosed from 2001 to 2007 with highly suspected IPMNs classified into BD type without criteria suggesting malignant development (mural nodule > 4 mm, BD diameter > 25 mm, or diameter of main pancreatic duct > 7 mm) were followed up prospectively using computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic ultrasonography (EUS) every 3 or 6 months.

Results: After a median follow-up period of 31 months, the development of ductal carcinoma of the pancreas distinct from BD type of IPMNs was detected in 5 patients of 83 (6%). All 5 patients with ductal carcinoma were resectable. Surgical resections revealed that there were two cases of stage I, one case of stage II, and two cases of stage IVa.

Conclusions: Patients with BD type of IPMN are at higher risks of carcinoma of the pancreas. A careful systemic follow-up for BD type of IPMNs may be able to detect ductal carcinomas of pancreas at early stage.

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EUS-Guided Choledochoduodenostomy for the Patients With Lower Malignant Biliary Stenosis

K. Hara, N. Mizuno, S. Hijioka, H. Imamura, A. Sawaki, Y. Kobayashi, K. Matsumoto, K. Yamao. Department of Gastroenterology, Aichi Cancer Center Hospital, Japan.

Aim: Recently, endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) has been described in patients with malignant biliary obstruction. We think that EUS-guided choledochoduodenostomy(EUS-CDS) is the best way of EUS-BD for the patients with lower malignant biliary stenosis. The Aim of this study is to confirm the safty and the efficacy of EUS-CDS.

Methods: 25 patients with lower malignant biliary strictures from 2003 to 2009 have been treated by EUS-guided Choledochoduodenostomy (EUS-CDS). Causes of obstruction were pancreatic carcinoma (20/25), arcinoma of ampula of Vater (2/24), uterus carcinoma (1/24). Gastric carcinoma (1/24), gall bladder carcinoma (1/24). Our standard method was reported in GIE 2006, Endoscopy 2008 by Yamao K, et al.

Results: The stent insertion was technically successful in 24 patients (24/25, 96%). All 24 patients were through the first portion of the duodenum. Liver dysfunction was improved in 23 patients(23/24,96%). One patient could not recover by the liver metastasis. The early complications were 1 pneumoperitoneum, 3 mild abdominal pain. But, no serious complications. The late complications were stent occlusion and stent migration. Stent occlusion occurred in 17 events, external stent migration occurred in one event during follow-up. The average time to stent occlusion was 138 days by the Kaplan-Meier method.

Conclusion: EUS-CDS was technically successful without any serious complications, offering clinically effective drainage, with a comparatively long patency period.

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Chronic Pancreatitis: An Underestimated Disease?

P.D. Hardt,1 N. Ewald,1 J.M. Loehr,2 C.W. Imrie,3 F. Marotta,4 J.E. Dominguez-Munoz,5 H.U. Kloer,1 R.G. Bretzel,1 P.K. Garg.6 1Third Med Dept, Giessen University Hospital, Germany; 2Dept of GI Surgery, Karolinska Institute, University Hospital Huddinge, Sweden, 3Dept of Surgery, Glasgow Royal Infirmary, UK, 4GI Unit, S. Giuseppe Hospital, Milano, Italy; 5GI Dept, University Hospital of Santiago de Compostela, Spain; 6All India Institute of Medical Sciences, New Delhi, India.

Background: Chronic pancreatitis (CP) is considered to be a rare disease.

Aim: To study the prevalence of CP and pancreatic exocrine insufficiency (PEI) in the general population and in risk groups.

Methods: A MEDLINE search was carried out using combinations of the terms 'chronic pancreatitis', 'prevalence', 'pancreatic exocrine insufficiency', 'steatorrhea', 'diabetes', 'EUS' and 'autopsy'. Main outcome measure was prevalence of CP and PEI.

Results: The prevalence of CP varied from 5/100,000 to 125/100,000 population. It was higher in certain risk groups - alcoholic cirrhosis (19%), cystic fibrosis (1.24%) and celiac disease (0.07%). At autopsie the prevalence of CP was 5-10%. EUS diagnosed changes suggestive of CP in up to 50% of patients with abdominal pain and 3.8% of persons with no risk factors of CP. The prevalence of PEI was reported to be 11.5% in healthy elderly persons. It was higher in patients with diabetes (41%), inflammatory bowel disease (14%-22%) and celiac disease (14.8%).

Conclusions: Autopsy, EUS data and the high prevalence of PEI suggest that CP remains an under-diagnosed disease. There is a need for well-designed community based epidemiological studies with modern diagnostic tools for correct estimate of the prevalence of CP.

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Risk-Analysis and Long-Term Outcome of Multivisceral Resections for Pancreatic Malignancies

W. Hartwig, T. Hackert, U. Hinz, M. Hassenpflug, O. Strobel, M.W. Büchler, J. Werner. Department of General Surgery, University of Heidelberg, Germany.

Background: Curative resection is the only potential cure for patients with pancreatic cancer, but some patients present with advanced tumors which are not resectable by a standard pancreatic resection. However, data on risk and survival analysis of extended pancreatic resections is limited. The aim of the present study was to evaluate the safety and outcome of multivisceral pancreatic resections for primary pancreatic malignancies.

Methods: One hundred and one patients who had a multivisceral pancreatic resection between 10/2001 and 12/2007 were identified from a prospective database, and perioperative and long-term results were compared to those of 202 matched patients with a standard pancreatic resection. Uni- and multivariate regression analysis were performed to identify parameters that are associated with perioperative morbidity. Long-term survival was evaluated.

Results: Colon, stomach, adrenal gland, liver, hepatic or celiac artery, kidney, or small intestine were resected in 37.6%, 33.7%, 27.7%, 18.8%, 16.8%, 11.9%, and 6.9% of the 101 patients with multivisceral resection, respectively. Additional portal vein resection was performed in 20.8% of patients. Overall and surgical morbidity but not mortality was significantly increased compared to standard pancreatic resections (55.5% vs. 42.8%, 37.6 vs. 25.3%, and 3.0% vs. 1.5%, respectively). Uni- and multivariate analysis identified a long operative time and the extended multivisceral resection of 2 or more additional organs as independent risk factors for intraabdominal complications or need for relaparotomy. Median survival was comparable to that of standard pancreatic resections.

Conclusions: Multivisceral resections can be performed with increased morbidity but comparable mortality and long-term prognosis as compared to standard pancreatic resections at high volume centers. Increased morbidity is related to extended multivisceral resections with a long operative time.

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Therapeutic Strategy for Pancreatic Cancer in Elderly Patients

F. Hasegawa,1 M. Kurata,1 G. Honda,1 K. Tsuruta,1 T. Kamisawa.2 1Department of Surgery, and 2Department of Internal Medicine, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan.

Aim: Some elderly patients with pancreatic cancer don't receive standard treatment due to their average life expectancy, comorbid conditions, and informed consent. In our institute, intraoperative radiotherapy (IOR) has been the standard treatment for locally advanced pancreatic cancer with or without resection. This study aimed to investigate the surgical outcome of elderly patients with pancreatic cancer.

Patients and Methods: We divided patients who underwent IOR in our institute between 1976 and 2007 into two groups according to their age on diagnosis. Group A consisted of 37 patients older than 75 years and their median age was 77.5 years (75-86). Group B consisted of 210 patients younger than 75 years.

Results: There were no difference in Stage between the two groups; Group A (Stage IA (n = 2), IB (n = 0), IIA (n = 13), IIB (n = 12), and III (n = 10)2:0:13:) and Group B (Stage IA (n = 2), IB (n = 5), IIA (n = 47), IIB (n = 94), and III (n = 55)). Rate of IOR with or without resection was 18/19 (49%) in Group A and 98/105 (48%) in Group B. The majority of the complications were cardiopulmonary. However, perioperative outcome showed no significant difference regarding length of hospital stay (68 vs.69 days), complication rate, or mortality rate (4.4 vs 2.7%). Median survival time in two groups was no significant different (IOR with resection 13.1 vs. 13.1 months; without resection 9.0 vs.11.1 months).

Conclusion: Elderly patients tolerate surgery and IOR as well as younger patients by choosing optimal therapies for individual patients.

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Can the Estimation of Physiologic Ability and Surgical Stress (E-PASS) Scoring System Predict Operative Morbidity After Pancreatic Resection?

D. Hashimoto,1,2 H. Takamori,1 M. Hirota,2 H. Baba.1 1Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; 2Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan.

Aim: To evaluate whether the the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system can predict the occurrence of complications after pancreatic resection.

Background: Morbidity rates after pancreatic resection still remain high. Therefore, it is important to identify predictors for operative morbidity after pancreatic resection. E-PASS scoring system was developed for comparative audit of general surgical patients.

Methods: 127 patients who underwent pancreatic resection (60.7% PD, 38.6% DP and 0.8% partial pancreatectomy) at Kumamoto University were studied. We determined correlations between the incidence rates of postoperative complications and the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of the E-PASS scoring system.

Results: Of 127 patients, 47 (37.0%) experienced a total of 80 postoperative complications. All E-PASS scores were significantly higher in patients with postoperative complications than in the patients without complications. The complication rate increased with increasing PRS, SSS and CRS scores.

Discussion: E-PASS has strong value of predicting morbidity. The system is easy to use because the required information can be retrieved easy from pre-anaesthetic sheets and from operation notes.

Conclusion: The E-PASS scoring system is useful to predict morbidity after pancreatic resection.

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Organ Preserving Total Pancreatectomy for Pancreatic Neoplasms

T. Hatori,1 A. Kimijima,1 I. Fujita,1 T. Furukawa,2 T. Imaizumi,3 M. Yamamoto.1 1Department of Surgery, Institute of Gastroenterology, 2International Research and Educational Institute for Integrated Medical Sciences, Tokyo Women's Medical University, Tokyo, Japan, 3Department of Gastroenterological Surgery, School of Medicine, Tokai University, Kanagawa, Japan.

Introduction: Organ preserving procedure should be chosen in terms of minimizing organ deficiency when total pancreatectomy is performed for the pancreatic neoplasms. The aim of this study is to evaluate the indication and results of organ preserving total pancreatectomy retrospectively.

Mehods: Twenty patients who underwent organ preserving total pancreatectomy between 2000 and 2008 were chosen in this study (IPMN 15, pancreatic cancer 3, metastatic pancreatic neoplasm 2). Fifteen patients underwent pylorus-preserving procedure (spleen preservation 4), three patients underwent duodenum-preserving procedure (spleen preservation 1, spleen and bile duct preservation 1) and two patients underwent subtotal stomach preserving procedure.

Results: Mortality rate was 0%. Massive dose of digestive enzymes was administered in all patient and daily dose of the insulin was required around 30 units. All the patients did rehabilitaion. Body weight of one year after surgery was maintained a level in a discharge and that of three years after surgery was 1.2 times in a discharge. HbA1c level was maintained around 7%.

Conclusions: Organ preserving total pancreatectomy is useful procedure for the pancreatic neoplasms in terms of minimizing of organ deficiency and maintaining good nutrition.

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A Report of Four Resected Cases of the IgG4-Related Sclerosing Disease in our Hospital

T. Hatsuno, K. Kondo, M. Kataoka, H. Nakayama, M. Hishida, Y. Hotta, N. Takano, H. Tanaka, H. Yano. Department of Surgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.

Introduction: The pathogenesis of autoimmune pancreatitis (AIP) is considered to involve autoimmune mechanisms such as increased levels of γ-globulin and IgG, the presence of autoantibodies, and good response to steroid therapy. In some cases, AIP shows extrapancreatic lesions such as sclerosing cholangitis, etc. When diagnosing AIP and extrapancreatic lesions, it is important to differentiate it from neoplastic lesions such as pancreatic or biliary cancers. We report four resected cases of tha IgG4-related sclerosing disease in our hospital.

Case 1: A 52-year-old man was referred to our hospital for further investigation of a tumor in the pancreatic body. He was diagnosed as having pancreatic double cancer in the pancreatic body based on highly elevated CA19-9 level and imaging studies. Therefore, distal pancreatectomy was performed. Postoperative pathological diagnosis was AIP.

Case 2: A 69-year-old man was referred to our hospital for further investigation of epigastralgia. He was diagnosed as having pancreatic head carcinoma by ERCP. Therefore, PpPD was performed. Postoperative pathological diagnosis was AIP and IgG4-related sclerosing cholangitis.

Case 3: A 74-year-old man was referred to our hospital for further investigation of liver disfunction. He was ddiagnosed as having hilar cholangiocarcinoma by ERCP. Therefore, extended right hepatectomy was performed. Postoperative pathological diagnosis was IgG4-related sclerosing cholangitis without pancreatic lesions.

Case 4: A 69-year-old man was referred to our hospital for further investigation of discomfort in the epigastrium. He was diagnosed as having AIP and gallbladder tumor by imaging studies. Therefore, laparoscopic cholecystectomy was performed. Postoperative pathological diagnosis was gallbladder carcinoma with IgG4-related sclerosing cholecystitis. As far AIP, steroid therapy was performed.

Conclusion: When diagnosing AIP, it is necessary to exclude malignant diseases such as pancreatic or biliary cancers, and it is important to avoid therapeutic diagnosis by steroid administration.

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Usefulness of Contrast Enhanced Ultrasonography Using Sonazoid for Pancreatic Cancer

M. Hattori, K. Inui, J. Yoshino, K. Okushima, H. Miyoshi, S. Yamamoto. Internal Medicine, Fujita Health University Second Teaching Hospital, Nagoya, Japan.

Aim: To demonstrate usefulness of contrast enhanced ultrasonography using a perflubutane-based contrast agent (Sonazoid) for diagnosis of pancreatic cancer.

Patients and Methods: In 8 patients with pancreatic cancer, we performed contrast enhanced ultrasonography using Sonazoid. Sonazoid was dissolved and infused intravenously as a bolus of 0.015 mg/kg. Ultrasonography was performed using a TOSHIBA SSA-770A. Contrast enhancement in early vascular phase was monitored for 30 seconds after administration of Sonazoid. Thereafter, monitoring was continued accordingly for around 3 minutes. High sound pressure was then applied for replenishment, followed by monitoring using micro flow imaging.

Results: The contrast enhancement pattern of lesions in the early vascular phase indicated hypovascularity in 6 patients and iso- or hypovascularity with heterogenous content in 2 patients. Irregularly winding, tortuous, and branched blood flow signals with variable diameters running toward the low echoic area at the center of a mass was also observed. Micro flow imaging clearly visualized irregular blood flow in the mass.

Discussion: Contrast enhanced ultrasonography showed no blood flow at the center of a mass, but did visualize irregular blood flow in the surrounding region, which was considered to indicate tumor vessels. The irregular blood flow signals with variable diameters, which is characteristic of pancreatic cancer, was also visualized.

Conclusion: Contrast enhanced ultrasonography using Sonazoid is useful for diagnosis of pancreatic cancer.

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Suppression of KLK7 Expression Inhibits Pancreatic Tumor Growth

R.S. Haun. Department of Pathology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR.

Introduction: Kallikrein 7 (KLK7/hK7) is a chymotryptic-like serine protease that is overexpressed in pancreatic ductal adenocarcinomas. hK7 participates both directly and indirectly in processes that may facilitate tumor invasion of surrounding tissues including the shedding of E-cadherin, cleavage of fibronectin, loss of adhesion to vitronectin, degradation of desmoglein-2, and activation of proMMP-9.

Aim: The goal of this study was to examine the effects of suppressing KLK7 expression on pancreatic tumor growth.

Methods: Tumor xenografts were established in SCID mice using 3 pancreatic cancer cell lines stably transfected with either a KLK7- or GFP-shRNA construct. Tumor development was monitored for 6 weeks at which time the mice were sacrificed and the primary tumors were excised and analyzed.

Results: KLK7 expression was suppressed in tumors derived from PK-1 cells transfected with KLK7-shRNA compared with the tumors derived from the GFP-shRNA cells. Strikingly, there was a dramatic difference in the mean tumor volume from mice inoculated with KLK7-shRNA cells compared with GFP-shRNA cells. Similarly, tumors developed from either MIAPaCa-2 or Panc-1 cells transfected with GFP-shRNA were dramatically larger than contralateral tumors derived from KLK7-shRNA cells.

Conclusion: This study demonstrates that suppression of KLK7 expression results in a dramatic decrease in pancreatic tumor growth. The inhibition of tumor growth elicited through the targeted suppression of this protease highlights the significance of aberrant KLK7/hK7 expression in pancreatic cancer.

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Non-Conjugated Bile Acids Induce Mitochondrial Damage and Inhibit Bicarbonate Transport Mechanisms in Pancreatic Duct Cells

P. Hegyi,1 J. Maléth,1 V. Venglovecz,2 Zs. Rázga,3 L. Tiszlavicz,3 Z. Rakonczay.1 First Department of 1Medicine, Department of 2Pharmacology and Pharmacotherapy, Department of 3Pathology University of Szeged, Szeged, Hungary.

Background: We have recently shown that a high dose (1 mM) of the non-conjugated bile acid chenodeoxycholate (CDC) had strong inhibitory effects on the activities of acid/base transporters on pancreatic ductal epithelial cells (PDEC). However, the same dose of conjugated glycochenodeoxycholate (GCDC) had no effect on the ion transporters. In addition, a high dose of CDC evoked a toxic sustained calcium elevation. Our aim was to characterize the intracellular mechanisms by which the ion transport mechanisms are inhibited.

Methods: Intra/interlobular pancreatic ducts were isolated from the pancreas of guinea pigs. High dose (1 mM) of CDC or GCDC was administered basolaterally for 1-10 minutes. Intracellular calcium concentration ([Ca2+]i), pH (pHi) and ATP level (ATP)i of PDEC were measured using microfluorometry. Morphological changes of PDEC were evaluated by transmission electron microscopy.

Results: Administration of 1 mM CDC for 10 min strongly damaged almost all of the mitochondria. GCDC did not damage the intracellular organelles. Administration of the mitochondrial toxin carbonyl cyanide m-chlorophenyl hydrazone (CCCP, 100 μM) mimicked the effect of CDC on mitochondria. Both CDC and CCCP decreased the (ATP)i in PDEC, however GCDC did not significantly alter (ATP)i. Importantly, the protonophore CCCP inhibited both bicarbonate uptake via NBC and bicarbonate secretion via the anion exchanger on PDEC suggesting that (ATP)i is important for bicarbonate transport mechanisms.

Conclusion: Our results suggest that non-conjugated bile acids damage the mitochondria resulting in a marked depletion of (ATP)i. This mitochondrial damage seems to be crucial in the toxic effects of bile acid.

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The Efficacy of Whole Body FDG-PET for Autoimmune Pancreatitis and Its Associated Extra-Pancreatic Autoimmune Lesions

S. Hijioka,1 N. Mizuno,1 K. Yamao,1 A. Sawaki,1 K. Hara,1 H. Imamura,1 K. Matsumoto,1 Y. Kobayashi,1 H. Suzuki,1 M. Mekky,2 T. Tamaki.3 1Department of Gastroenterology, Aichi Cancer Center, Nagoya, Japan; 2Department of Tropical Medicine and Gastroenterology, Assiut University Hospital, Egypt; 3East Nagoya Imaging Diagnosis Center, Nagoya, Japan.

Introduction and Aims: The role of whole-body 18-Fluorodeoxyglucosepositron emission tomography (FDG-PET) in evaluation and follow-up of autoimmune pancreatitis (AIP) was not fully studied. So, we evaluated the efficacy of FDG-PET in AIP and its associated extra-pancreatic lesions and its role in excluding malignancy by short-term follow-up PET.

Patients and Methods: According to Japanese diagnostic revised criteria of AIP, 22 patients (mean age, 64.1 ± 10.2 y; M:F = 18:4) were evaluated for whole-body PET pattern.

The initial PET scans were performed before treatment. Follow-up PET scans were performed within 1 week after steroid therapy in 10 patients (out of 19 patients received steroid).

Result: FDG uptake was found in all 22 patients (100%). The accumulation pattern was diffuse in 50% (11/22), solitary nodular in 31% (8/22), and patchy in 14% (3/22).

Short-term follow-up PET in 10 patients revealed an average decreasing rate of SUVmax to be more than 10% (42.7%) in 9 of them, and less than 10% in one patient; where malignancy was suspected. Extra-pancreatic FDG uptake was observed in 86.3 % (19/22) and mediastinal lymphadenopathy was the most frequent.

Conclusion: Whole body FDG-PET may be useful for evaluating AIP and its extra-pancreatic lesions and short-term follow-up PET may be useful for differentiating malignancy from AIP.

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Three Cases of Minute Pancreatic Cancer (Less Than 10 mm) in Our Institutes

K. Hiramatsu,1 H. Hasuoka,2 M. Watanabe,2 K. Ochi.3 1Department of Internal Medicine, Okayama Rousai Hospital, Okayama, Japan; 2Department of Surgery, Okayama Chuo Hospital, Okayama Japan; 3Center for the Deveropment of Medical and Health Care Education, Okayama University, Okayama, Japan.

Pancreatic cancer is a lethal disease with an increasing incidence. Because of little discrepancy between its morbidity and mortality, its diagnosis is a virtual death sentence. Recent studies demonstrated that small pancreatic cancer (less than 2 cm in diameter) did not necessarily mean early pancreatic cancer. Therefore we defined a minute pancreatic cancer as less than 1 cm in diameter and reviewed three cases of minute pancreatic cancer in our institutes in order to clarify the strategy to detect the smaller pancreatic cancer. Case 1: 61-year-old male was admitted to our hospital because of deterioration of diabetic control. Abdominal CT showed dilatation of the main pancreatic duct (MPD) without a mass in the pancreas and ERCP showed abrupt obstruction of MPD in the head. Case 2: 48-year-old female was referred to our hospital because of abdominal pain with hyperamylasemia. Although abdominal CT showed no mass formation, complete obstruction of MPD in the body was observed in ERCP. Case 3: 60-year-old female. Although she was asymptomatic, the dilation of MPD was observed in the abdominal ultrasonography. Subsequent pancreatography detected the irregular stenosis of MPD in the head. Each case was proven to be pancreatic adenocarcinoma less than 1 cm in diameter (5 mm, 9 mm, 8 mm, respectively). Our cases suggest that it is difficult to identify as a pancreatic mass in minute pancreatic cancer.

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Long Period Endoscopic Therapy Needs High Costs and Long Hospital Stays as Compared to Surgery

M. Hirota, T. Asakura, A. Kanno, K. Satoh, A. Masamune, K. Kikuta, K. Kume, S. Hamada, T. Watanabe, H. Itoh, T. Shimosegawa. Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan.

Aim: The aim of this study was to compare the benefical points between endoscopic and surgical drainage of the pancreatic duct for patients with chronic pancreatitis.

Materials and Methods: Sixty eight patients were classified as endoscopic (n = 34) or surgical (n = 34) treatment group. Patients receiving endoscopic treatment were further divided into 2 subgroups: short period group, patients who did not need to continue pancreatic stenting within 1 year, n = 19; long period group, patient who needed pancreatic drainage by serial endoscopic stenting for more than 1 year; n = 15. The medical records for these patients were retrospectively analyzed.

Results: Hospital stays (19.9 days vs 18.6 days, p = 0.83), frequency of hospitalizations (0.85/year vs 0.67/year, p = 0.37) and medical expense ($8,470/year vs $10,200/year, p = 0.46) were similar between short period endoscopic group and surgery group. On the other hand, patients in long period endoscopic treatment group required longer hospital stays (41.3 days, p = 0.01), more frequent hospitalizations (2.5/year, p < 0.001) and medical expense ($20,300, p < 0.01) than short period endoscopic group did. Moreover, they also required more frequent hospitalizations (p < 0.001) and medical expense (p < 0.01) than surgery group did.

Conclusion: Therefore, patient who was necessary for endoscopic treatment for more than 1 year had no benefit compared to surgical treatment.

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Salvage ERCP and Emergency Pancreatic Stent Placement to Prevent the Evolution of Post-ERCP Pancreatitis

H. Hisai, I. Tanaka, T. Okuda, K. Ono. Department of Gastroenterology, Japan Red Cross Date General Hospital, Date, Japan.

Introduction: Impaired drainage of the pancreatic duct resulting from papillary edema is the one of the possible triggers for post-ERCP pancreatitis (PEP). Salvage ERCP and emergency pancreatic stent placement against PEP as a possible endoscopic therapy has seldom been reported.

Methods: Between August 2002 and April 2009, we performed endoscopic pancreatic stent placement against PEP in 20 patients (6 men, 14 women; mean age 66 years, range, 34-83 years). The indications for initial ERCP were choledocholithiasis in 16 pts and diagnosis of pancreatobiliary diseases in 4. The mean serum amylase level before initial ERCP was 71 ± 34 IU/L. A straight, double-barbed, 5F in diameter and 3 cm in length pancreatic stent (Geenen stent, COOK Endoscopy) was used. Rescue pancreatic stenting after the initial ERCP was performed within 24 hrs in 18 pts and 48 hrs in 2. A diagnosis and severity of PEP was made according to Cotton's classification.

Results: Moderately to severe papillary edema was observed in all patients at salvage ERCP. The mean serum amylase levels of the next day after stenting (975 ± 972 IU/L) were decreased significantly compared with those before stenting (2119 ± 1614 IU/L; P < 0.001). Serum amylase levels were normalized within 72 hrs after stenting in 16 pts (80%). Pancreatic pain was promptly reduced after the procedure in 18 pts (90%). Four patients developed severe pancreatitis. There were no procedure-related deaths.

Conclusions: Salvage endoscopic pancreatic stenting seems to be an effective procedure against PEP.

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Two Cases of Total Pancreatectomy With Segmental Duodenectomy

M. Hishida,1 T. Hatsuno,1 A. Nakao.2 1Department of Surgery, Nagoya Medical Center; 2Gastroenterological Surgery (Department of Surgery II), Nagoya University Graduate School of Medicine.

Total pancreatectomy with segmental duodenectomy (TPSD) is reasonable technique because of preserving pancreatic function (exocrine and endocrine). We report two cases of TPSD.

First case: A 58-year-old man was referred to our hospital because of high number of tumor maker CA 19-9. He has the diabetes and chronic pancreatitis. On computed tomography and magnetic resonance cholangiopancreatography, the pancreatic duct of pancreas- body was narrow, and there was the cystic tumor in the pancreas-tail. The number of tumor makers was high. We diagnosed the tumor as pancreas-body cancer, and we planed distal pancreatectomy. In operation, we checked the pancreatic duct of pancreas-head pathologicaly. It revealed that the carcinoma in situ was left in the pancreatic duct. So, we additionally performed pancreas head resection with segmental duodenectomy preserving gastro colic trunk and right gastroepiploic vein. As a result, we performed TPSD preserving gastro colic trunk and right gastroepiploic vein.

Second case: A 68-year-old man was referred to our hospital because of the cystic tumor of pancreas. On computed tomography and magnetic resonance cholangiopancreatography, the pancreatic duct of pancreas was dilated, and there was papillary tumor in the pancreatic duct of the pancreas-head. We diagnosed the tumor as main duct intraductal papillary mucinous neoplasm (IPMN). So, we performed TPSD preserving spleen.

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Long-Term Survivors With Lung Metastasis After Pancreatoduodenectomy for Pancreatic Cancer: Report of Two Cases

Y. Homma, R. Matsuyama, K. Taniguchi, N. Kumamoto, H. Takakura, K. Takeda, N. Ueda, Y. Nagano, K. Tanaka, I. Endo. Department of Gastroenterological Surgery, Yokohama City Univercity, Yokohama, Japan.

Background: Despite curative resection, long-term survival remains low in pancreatic cancer because of local recurrence and distant metastases. Recurrent tumor is hardly fit for re-resection. We report two cases of long-term survivors with resection of lung metastasis after pancreatoduodenectomy (PD).

Case 1: Patient was 79-year-old woman. She underwent PD for pancreatic cancer. She received adjuvant chemotherapy of Gemcitabine hydrochloride (GEM) for 7 months. A lung mass was detected 8 months after the initial operation. FDG-PET scan detected no other suspicious tumors. After 16 months observation, partial resection of the right lung was performed. She is now alive for 43 months after the initial operation with no evidence of recurrence.

Case 2: Patient was 74-year-old woman. She underwent PD for pancreatic cancer. She received adjuvant chemotherapy of GEM for 18 months. A lung mass was detected 24 months after the initial operation. After 6 months observation, lower lobectomy of the left lung was performed. She is now alive for 80 months after the initial operation with no evidence of recurrence. Immunohistochemical stainings of the lung specimens for Thyroid Transcription Factor-1 (TTF-1) were negative in both cases. These result revealed metastases from pancreatic cancer.

Conclusion: For a solitary lung metastasis of pancreatic cancer after curative resection followed by adjuvant chemotherapy, surgical resection may have survival benefit in selected cases.

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A Novel Marker Distinguishes Pancreatic Adenocarcinoma From Cholangiocarcinoma and Gallbladder Cancer

J.E. Hooper,1 T. Morgan,1 H. van de Vrugt,2 K.M. Hardiman,3 C. Corless,1 B.C. Sheppard,3 M. Grompe,2 P.R. Streeter.2 1Department of Pathology; 2Oregon Stem Cell Center; 3Department of Surgery; all of Oregon Health and Science University, Portland, OR.

Background: We recently developed a monoclonal antibody against a 70 kD cell-surface glycoprotein expressed by pancreatic ductal adenocarcinoma cells called HPC2 1-B3 (1-B3). Our objective was to determine whether 1-B3 can distinguish metastatic pancreatic ductal cancer from cholangiocarcinoma and gallbladder cancer.

Method: 50 cases of metastatic pancreatic carcinoma (n = 17), cholangiocarcinoma in liver (n = 10), primary gallbladder cancer (n = 3), primary and metastatic ampullary carcinoma (n = 10), and metastatic colon cancer to liver (n = 10) were retrospectively identified from surgical pathology archives dated 2001-2009. Histologic sections were immunostained for 1-B3 and scored as either positive (>10% of tumor cells) or negative by expert surgical pathologists (JH and TM). The relationship between positive staining and primary tumor type was tested by Chi-square analysis.

Results: Scoring for positive staining was highly reproducible between pathologists and strongly correlated with pancreatic or ampullary adenocarcinoma (X2 = 19.5; p < 0.001). One of ten cholangiocarcinomas stained for 1-B3 and none of the gallbladder cancers stained for 1-B3.

Conclusion: The data indicates that the novel monoclonal antibody, 1-B3, may provide significant diagnostic information for distinguishing primary cholangiocarcinoma or gallbladder cancer from metastatic pancreatic or ampullary carcinoma Separating these tumors has important implications for patient prognosis and treatment.

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Hypoxia Induces Tumor Aggressive Phenotype by Acquired Stemness in Pancreatic Cancer

Y. Hori, O. Hashimoto, Y. Ku. Dept. of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.

Background: Intratumoral hypoxia is a negative prognostic indicator, as it has been associated with increased aggressiveness and distant metastasis. Although hypoxia can drive the metastatic phenotype secondary to genetic instability and clonal selection of aggressive tumor cells, the interplay underlying them is to be unanswered. We hypothesized that mature cancer cells might acquire the stemness under hypoxia, consequently leading to aggressive phenotype.

Methods: Under normoxia (20% O2) or hypoxia (1% O2) condition, the expression of CD133 (cancer stem cell marker), CXCR4 (chemokine receptor), HIF1a, and pimonidazole (hypoxic probe) were examined by quantitative RT-PCR and imuunohistochemistry using human pancreatic cancer cell lines. Moreover, we evaluated the expression of CD133, pimonidazole, and HIF1α in xenograft and human pancreatic cancer specimen. Furthermore, we transfected dominant active HIF1α (HIF1α ΔODD) and examined CD133 expression and achieved invasion assay under normoxia.

Results: We demonstrated that hypoxia induces tumor aggressive phenotype in pancreatic cancer, including invasiveness and CXCR4 expression. Furthermore, this phenotype is followed dintinctively by the subpopulation of CD133+ pancreatic cancer cells, which themselves show hypoxic and invasive properties, indicating that mature cancer cells might reacquire an undifferentiated stemness. In addition, both acquired stemness and invasiveness under hypoxia are predominantly in a HIF1α/CXCR4-dependent manner.

Conclusion: We demonstrated hypoxia induces tumor aggressive phenotype by acquired stemness in pancreatic cancer.

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Isolation of Putative Pancreatic Progenitor Cells by Sorting for CD133 and PDGFR-BETA

Y. Hori, Y. Ku. Dept. of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.

Background: Success in islet transplantation-based therapies for type 1 diabetes mellitus and an extreme shortage of pancreatic islets has motivated recent efforts to develop renewable sources of islet-replacement tissue. Although pancreatic progenitor cells hold a promising potential, only a few attempts have been made at the prospective isolation of pancreatic stem/progenitor cells, due to the lack of specific markers and the development of effective cell culture methods.

Methods: We found that prominin1 (also known as CD133) recognized the undifferentiated epithelial cells, while PDGFR-beta was expressed on the mesenchymal cells in the mouse embryonic pancreas. We then developed an isolation method for putative stem/progenitor cells by flow cytometric cell sorting and characterized their differentiation potential to pancreatic tissue using both an in vitro and in vivo protocol.

Results: Flow cytometry and the subsequent RT-PCR and microarray analysis revealed pancreatic epithelial progenitor cells to be highly enriched in prominin1highPDGFRb- cell population. During in vivo differentiation, these cell populations were able to differentiate into endocrine, exocrine, and ductal tissues, including the formation of insulin-producing cell cluster.

Discussion: Since this strategy is based on the cell surface markers common to human and rodents, these findings may lead to the development of new strategies to derive transplantable islet-replacement tissues from human pancreatic stem/progenitor cells.

Conclusion: We established the prospective isolation of putative pancreatic epithelial progenitor cells by sorting for prominin1 and PDGFR-beta.

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Caffeine Ameliorates Murine Caerulein-Induced Acute Pancreatitis

W. Huang,1,3 R. Mukherjee,1,3 D. Booth,3 A. Tepikin,3 O.H. Petersen,3 D.N. Criddle,3 R. Sutton.1,2 1Division of Surgery and Oncology and 2NIHR Pancreatic Biomedical Research Unit, Royal Liverpool University Hospital, Daulby Street, Liverpool L69 3GA, UK; 3Physiological Laboratory, University of Liverpool, L69 3BX, UK.

Introduction: Coffee consumption is associated with a reduced risk of alcoholic pancreatitis, although the mechanism(s) is unclear. Caffeine has multiple effects such as inhibition of inositol(1,4,5)-trisphosphate (IP3) and adenosine receptors, and phosphodiesterase (PDE). We have investigated the effects of caffeine, 2-aminoethoxydiphenyl borate (2-APB; an IP3R blocker) and rolipram (a PDE4 inhibitor) in a caerulein-induced pancreatitis model.

Methods: Acute pancreatitis was induced in CD1 mice by repeated caerulein injections (×7). Treatment groups were given either caffeine, or rolipram, or 2-APB. Caffeine (25 mg/kg/h ×7) were given either 1 h before or 3 h after the first caerulein injection, rolipram (3 mg/kg) and 2-APB (15 mg/kg or 7.5 mg/kg) were given 30 min before caerulein. At designated time points the severity of pancreatitis was assessed by biomedical markers and histopathology.

Results: Caffeine, both pre- and post-treatment, ameliorated all pancreatitis parameters at all time points. Rolipram significantly attenuated pancreatitis severity but had less effect than caffeine. 2-APB only reduced pancreatic myeloperoxidase activity.

Conclusion: Caffeine was protective in caerulein-induced pancreatitis, an effect which might occur at least partially through inhibition of PDE4. More specific IP3R blockers are needed to more fully explore the role of IP3R in the pathogenesis of acute pancreatitis.

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Inhibitory Effects of GLP-1 on Proliferation and Tumiorgenicisty of Pancreatic Cancer Stem Cells In Vitro

H. Hui,1,2 Y.G. Tang,3 K.Y. Wang,1 S.J. Pandol,1,2 V.L.W. Go.1 1UCLA Center for Excellence in Pancreatic Disease, David Geffen School of Medicine; 2Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System; 3Division of Medical Genetics, Cedar-Sinai Medical Center, Los Angeles CA.

Background and aim: The pancreatic cancer stem cell is believed to be responsible for the resistance to chemotherapy and radiation therapy. Glucagon-like peptide 1 (GLP-1), an intestine L-cell incretin hormone, can induce the differentiation of pancreatic ductal carcinoma cells and stem cells (Tissue Eng 12:2105 and Diabetes 50:785). Thus, we hypothesize that GLP-1 may have the therapeutic potential in pancreatic cancer treatment. This study was aimed to assess the effect of GLP-1 on the proliferation and tumorigenicity of pancreatic cancer stem cell in vitro.

Methods and results: Pancreatic cancer stem cells (PCSC, CD44+CD24+ESA+), sorted from Gemcitabine-treated Panc-1 by FACS, were treated with GLP-1 (10 nm). MTT assay revealed a cell proliferation inhibition of 21.73% at 48 hours, 33.61% at 72 hours (p < 0.05), the reduction of S phase was 26.59% at 48 h and 38.93% at 72 h (P < 0.001 and P < 0.01), and the DNA synthesis was inhibited 54.25% (P < 0.001) at 72 hours. Exendin 4, GLP-1 analogue, showed a similar effect, while Exendin 9 abolished the inhibitory effect. In addition, GLP-1 treated PCSC showed a 69.11-85.26% decreased expression of CD44 and ESA by Western blots, 93.52% decreased proportion of SP cells by long-term differentiation analysis, 95.44% decreased clongenicity by colony-forming assay, and 12.72% of spheres formation by Sphere formation assay (N = 4, p < 0.05).

Conclusion: GLP-1 inhibits proliferation and tumorigenicity of pancreatic cancer stem cell in vitro.

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GLP-1 Directed Human Embryonic Stem Cells Differentiation Into Insulin Producing Cells Via Hedgehog, CAMP, PI3K Pathways

H. Hui,1-3 Y.G. Tang,3 L. Zhu,3 N. Khoury,3 K.Y. Wang,1 R. Perfetti,3 S.J. Pandol,1,2 V.L.W. Go.1 1UCLA Center for Excellence in Pancreatic Disease, David Geffen School of Medicine at UCLA; Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System; 3Cedar-Sinai Medical Center, Los Angeles CA.

Background and aim: Glucagon-like peptide-1 (GLP-1) induces differentiation of primate embryonic stem cells into insulin-producing cells has been reported by our lab and others. In current studies, we elucidated the signaling pathways involved in this differentiation process.

Methods and results: We induced the differentiation of human embryonic stem cells HUES1 into insulin secretion cells with GLP-1 treatment, and investigated the signaling pathways during this differentiation. A time-dependent pattern of down expression of the stem cells markers (HTERT and Oct-4), and the appearance of multiple β-cells markers (insulin, GK, Glut2 and IDX-1), as well as hedgehog signal molecules (IHH, SHH and PTC) have been identified. Co-treatment with hedgehog signal inhibitor, cytopamine, blocked the differentiation. In addition, increased transcripts of AP-1, SRE, E2F, and CRE transcriptional factors were observed during stem cell differentiation. Among three pathways identified, the inactivation of insulin production was observed in the present of the cAMP pathway inhibitor Rp-cAMP and the PI3K pathway inhibitor LY294002, but not the MAPK pathway inhibitor PD98059.

Conclusion: These observations support that GLP-1 directs human embryonic stem cells differentiation into insulin producing cells via hedgehog, cAMP and PI3K pathways.

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Pancreatic Stellate Cells Secrete the WNT Inhibitor DKK3

H. Husted,1 T. Moore,1 B. Ji,2 V. Ramachandran,2 T. Arumugam,2 C.D. Logsdon,2 R.F. Hwang.1 Departments of Surgical Oncology1 and Cancer Biology2, University of Texas-M.D. Anderson Cancer Center, Houston, TX.

Introduction: We have previously shown that pancreatic stellate cells (HPSCs) increase tumor progression in vitro and in orthotopic models of pancreatic adenocarcinoma (PAC). The Wnt pathway is known to be activated in PAC but its role is not well understood. In this study, we investigated the expression of Wnt signaling mediators with a focus on the putative Wnt inhibitor DKK3.

Methods: Expression of Wnt mediators by HPSCs and PAC cells (L3.6pl, Panc1, Bxpc3) was determined by RT-PCR. Expression of DKK3 was determined in HPSCs and PAC cells alone and after co-culture by quantitative RT-PCR and Western blotting. Microarray profiling of human PAC samples and transgenic K-Ras-expressing mouse models of pancreatitis and PAC was performed. The effects of recombinant DKK3 on cell proliferation and migration were determined.

Results: HPSCs expressed mediators of the canonical and non-canonical Wnt pathway including the putative Wnt inhibitor DKK3. Expression of DKK3 was 14-fold higher in HPSCs vs. PAC cells and was further enhanced after co-culture. Western blotting confirmed secretion of large amounts of DKK3 by HPSCs. In human PAC, DKK3 mRNA expression was 4.5-fold higher compared to normal pancreas. In transgenic mouse models, DKK3 was increased in pancreatitis and PAC but was absent in isolated cancer cells. Recombinant DKK3 increased proliferation and migration of HPSCs and cancer cells.

Conclusion: HPSCs express Wnt mediators including high levels of DKK3 which appears to be a tumor promoter.

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The Relationship Between the Serum IgG4 Level and the Activity of the Autoimmune Pancreatitis

H. Igarashi, T. Ito, T. Oono, M. Yasuda, T. Nakamura, N. Fujimori, Y. Niina, M. Uchida, R. Takayanagi. Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan.

Background: Autoimmune pancreatitis (AIP) is a recently defined form of chronic pancreatitis characterized by a high serum IgG4 concentration, and complications involving various extrapancreatic lesions (EL).

Aim: To analysis the clinical meanings of the serum IgG4 level in AIP.

Methods: Since 2006, we experienced 22 AIP patients in our department, 18 men and 4 women aged 49-84 yr (median age, 66 yr). 16 patients were diagnosed by the Japanese clinical diagnostic criteria 2006. Remaining 6 patients could be diagnosed by the Hisort Criteria, Korean Criteria and/or Asian Criteria. All patients were studied for EL, and analyzed the relationship with serum IgG4 level.

Results: Serum IgG4 levels were measured in 20 patients, 50 mg/dl - 2820 mg/dl (mean: 830 mg/dl) and all patients except one revealed more than 135 mg/dl. Among these 20 patients, 18 patients complicated EL (i.e. sclerosing cholangitis, sialadenitis, chronic thyroiditis, hylar lymphadenopathy, retroperitoneal fibrosis). Most common complicated EL was sclerosing cholangitis (12/20). The serum IgG4 levels of the subgroups of the patients by the number of the involved organs were below: A) the pancreatic lesion (PL) with/without one organ of EL (n = 4); 284 ± 327 mg/dl, B) PL and two organs of EL (n = 10); 533 ± 451 mg/dl, C) PL and three or more organs of EL (n = 6); 1928 ± 809 mg/dl (mean ± SD).

Conclusion: The serum IgG4 level could be useful tool for the evaluation the activity of the AIP as well as the diagnosis.

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A Case With Double Cancers Arising in the Pancreas and Bile Duct in a Background of IgG4-Relataed Sclerosing Disease

N. Iida, K. Kakinoki, K. Okano, H. Suto, K. Izuishi, Y. Suzuki. Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.

Case report: A 71-year-old male with jaundice was referred to our hospital. Laboratory tests showed obstructive jaundice and a remarkable elevation of serum IgG4 (321 mg/dl). Enhanced CT revealed enlargement of the pancreas head, a cystic mass in the pancreas body and an enhanced segmental wall thickening in the inferior common bile duct (CBD). FDG-PET showed focal FDG accumulations in both pancreas head and body. ERCP showed strictures in the proximal main pancreatic duct and inferior CBD. Adenocarcinoma cells were detected in the bile. Under preoperative diagnosis of pancreas or bile duct cancer with autoimmune pancreatitis (AIP), we performed total pancreatectomy. Microscopic examination revealed remarkable fibrosis and diffuse lymphoplasmacytic infiltration which was strongly positive by immunostaining for IgG4, throughout the entire pancreas, bile duct and gallbladder. Furthermore, well to poorly differentiated tubular adenocarcinoma of the pancreas head and CBD were diagnosed histopathologically.

Discussion: To date, there have been a few case reports of concomitant AIP and cancer. Although the cause and effect relationship between IgG4-relataed sclerosing disease and pancreas or bile duct cancer needs to be determined by further studies, this report emphasized that IgG4-relataed sclerosing pancreatitis and cholangitis can coexist with cancer. Importantly, histologic exclusion of malignancy is another essential step in the diagnosis of IgG4-relataed sclerosing disease.

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Micro RNAs Associated With MAPK Activity in Human Pancreatic Cancer

Y. Ikeda,1,2 N. Makino,2 S. Kawata,2 T. Furukawa.1 1International Research and Educational Institute for Integrated Medical Sciences, Tokyo Women's Medical University, Tokyo, Japan; 2Deptertment of Gastroenterology, Yamagata University, School of Medicine, Yamagata, Japan.

Background: Aberrant expressions of micro RNAs (miRNAs) are associated with phenotypes of various cancers including pancreatic cancer. However, mechanisms of the aberrant expressions are largely unknown. RAS-MAPK signaling pathway plays a crucial role in pancreatic cancer. In this study, we explored miRNAs associated with MAPK activity in pancreatic cancer cells.

Methods and Results: Expressions of 192 miRNAs were assayed by the real time quantitative PCR method in MIA PaCa-2 and PCI-35, human pancreatic cancer cell lines with constitutive active MAPK, treated with U0126, an inhibitor of MEK, and in HEK293 transfected with active MEK to induce constitutive activation of MAPK. We found miRNAs differentially expressed in association with MAPK activity; miR-7 to be upregulated and miR-34a, -181d and -193b to be downregulated. To know functional significance of these miRNAs, we transfected sense or antisense oligonucleotides against these miRNAs into MIA PaCa-2 and performed proliferation assay. MiR-7, -34a, and -193b suppressed proliferation of the cell. To know mechanisms of transcriptional regulations of these miRNAs, we performed promoter analyses of genes harboring the miRNAs. We found that the promoter activities were associated with MAPK activity in some of the miRNAs.

Conclusion: Constitutive activation of MAPK may induce aberrant expressions of miRNAs in pancreatic cancer.

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Detection Rates of Pancreatic Tumors According to Location by Contrast-Enhanced Ultrasonography, Endosonography and Multidetector Row CT

H. Imai,1 M. Kitano,1 Y. Suetomi,1 H. Sakamoto,1 T. Komaki,1 K. Noda,1 K. Kamta,1 Y. Takeyama,2 M. Kudo.1 1Department of Gastroenterology and Hepatology, Kinki University School of Medicine; 2Department of Surgery Kinki University School of Medicine.

Aim: Imagings such as contrast-enhanced ultrasonography (CE-US), endosonography (EUS), multidetector-row CT(MDCT) are used for a diagnosis of pancreatic tumors, but there are few reports that reviewed detection sensitivity according to location of pancreatic tumors. Therefore, we performed CE-US, EUS and MDCT for 58 cases that underwent surgical resection between January 2006 and March 2009, and weighed diagnostic ability according to location of pancreatic tumors.

Material and Method: Consecutive 58 patients who underwent surgical resection due to pancreatic tumors were enrolled in this study. (20 men; mean age, 64.3; mean BMI,21.4). All patients had undergone 3 imaging examinations. Thirteen tumors were located at uncinate process, 18 at head, 13 at body and 14 at tail. Final diagnoses of pancreatic tumors were carcinomas (n = 30), IPMNs (n = 17), endocrine tumors (n = 7), pseudocysts (n = 3) and SPT (n = 1).

Results: Overall detection rates of pancreatic tumors by CE-US, EUS and MDCT were 84.5%, 98.0% and 89.6%, respectively. At uncinate prosess, detection rates by CE-US,EUS and MDCT were 69.2%, 100% and 84.6%, respectively. At head, those rates were 100%, 100% and 94.4%. At body, those rates were 92.3%, 92.3% and 92.3%. At tail those rates were 84.5%, 98.2%, 89.6%. In addition, as for detection rates of an intramural nodule of IPMN by CE-US, EUS and MDCT were 47.0%, 70.5% and 29.4%, respectively.

Conclusion: EUS, at any location, was the most sensitive modality. CE-US was inferior to the other modality at uncinate prosess and tail of pancreas, but was more useful for detection of an intramural nodule of IPMNs than MDCT.

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Endoscopic Ultrasoundsonography-Guided Fine Needle Aspiration Biopsy Using 22-Gauge Needles Is Effective for Exclusion of Pancreatic Malignancy in Cases of Autoimmune Pancreatitis

K. Imai,1 H. Matsubayashi,1 H. Ono,1 K. Uesaka,2 K. Sasaki.3 Division of 1Endoscopy, 2Hepato-biliary-Pancreatic Surgery and 3Pathology, Shizuoka Cancer Center, Shizuoka, Japan.

Objectives: This study aimed to evaluate the effectiveness of Endoscopic ultrasoundsonography-guided fine-needle aspiration biopsy (EUS-FNAB) using 22-gauge needles for exclusion of pancreatic malignancy in patients with autoimmune pancreatitis (AIP).

Patients and Methods: In 80 patients with pancreatic solid mass, including 18 patients with AIP, EUS-FNAB was examined. AIP was diagnosed according to Japanese criteria 2006. Diagnostic ability of EUS-FNAB were compared in respect to location of lesion, size of lesion, and number of needle passes.

Results: Overall technical success rate of the whole was 96.3% (77/80). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of histological diagnosis of malignancy were 90%, 100%, 100%, and 83%, respectively. Number of needle passes and size of target lesion in cases of AIP and the others were 3.9 times (range 27-5) and 3.7 times (range 2-5), 29.4 mm (range 21.4-36.9) and 29.4 mm (range 18.4-46.7), respectively. Tissues obtained from patients with AIP, although none of them were diagnosed as malignant or neoplastic, did not demonstrate enough histological evidence for definitive AIP.

Conclusions: EUS-FNAB using 22-gauge needles is supposed to be an accurate procedure to ensure exclusion of pancreatic malignancy in patients with AIP.

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Three Cases of Solid Papillary Tumor - Typical and Atypical Cases

K. Imai,1 H. Matsubayashi,1 H. Ono,1 K. Uesaka,2 K. Sasaki.3 Division of 1Endoscopy, 2Hepato-biliary-pancreatic Surgery and 3Pathology, Shizuoka Cancer Center, Shizuoka, Japan.

Radiological findings of solid pseudopapillary tumor is various according to level of tumor's progression.

Case 1: A 56-year-old woman underwent abdominal computed tomography (CT) in preoperative scrutiny for her breast cancer, and a 52 mm mass with calcification was found at the periphery. The tumor was consisted of solid and cystic components divided by obvious septa, suggestive of a typical SPT.

Case 2: A previously healthy 34-year-old woman was admitted because of sonographic evidence of pancreatic mass detected by screening for upper abdominal discomfort on pregnancy. CT revealed a well-defined, faintly enhanced, solid mass, 28 mm in size, without cystic component and calcification. SPT and endocrine cell tumor was suspected as preoperative diagnosis.

Case 3: A 54-year-old woman was admitted for further examination of a pancreatic tumor incidentally found. CT demonstrated a 94 mm tumor consisted of cystic component only, without obvious mass lesion. The tumor accompanied with calcifications at the periphery. We rather suspected SPT than pseudocyst because of the absence of abdominal symptoms and previous history of pancreatitis.

All of three cases were surgically resected and revealed to be non-metastatic. In our cases, SPT demonstrated various level of cystic degeneration according to its tumor size. In cases of suspected SPT, we need to keep various forms of SPT in our mind and carefully differentiate from other diseases of the pancreas.

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Analysis of K-ras Point Mutation in Pancreatic Mass Lesions Using Endoscopic Ultrasonography-Guided Fine Needle Aspiration

H. Imamura,1 K. Yamakita,1 A. Sawaki,1 N. Mizuno,1 K. Hara,1 S. Hijioka,1 S. Kondo,1 T. Nakamura,1 M. Tajika,1 H. Kawai,1 Y. Kobayashi,1 K. Matsumoto,1 T. Saeki,1 N. Akabane,1 H. Suzuki,1 K. Hosoda,2 Y. Yatabe,2 K. Yamao.1 1Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan; 2Department of Genetic Pathology, Aichi Cancer Center Hospital, Nagoya, Japan.

Background: Differentiation between benign and malignant pancreatic mass lesions still remains a great challenge in clinical practice. Moreover, there are still some patients who undergo surgery and finally prove to have a benign disease. In this study, we investigated the diagnostic accuracy of EUS-FNA and the frequency of K-ras point mutation in the specimens obtained by EUS-FNA in various kinds of pancreatic mass lesions.

Materials and Method: We reviewed 89 patients with pancreatic mass who underwent EUS-FNA from April 2006 to August 2008. The final diagnosis was made by surgery, EUS-FNA result or clinical follow up, more than 6 months. 89 patients included 63 pancreatic ductal carcinomas, 13 endocrine tumor, 11 tumor-forming pancreatitis (TFP), 1 solid pseudopapillary tumor(SPT) and 1 acinar cell carcinoma(ACC). The EUS-FNA specimen was also examined for the frequency of K-ras mutation.

Result: The frequency of K-ras mutation was 82.5% in pancreatic ductal carcinomas. K-ras point mutation was also observed in one TFP and one endocrine tumor; (endocrine cell carcinoma). K-ras point mutation was not observed in SPT and ACC. There was significant difference between pancreatic ductal carcinomas and TFP in the occurrence rate of K-ras point mutation (p < 0.05). When we defined the tumor with a positive K-ras point mutation as a pancreatic ductal carcinomas, the sensitivity, specificity, and overall accuracy for differentiation between pancreatic ductal carcinomas and TFP were 82.5%, 90.9%, and 83.8%, respectively. The sensitivity, specificity, and overall accuracy of EUS-FNA for differentiation between pancreatic ductal carcinomas and TFP were 88.9%, 100%, and 90%, and 90.8%, respectively. Only one pancreatic ductal carcinoma was observed which was negative for EUS-FNA and positive for K-ras point mutation.

Conclusions: It was thought that analysis of K-ras point mutation was useful, especially when the diagnostic ability of EUS-FNA was low. But because K-ras point mutation was also observed in one TFP, accumulation of more cases should be performed.

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The Safety and Utility of EUS-FNA Prior to Neoadjuvant Chemoradiotherapy for Pancreatic Cancer

H. Inoue,1 M. Katurahara,1 K. Tanaka,1 N. Horiki,1 M. Kishiwada,2 S. Isaji,2 Y Takei.1 1Department of Gastroenterology and Hepatorogy, Mie University Graduate school of Medicine, Japan; 2Department of Hepatobiliary Pancreatic Surgery, Mie University Graduate school of Medicine, Japan.

Background: Neoadjuvant chemoradiotherapy (NCRT) for pancreatic cancer is increasingly being used. Few cases of seeding after EUS-FNA were reported. Peritoneum dissemination was considered to be a serious problem as complication of EUS-FNA. This study evaluated the safety and utility of EUS-FNA prior to NCRT for pancreatic cancer.

Methods: We retrospectively analyzed patients who received EUS-FNA between April 2006 and April 2009. Seventy-eight patients (53 men/25 women) had EUS- FNA of pancreatic lesions (49 head/neck, 23 body, 6 tail). Thirty patients (22 men/8 women) had EUS-FNA prior to NCRT for pancreatic cancer (24 head/neck, 5 body, 1 tail). Those patients had operation after NCRT. The mean period after EUS-FNA until operation was 94.5 days (70-134).

Results: EUS-FNA had a sensitivity of 89.4%, specificity of 100%, and diagnostic accuracy of 91.0% for pancreatic lesions, respectively.

In potential NCRT 43 cases, EUS- FNA had diagnostic accuracy of 88.4%, clinical decisions were influenced in 10 of 43 (23.2%) patients. There is no truck seeding after EUS-FNA prior to NCRT in pancreatic cancer. Seven patients (13.3%) showed ascites or peritoneum nodule after EUS-FNA FNA prior to NCRT. Nevertheless there was no significant difference between patients who underwent EUS-FNA and those without EUS-FNA in regard to incidence of ascites.

Conclusion: EUS-FNA prior to NCRT is safe, and can help to make surgical decisions regarding pancreatic carcinoma patients.

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Gender Is The Only Predictor of Delayed Gastric Emptying After Pancreaticoduodenectomy

Y. Inoue,1 T. Nakamura,1 Y. Ambo,1 T. Noji,1 A. Kamaei,1 Y. Hashimoto,1 N. Okada,1 Y. Nanno,1 O. Suzuki,1 F. Nakamura,1 A. Kishida,1 A. Kurita,2 M. Osanai,2 A. Katanuma,2 K. Takahashi,2 H. Maguchi,2 N. Kashimura.1 1Department of Surgery, Teine-Keijinkai Hospital, Sapporo, Japan; 2Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan.

Background: Delayed gastric emptying (DGE) is the most annoying and most frequent complication after pancreaticoduodenectomy (PD). This report was undertaken to determine which factors influence the development of DGE after PD.

Methods: Between November 2004 and April 2009, consecutive 135 patients underwent PD at the Department of Surgery, Tenine-keijinkai Hospital. All reconstrucition were Childs procedures with ante-colic gastro-jejunostomy and were performed by four experienced operators. DGE was defined as the need for cessation of oral intake with evidence of radiographic gastric dilation. The multiple perioperative factors were examined retrospectively.

Result: DGE occurred in 39 patients (28.9%), with 11 days longer postoperative hospital stay than 96 other patients (median 32 versus 21 days; P < 0.001). Statistical analysis identified male gender was the only risk factor for DGE (p = 0.018). DGE was not related to operator, diabetes, pancreatic fistula and intraabdominal complication in this study.

Conclusion: Gender was only risk factor for DGE.

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Treatment of Pancreatic Stricture With Short-Term Metalic Stent Placement

K. Inui, J. Yoshino, K. Okushima, H. Miyoshi, M. Hattori, T. Naito, T. Yamamoto. Department of Internal Medicine, Second Teaching Hospital, Fujita Health University, Nagoya, Japan.

Background: Extracorporeal shock-wave lithotripsy and endoscopic lithotripsy for pancreatic stones are useful, but stone recurrence and pancreatic stricture need to be treated effectively to improve outcome.

Aim: We temporarily introduced an expandable metallic stent expecting that expandable properties of the stent should dilate the stricture. We studied usefulness of such short-term dilation of pancreatic strictures in preventing stone recurrence.

Patients and Methods: We performed this method in 6 patients with pancreatic stricture at the head of the pancreas between 2001 and 2008. All patients were men, ranging in age from 32 to 62 years (mean 52). Etiology was alcohol-related in 5 patients and idiopathic in 1. We used a Diamond Stent 8 or 10 mm in diameter and 40 mm in length, Boston Scientific Co. In all patients endoscopic pancreatic sphincterotomy had been performed. We inserted a guidewire into the main pancreatic duct and passed it through the stricture. A stent delivery system was inserted along with the guidewire, and the stent was left in place.

Results: Five of 6 strictures were dilated successfully. We removed the stent 2 to 7 days after insertion (mean, 4.6). No notable complications occurred except abdominal pain without an increase in serum amylase concentration. No patient has had recurrence of pancreatic stones during follow up periods ranging from 18 to 67 months (mean, 45.6). Two of 5 patients had acute pancreatitis attacks at 6 or 48 months after treatment associated with excessive alcohol intake.

Conclusion: Short-term metallic stent placement is useful for dilating strictures of the pancreatic duct and possibly for preventing recurrence of pancreatic stones after lithotripsy in patients with strictures.

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ABO Blood Group and Pancreatic Cancer

S. Iodice,1 P. Maisonneuve,1 E. Botteri,1 A.B. Lowenfels.2 1Division of Epidemiology and Biostatistics, IEO, Milan; 2Department of Surgery, New York Medical College, Valhalla, NY.

Background: ABO blood group has been associated with various malignancies, including pancreatic cancer. We examined the distribution of ABO blood groups among patients with various forms of cancer who were registered in the hospital-based tumor registry of the European Institute of Oncology.

Methods: We retrieved data from all 13,564 patients referred to the Institute during 2000-2003 with a histologically confirmed cancer diagnosis. Information on blood group was retrieved from medical records and categorized into O and non-O. We compared the blood group distribution of patients with any particular cancer with that of patients with all other forms of cancer.

Results: We found a significantly lower proportion of type O in patients with pancreatic cancer (n = 104) compared to patients with other cancer (33% vs. 67%, P = 0.02). The proportion of type O was even smaller when we considered only exocrine pancreatic tumors (28% vs. 72%, P < 0.001). The blood group distributions were homogeneous for all the other tumor types and similar to that of the general Italian population. Our results agree with previous studies (Annese 1990; Vioque 1991; Wolpin 2009) reporting low proportions of O type ranging from 34 to 36% among pancreas cancer patients and suggesting a protective effect of O blood type on this cancer.

Conclusion: In our tumor registry, pancreatic cancer was the form of cancer associated with the lowest frequency of O blood type. Further studies are necessary to clarify the mechanisms by which ABO blood type, together with other risk factors, may influence cancer risk.

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Clinical Outcomes in Patients Who Underwent Extracorporeal Shockwave Lithotripsy and Endoscopic Therapy for Pancreatic Stones

T. Ishihara, M. Tada, S. Yasui, H. Sugiyama, T. Fujimoto, R. Etoh, Y. Sakai, T. Tsuyuguchi, O. Yokosuka. Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan.

Aim: Clinical outcomes were evaluated in patients with chronic calcified pancreatitis who were treated by Extracorporeal Shockwave Lithotripsy (ESWL) and endoscopic therapy.

Methods: A total of 144 (Male; 109, Female; 35) patients with symptomatic pancreatic stones underwent ESWL and endoscopic therapy in our institute from May 1991 to December 2006. ESWL was performed as the first-line treatment and those in whom stones were not removed by ESWL were subjected to endoscopic therapy.

Results: Of 144 patients who underwent ESWL first, 83 patients (57.6%) required additional endoscopic therapy. Complete removal and incomplete removal of stones were achieved in 82 (56.9%) and 54 (37.5%) patients respectively. A total of 137 patients (95.1%) had immediate pain relief after treatment. There were no severe complications related to these series of treatments. Fifty nine patients who were followed-up for over 5 years after treatment were evaluated for long-term outcome. Pain relapse occurred in 26 of 59 patients (44.1%). Of the 26 patients with pain relapse, 23 were treated successfully by additional ESWL and endoscopic therapy. Three patients were performed subsequent surgery. Both endocrine and exocrine function deteriorated after the long-term follow-up period.

Conclusions: ESWL in conjunction with endoscopic therapy is effective in short-term and long-term pain relief in patients with symptomatic pancreatic stones.

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Evaluation of Pancreaticoduodenectomys in Our Institution

H. Ishikawa, H. Kinoshita, M. Yoshitomi, G. Akasu, H. Horiuchi, K. Shirouzu. Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan.

Background: Pancreaticojejunal anastomotic leakage (AL) is the most common major complication after pancreaticoduodenectomy (PD). The aim of study was to evaluate the results of pancreaticojejunostomy (PJ) in our institution.

Patients: A total of 530 consecutive patients who underwent PD for various diagnosis between 1965 and 2008.

Operative Techniques: The remnant pancreas is sharply transected with a scalpel. The pancreatic stump is coagulated by using the VIO soft coagulation system. No other treatment of the stump is performed. Modified Kakita method of PJ was performed via anastomosis of the duct to all layers of jejunal wall using 5-0 absorbable sutures and anastomosis of the pancreatic parenchyma to the jejunal seromuscularis using 4-0 nonabsorbable sutures. The omental flap is set around the PJ to prevent pancreatic juice from spreading in the abdomen.

Results: AL was identified in 8.7% (46/530) of the patients. Soft pancreas and small pancreatic duct were risk factors of leakage (p < 0.05). Intraabdominal hemorrhage that result from AL, occurred in 2.1% (11/530) of the patients. Most of the intraabdominal hemorrhage was treated with TAE. The use of omental flaps is decreased the risk of major vascular complications related to AL.

Conclusion: The operative mortality rate after PD has significantly declined due to the progression of surgical techniques and interventional treatments. The omental flaps is useful for decreasing the risk of major vascular complications related to pancreaticojejunal anastomotic leakage following PD.

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Radiation Therapy as Adjuvant Therapy for Surgery in Pancreatic Cancer

J. Itakura,1 H. Kawaida,1 H. Kohno,1 H. Onishi,2 H. Fujii.1 1Dept of Surgery, 2Dept of Radiology, University of Yamanashi, Japan.

Aim: The primary objective of this trial was to evaluate the efficacy of radiation therapy as the adjuvant therapy of surgery for pancreatic cancer.

Methods: Intra-operative radiotherapy (IORT) was directed at the pancreatic tumor bed and regional lymphatics to a dose of 20-25 Gy. EBRT was directed at the same area with IORT to a total dose of 30-50 Gy by 2 Gy in fraction 5 days per week after surgery. Patients received weekly Gem (200 mg/m2) on the first days of the weak with concurrent external-beam radiotherapy (EBRT).

Results: Since Aug 2001 to Dec 2007 55 patients were entered onto this trial. Patients characteristics: 31 male / 24 female; mean age 67.1 years (47-80); Stage II 1, III 18, IVa 20, IVb 16. The median overall survival of these 55 patients was 21.6 months, and 1, 3, 5 years survival rate were 66.0, 38.4 and 34.0%, respectively, and the survival rate was significantly higher than that of 86 non-radiation control group. The MST of 39 stage II∼IVa cases was 39.8 months and it indicated significant longer survival compared with non-radiation group. While 16 stage IVb cases did not indicate significant difference with non-radiation group. The MST of 37 R0 or R1 cases was 27.9 months and it indicated significant longer survival compared with 48 non-radiation cases. The recurrence rate and DFS of these 37 R0-1 cases was 62.2% and 7.8 Mo and these were significantly different from 93.8% and 3.7 Mo of non-radiation cases. The local recurrence rate of R0-1 cases was 21.7% and it was much lesser than 51.3% of non-radiation group.

Conclusion: This preliminary data would suggest that combination radiation therapy is efficient as adjuvant therapy for surgery in pancreatic cancer with local recurrence control.

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Successful Surgical Treatment for Pancreatic Pseudocyst With Intracystic Hemorrhage From Superior Mesenteric Artery: A Case Report

D. Ito, K. Eshita, R. Mizuno, T. Mori, K. Furumoto, M. Kogire. Department of Surgery, Kishiwada City Hospital, Kishiwada, Japan.

Introduction: Intracystic hemorrhage of a pancreatic pseudocyst is a rare complication of pancreatitis with a high mortality. We report here a case of pancreatic pseudocyst with intracystic hemorrhage from superior mesenteric artery which was successfully treated with an urgent surgical treatment.

Case: A 49-year-old male alcoholic patient was referred to our institute from a nearby mental hospital. The patient complained of lumbago and left upper quadrant pulsating mass. Contrast enhanced computed tomography and selective angiography showed a huge pancreatic pseudocyst with active hemorrhage directly from the lateral wall of superior mesenteric artery. Because interventional hemostasis such as embolization was impossible, we performed urgent surgical treatment. Pseudocyst was 10 cm in diameter, located in the pancreas uncus. Superior mesenteric artery was compressed and stretched to the left by the cyst. Although feeding artery could be identified, its stalk was too short to be ligated extra cystically. The feeding artery was sutured intra cystically following distal pancreatectomy and cyst wall fenestration. After hemostasis, Roux-en-Y pancreatic cyst jejunostomy was performed. Eighteen months after the surgical treatment, he is well with no evidence of recurrence.

Conclusion: Angiographic embolization is well-established treatment of pancreatic pseudocyst with hemorrhage. However, for technically infeasible or hemodynamically unstable case, urgent surgical treatment must be taken into consideration.

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A Case of Pancreatic Intraepithelial Neoplasia (PanIN-3) Resected Nine Months After Following Up Main Pancreatic Duct Dilatation

H. Ito, H. Nitta, S. Yamashita, H. Omoto, F. Ishikawa, I. Iizuka, H. Kurosawa, D. Okamura, M. Takada, T. Suwa. Department of Surgery, Fukaya Red Cross Hospital, Fukaya, Japan.

Background: Carcinoma in situ are often detected in intraductal papillary mucinous neplasm (IPMN) of pancreas, however, they are not often found in usual pancreatic tissue. We have experienced a case of pancreatic intraepithelial neoplasia resected nine months after following up main pancreatic duct dilation.

Case report: A 61-year-old man was referred to our hospital presenting with discomfort in epigastrium. Ultrasonography (US) and computed tomography (CT) revealed dilatation and blocking of main pancreatic duct (MPD). No tumorous lesion in pancreas head was detected. Fluorine-18-2-fluoro-D-glucose positron emission tomography (FDG-PET) also did not detect any abnormal lesion in pancreas. Serological data including tumor marker (CEA, CA19-9) did not show any abnormalities. After periodical examination of every three months, we obtained consent of patient and his family, and decided performing operation without definitive diagnosis. Pancreatoduodenectomy was performed. Comparatively hard mass about 3 cm was palpated in pancreas head. In the resected specimen mass lesion was presented as whitish fibrous lesion. Histological examination detected intraepithelial neplasia lesion (PanIN-3) in small pancreatic duct branch adjacent to fibrous lesion.

Discussion: We hardly determine that PanIN-3 lesion found in our resected specimen will develop into ductal pancreatic carcinoma or IPMN, however, careful observation should be required if abnormal finding such as MPD dilatation detected in pancreas.

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Laparoscopic Pancreatic Surgery: Totally Laparoscopic Pancreatoduodenectomy and Reconstruction

M. Ito, A. Horiguchi, S. Ishihara, K. Furusawa, Y. Asano, T. Shimizu, T. Yamamoto, K. Tuda, S. Morigaki, C. Yamada, I. Uyama, S. Miyakawa. Department of Surgery, Fujita-Health University, Toyoake, Aichi, Japan.

Background: Recent advances in operative techniques and instrumentation have empowered surgeons to perform virtually all minimally invasive procedures in the pancreas, including the Whipple procedure. Some of these procedures represent the most sophisticated application of minimally invasive surgery, and their outcomes are reportedly better than those of conventional open approaches. The purpose of this study is to critically analyze the indications for and outcomes after laparoscopic pancreatoduodenectomy (Lap-PD).

Methods: The medical records of all patients undergoing laparoscopic resection of pancreatic head from April 2007 to December 2008 were performed. Pancreatoduodenectomy (PD) was 15 patients. Data are expressed as mean +/− standard deviation.

Results: Lap-PD was performed in 5 patients (M:F,3:2) with a mean age of 69.2 +/− 15.1 years, Open-PD was performed in 10 patients with 68.0 +/− 12.1 years. Indications for Lap-PD were carcinoma of the papilla of vater (3), Lower bile duct camcer (1), IPMN (1). Indications for Open-PD were carcinoma of the papilla of vater (4), Lower bile duct cancer (3), IPMN (2), chronic pancreatitis (1).

Laparoscopic pancreatoduodenectomy was attempted in 5 patients and completed in 5, and Open-LD was performed in 10 patients during same sentence.

Mean operative time was 606 ± 53 min VS 484 ± 134 min. (p > 0.05), Pancreas jejunum anastomosis time: 82 ± 35 min. VS 29 ± 7 min. (p > 0.05) and mean blood loss was 268 ± 288 ml VS 764 ± 412 ml. (p > 0.05)

The mean postoperative LOS was 48 ± 38 days VS 43 ± 12 days there was not the significant difference between two groups.

Five patients in Lap-PD experienced a total of two postoperative complications, pancreatic fistula in early 2 examples (2) and gastric empting (one), and Two pancreatic fistulas were managed by percutaneous drainage. Ten patients in Open-PD experienced a total of two postoperative complications, pancreatic fistula and gastric empting.

Conclusions: Laparoscopic pancreatic resection is safe and feasible in selected patients with pancreatic head area. There were significantly few amounts of bleeding. However, about a pancreas jejunum anastomosis, the establishment of the manual skill that I included shortening, the prevention of pancreatic fistula in operation time is a future problem. This problem remains an area of development for the minimally invasive technique.

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2 Cases of the Early Pancreatic Cancer

N. Ito, T. Kurokawa, K. Suzumura, T. Nonami. Gastroenterological Surgery, Aichi Medical University, Nagakute-cho, Japan.

Background: By the development of the diagnostic technology, the reports of the early pancreatic cancer become increasing. We report in this time 2 cases of the early pancreatic cancer.

Case report: Case 1 is 53 years old woman. She was visiting other hospital for treatment for diabetes. She was pointed out the expansion of the main pancreatic duct by abdominal ultrasonography and became the hospitalization for close inspection with the introduction to our hospital. In the Computed tomography (CT) scan examination, a pancreas tumor did not detect it and accepted the stricture of the main pancreatic duct in Endoscopic Retrograde Cholangio-pancreatography (ERCP), and it was views to suspect pancreatic cancer by the pancreatic juice cytological diagnosis. We diagnosed it as minute pancreatic cancer. We performed the distal pancreatectomy with splenectomy in December 2007. The pathological diagnosis was PanIN-3 (carcinoma in situ), stage 0. Case 2 is a man of 66 years old. He was going to the internal medicine of our hospital for chronic hepatitis C. He was pointed out a high amylase value by a blood test and we detected diameter 13 mm pancreas head tumor by abdominal ultrasonography and CT scanning. In ERCP recognized the complete stricture of the main pancreatic duct and recognized the adenocarcinoma by brushing cytological diagnosis. We diagnosed the Stage 1 pancreatic cancer. We preformed the pylorus preserving pancreaticoduodenectomy in July 2008, the pathological diagnosis was pT1, pN0, sM0, f Stage 1.

Discussion: The early detection of the pancreatic cancer is still difficult, but it is thought that it is important that we set high risk group such as chronic pancreatitis or diabetes for the early detection and not to overlook the indirect views such as the pancreatic duct expansion by screening examination such as ultrasonography or Multidetector-row CT.

Conclusion: We experienced 2 cases of the early pancreatic cancer. It is thought that the early pancreatic cancer will increase by the development of the diagnosis method in future.

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Possible Chronic Pancreatitis (CP) With Increased Serum Pancreatic Enzymes' Levels Would Be Progressive to Definite or Probable CP

T. Ito,1 M. Naito,1 T. Michida,1 Y. Ito,2 H. Hagiwara.2 1Department of Medicine, Osaka Koseinenkin Hospital, Osaka, Japan; 2Department of Medicine, Kansai Rosai Hospital, Hyogo, Japan.

Aim: Most patients with CP were diagnosed by pancreatic malfunction. It seems important to find patients with early or subclinical stages of CP to prevent the progression. Aim of this study was to estimate the prevalence of CP and to observe the outcome for years.

Methods: We selected 81 patients examined with both serum pancreatic enzymes and imaging studies from patients complaining of continuous or intermittent abdominal symptoms over one month in our gastroenterological outpatient clinics from June to August 2005. Observation was done by March 2009.

Results: Male/Female was 40/41. Median age was 55. Elevated serum pancreatic enzymes were as follows: amylase, 6/70; lipase, 7/57; trypsin, 13/66; elastase-I, 5/49. Seventeen patients had elevated enzymes' levels. Using diagnosis criteria of Japan Pancreas Society('01), 17 patients were 1, definite CP and 16, possible CP. However, 4 patients who have no pathological findings for the first month became to have possible CP by March 2006. At the end of March 2009, 21 CP patients were consisting of 3, definite CP; 2, probable CP; 14, possible CP; and 3, healthy, referring latest records.

Conclusion: Our present study was showing that the prevalence of CP was higher as known before. Though the clinical manifestations of CP are quite varies, tests using several serum pancreas enzymes are helpful to diagnose CP preciously. Moreover it is noteworthy that possible CP could be progressive to probable or definite CP.

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Is Visceral Fat Area Associated With the Development of Post-ERCP Pancreatitis?

Y. Ito,1 T. Tsujino,1 H. Isayama,2 R. Nakata.1 1Department of Gastroenterology, Japanese Red Cross Medical Center; 2Department of Gastroenterology, University of Tokyo, Tokyo, Japan.

Purpose: To determine whether visceral fat area was associated with the development of post-ERCP pancreatitis (PEP).

Patients & Methods: Patients receiving a first diagnostic or therapeutic ERCP in our hospital and undergoing abdominal CT before ERCP were included. PEP was diagnosed and graded according to the 1991 consensus guideline. Visceral fat area (cm2) was measured at the navel position of CT scan.

Results: Of the 137 patients, PEP; occurred in 9 patients (6.7%); mild in 3, modelate in 4, and severe in 2 patients. By univariate analysis of risk factors for PEP, visceral fat volume, middle to lower bile duct cancer, difficult cannulation, and female sex were significant. By multivariate analysis, however, visceral fat area (OR 1.021 [95% CI 1.004-1.038], p = 0.0147), and difficult cannulation (OR 7.654 [95% CI 1.409-41.575], p = 0.0184) remained statistically significant.

Conclusion: Patients with high visceral fat area are at a high risk of PEP.

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Localization-Oriented Treatment Strategy for Main Duct Type IPMN

T. Itoh, R. Doi, K. Nagai, A. Kida, M. Koizumi, T. Masui, Y. Kawaguchi, S. Uemoto. Division of Hepato-biliary pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University, Kyoto, Japan.

Introduction: Surgical resection is indicated for main duct type intraductal papillary mucinous neoplasm (mIPMN) of the pancreas whenever the lesion is found; however, it is not clear which mode of operation should be chosen or which portion of the pancreas should be resected. This study investigated the pathological spread of the mIPMN lesion in the pancreas to discuss the rationale of the total pancreatectomy for mIPMN.

Materials: Materials were obtained by total pancreatectomy in 19 patients for mIPMN by imaging studies.

Results: The patients included 6 female and 13 male, the mean age was 66.7 ± 6.02 years. Seventeen patients had CIS or higher lesion in the pancreas. Two patients had no cancer lesion but had wide spread border-line lesions in the whole pancreas. The mapping of pathological spread of the mIPMN lesions disclosed that, at least, borderline or higher lesion was present both in the head and distal pancreas in the individual patient. Although two patients who diagnosed advanced cancer were died with cancer, other patients have not been recurrence.

Conclusion: According to the mapping of pathological spread of mIPMN lesion, it seems difficult to diagnose the localization of border line or higher lesion before operation. Considering the curability, mortality and morbidity, total pancreatectomy would be a feasible and indispensable mode of operation for mIPMN.

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Clinically Aggressive Solid Pseudopapillary Tumor: A Case Report

T. Iwao,1,2 K. Yoshida,2,3 Y. Tada,2 S. Morimoto,2 Y. Nomura,2 T. Kawase,3 M. Sato,2 Y. Nagata,2 S. Nishina.3 Y. Tomiyama,3 N. Yoshioka,3 A. Ishino,2 J. Ushio,3 Y. Hara,3 K. Korenaga,3 M. Korenaga,1 H. Miyata,2 K. Sato,2 K. Hino.1 1Department of Gastroenterology, Hoshi General Hospital, Fukushima, Japan, 2Advanced Research Institute of Gastroenterological Imaging, Fukushima, Japan; 3Division of Hepatobiliopancreatology, Department of Internal Medicine, Kawasaki Medical School, Okayama, Japan.

Solid pseudopapillary tumor (SPT) of pancreas is a rare type of pancreatic neoplasm found mainly in young women. Almost case with SPT behave as benign. We report an extremely rare case of malignant SPT, so-called clinically agressive SPT. A 36-year-old woman who underwent chemotherapy for malignant lymphoma of the breast 2 years earlier and consulted about upper abdominal pain. Ultrasonography showed hypoechoic mass of the body of pancreas. It was about 40 mm in diameter and included cystic lesion suggesting SPT or malignant lymphoma of the pancreas. We resected this mass. Histological examination showed the mass was typical histologic features of SPT,and might have been indicative of their aggressive behavior, included a diffuse growth pattern, tumor necrosis, significant nuclear atypia, an unusually high mitotic rate (MIB1 labelling index: 50%), invasion to the parenchyma of the pancreas, retroperitoneum and serosa. Immunohistochemically, tumor cells were positive for CD56, NSE, α-1antitripsin,and synaptphysin staining, and negative for AE1/AE3, Cam5.2, EMA, chromogranin, CD10, and amylase staining. Her postoperative course was miserable with peritoneal recurrence.

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Analysis of Prognostic Factors and a Proposed New Classification for Invasive Papillary Mucinous Neoplasms

J.Y. Jang,1 D.W. Hwang,1 M.A. Kim,2 M.J. Kang,1 C.S. Lim,1 S.E. Lee,1 S.W. Kim.1 1Department of Surgery, 2Department of Pathology, Seoul National University College of Medicine.

Aim: The authors undertook to investigate prognostic factors and to examine the clinical significance of percentage pancreatic volume occupied by the invasive component in invasive IPMN.

Background: Few reports have been issued on invasive IPMN, and thus, its characteristics have not been fully explored. Furthermore, a straightforward method is needed to describe its aggressiveness.

Methods: Of 217 patients that underwent surgical resection with a diagnosis of IPMN between 2001 and 2008, 41 had invasive IPMC. Clinical data were collected prospectively using an electric medical form and reviewed. We serially sectioned pancreatic parenchyma at 5-7 mm intervals. Whole slides were reviewed by a pancreas-biliary tract special pathologist, who determined the percentage pancreatic volumes occupied by the invasive components (IC%) in whole IPMN lesions.

Results: By multivariate analysis, perineural invasion ([HR] = 15.33, p = 0.015), metastasis ([HR] = 6818.29, p = 0.013), AJCC stage ([HR] = 0.15, p = 0.035) and invasive component percentage (IC%) ([HR] = 7.40, p = 0.036) significantly predicted prognosis.

IC% was found to be significantly associated with survival. Patients with an IC% of <10 had a 3 year survival rate (YSR) of 100%, whereas patients with an IC% of >50% had a 3 YSR of 36.5% and those with an IC% of 10 to 50% had a 3 YSR of 71.4% (p = 0.041).

Conclusion: In addition to conventional prognostic factors like AJCC stage and perineural invasion, the percentage of pancreatic volume occupied by the invasive component (IC%) appears to be an important prognostic factor in invasive IPMN. The concept of IC% is straightforward, semi-quantitative, and objective, and offers a means of determining tumor aggressiveness, and hence, it could be a means of classifying invasive IPMN.

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Ras Activity Links Chronic Pancreatitis and Pancreatic Cancer

B. Ji, L. Tsou, H. Wang, S. Gaiser, D. Chang, J. Daniluk, Y. Bi, T. Grote, D.S. Longnecker, C.D. Logsdon. Dept of Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background & Aims: Endogenous expression of mutant KRas in the pancreas with developmental promoters causes pancreatic adenocarcinoma (PDAC) over a long time span. Ras activity within the tumors is much higher than in non-tumors bearing endogenous levels of mutant KRas. We hypothesized that spontaneously upregulated Ras activity is key to cancer progression.

Methods: The effects of mutant KRas expression at different levels were compared on Ras activity and on the development of pancreatic diseases in genetically engineered mice.

Results: Expression of endogenous levels of mutant KRas in acinar cells resulted in sparse mPanINs that did not progress to PDAC unless p53 was simultaneously deleted. Ras activity was greatly elevated in both mPanINs and PDAC cells compared to surrounding acinar cells with endogenous expression of mutant KRas. In contrast, transgenic expression of mutant KRas at higher levels generated Ras activity equal to that observed in both human and mouse PDAC. This level of Ras activity led to acinar cell senescence, generated inflammation and fibrosis resembling the histological features of chronic pancreatitis (CP). With higher Ras activity abundant mPanINs formed and spontaneously progressed to both cystic papillary carcinomas (CPC) and PDAC.

Conclusions: There is an important relationship between Ras activity levels and the progression of PDAC. Sufficient Ras activity in pancreatic acinar induces several important pancreatic disease manifestations and supports a potential direct linkage between CP and PDAC.

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Motilin Regulates Interdigestive Pancreatic Blood Flow in Dogs

C.X. Jin,1 S. Naruse,2 H. Ishiguro,3 M. Nakajima,2 T. Hayakawa.4 1Second Hospital of Jilin University, Changchun, China; 2Department of Internal Medicine, Nagoya University, Nagoya, Japan; 3Department of Human Nutrition. Nagoya University Graduate School of Medicine, Nagoya, Japan; 4Meijo Hospital, Nagoya, Japan.

Background & Aims: Gastric blood flow and Pancreatic secretion exhibits cyclical increases in phase with the interdigestive contractions and secretion of the stomach in conscious dogs. The aim of this study is to clarify the regulatory role of motilin in interdigestive pancreatic blood flow in dogs.

Methods: Blood flow of pancreatic (PA) and superior mesenteric (SMA) arteries were measured by ultrasound transit-time blood-flow meters in 5 conscious dogs. Motilin was infused intravenously with or without phe-cyclo [Lys- Tyr(3-tBu)- Ala-] ·trifluoroacetate (GM-109; motilin antagonist), granisetron (5- HT3 antagonist), atropine, hexamethonium (C6), phenoxybenzamine, propranolol.

Results: Motilin (12.5, 25, 50, and 100 pmol·kg−1·h−1) induced PA blood-flow changes, which resemble the spontaneously occurring periodic changes associated with gastric motility. GM-109, atropine, C6, granisetron completely abolished the PA and secretory responses to motilin (100 pmol· kg−1· h−l). The PA flow responses to motilin were not inhibited by α-adrenergic and β-adrenergic blockers. Motilin induced pancreatic vasodilatation is similar to the equivalent doses of VIP in lower dose.

Discussion: Motilin has a potent pancreatic vasodilator effect, which appears to be mediated secondarily by both cholinergic and noncholinergic mechanisms.

Conclusions: Motilin plays an important role in the regulation of interdigestive pancreatic blood flow in dogs.

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Development of a Biological Resource for Genomic Characterisation of Pancreatic Cancer

A.L. Johns,1 E.K. Colvin,1 M. Pinese,1 A.J. Gill,1,2 R.H. Hruban,4 J.R. Eshleman.4 A. Maitra,4 S.M. Grimmond,5 A.V. Biankin.1,3 For the Australian Pancreatic Cancer Genome Initiative 1Cancer Research Program, Garvan Institute of Medical Research, Sydney Australia; 2Department of Anatomical Pathology, Royal North Shore Hospital, Sydney Australia; 3Department of Upper GI Surgery, Bankstown Hospital, Sydney Australia; 4Sol Goldman Pancreatic Cancer Research Centre, Johns Hopkins Medical Institutes, Baltimore, USA; 5Institute for Molecular Bioscience, University of Queensland, Brisbane Australia.

With recent advances in DNA sequencing technology, medicine is entering an era in which a personalised approach to diagnosis and treatment of disease is achievable. However, discovering the role of altered DNA sequences in cancer will be a challenging task. To facilitate this the International Cancer Genome Consortium (ICGC) was established to coordinate the generation of catalogues of genetic abnormalities in a variety of different cancer types globally. This has stimulated a growing demand for appropriately qualified well- annotated tumour specimens worldwide. However, tissue acquisition and resource development has proven to be the rate-limiting factor. We present the development of a molecular specimen pipeline at the Garvan Institute where we identify the major challenges in the creation of a genomics ready bio-resource, including ethics and privacy issues, procurement strategies and adequate clinical annotation, and how they can be overcome. We highlight the significance of setting appropriate standards from the projects initiation to ensure high quality samples that accurately represent the spectrum of pancreatic cancer.

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Exocrine Pancreas-Specific Expression of Oncogene Bmi1 Using GAL4-UAS System in Zebrafish

I.H. Jung, O.H. Kwon, E.J. Lee, J. Park, S. Bang, S. Song, J.B. Chung, S.W. Park.. Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea.

Background: Since the introduction of zebrafish it has been a powerful model for the study of developmental biology. Its advantages, such as feasibility of high throughput study and drug screening, have lead to application of this model for the study of tumor biology. Once established, zebrafish models of human cancer can serve a platform for the screening of candidate cancer drugs on a scale not feasible in the mouse. Though its function has not been fully elucidated, the Bmi1 has been known as a putative stem cell marker and oncogene. The well-known hedgehog signaling is markedly activated in pancreatic cancer and is known to up-regulate Bmi1. In an effort to investigate the role of Bmi1 in pancreatic tumorigenesis, we established transgenic lines expressing bmi1 in exocrine pancreas-specific manner.

Materials and Methods: We took advantage of ptf1a-gal4 transgenic line previously established by BAC recombineering technology, in which Gal4-vp16 is expressed in ptf1a domain. For transgenesis, UAS-Bmi1GFP and UAS-GFPBmi1 which have Tol2 arms on both 5' and 3' flanking region were microinjected in a mixture with transposase mRNA into 1 cell-stage yolk of pta1a-gal4 embryos. The GFP gene was fused with Bmi1 either 5' or 3' region to enable real-time visualization of transgene expression. After yolk injection of the BAC transgenes, founder fish were raised and bred to generate non-mosaic transgenic lines.

Results: Both ptf1a-gal4/UAS-Bmi1GFP and ptf1a/gal4/UAs-GFPBmi1 transgenic lines were successfully established. Transgene expression, through not robust based on GFP expression, spatiotemporally recapitulated the ptf1a gene expression pattern in all transgenic lines, i.e., expression in retina, hindbrain, and exocrine pancreas during development. As the Bmi1 gene serves for maintaining stemness in a cell, forced expression of Bmi1 in exocrine pancreatic progenitor cells might expand stem cell compartment leading to enlargement of exocrine pancreas. To facilitate real-time visualization those lines were bred with UAS-RFP fish which was also established in our Lab. At 72 and 96 hpf, the size of exocrine pancreas were larger in ptf1a-gal4/UAS-Bmi1GFP/UAS-RFP and ptf1a-gal4/UAS-GFPBmi1/UAS-RFP than in UAS-RFP/ptf1a-gal4 embryos. In situ hybridization for trypsin and immunofluorescence staining for carboxypeptidase A also revealed enlarged exocrine pancreas in Bmi1-expressing embryos. As the ptf1a expression sustains for life-long time in exocrine pancreas the oncogenic effect of Bmi1 might appear at later in adult fish. These transgenic lines are still under investigation to see the short-term and long-term phenotypic changes induced by Bmi1 expression.

Conclusion: We generated transgenic zebrafish lines demonstrating selective pancreatic expression of Bmi1 and these fish now provide a novel platform for study of both short- and long-term effects of Bmi1 in exocrine pancreas.

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Pancreatic Transection With Cusa and Reconstruction With 4 Parenchymal Stitches for a Soft Friable Pancreas

K. Kakinoki, K. Okano, H. Suto, N. Iida, K. Izuishi, Y. Suzuki. Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University.

Introduction: Pancreas fistula(PF) remains a major complication following pancreaticoduodenectomy for a soft pancreas. To reduce PF, we recently started to transect the pancreas with CUSA and add 4 stitches between the pancreatic parenchyma and jejunal seromuscular layer as the final step of the reconstruction procedures.

Materials and Methods: The pancreas with a soft gland was transected with CUSA. During this procedure, even branch pancreatic ducts were identified, ligated and divided. The small main duct was exposed easily by CUSA. A remnant pancreas was reconstructed with our original duct-invagination anastomosis or a conventional duct-to-mucosa anastomosis. Subsequently, 4 stitches of 3-0 monofilament sutures were placed between the stimp parenchyma and jejunal seromuscular layer, previously reported by Kakita, et al.

Results: We reported this pancreatic transaction and reconstruction technique to the consecutive 21 patients with periampullary tumors and 1 with pancreatic trauma. Main pancreatic duct caliber was <2 mm in all patients, except 3(10 mm in 1 and 5 mm in 2). Excluding 3 patients who had postoperative pancreatitis, grade A (n = 3) and B (n = 2) PFs developed but grade C PF did not occur in this series. There was no mortality in this series.

Conclusion: Our novel pancreatic transaction and reconstruction technique resulted in favorable outcomes although it could not eliminate mild PF.

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Comparison of Clinical Profiles of New-Onset Diabetes in Pancreatic Cancer (PaC) and New-Onset Type 2 DM

P. Kamada,1 K. Rabe,2 S. Srinivasan,3 S.T. Chari.1 1Division of Gastroenterology and Hepatology and 2Health Sciences Research, Mayo Clinic Rochester, MN and 3Chandler High School, AZ.

Background: New-onset diabetes (DM) may be a harbinger of pancreatic cancer (PaC). Our goal was to identify clinical clues that distinguish new-onset DM associated with PaC (PaCDM) from new-onset type 2 DM.

Methods: We identified Olmsted County residents with PaC and age- and gender-matched controls without PaC that first met criteria for DM (fasting blood glucose (FBG) ≥126 mg/dl) within three years of index date, which was the date of PaC diagnosis in cases. We compared the clinical profiles of new-onset PaCDM and type 2DM.

Results: Subjects with PaCDM (n = 47) and type 2 DM (n = 72) were similar in age (72.8 ± 9 vs 75.8 ± 6.6 years), gender distribution (%males 51% vs 53%), proportion with parental history of DM (22% vs 29%) and body mass index at least 1 year before meeting criteria for DM (29.3 ± 5.3 vs 30.4 ± 8.6 kg/m2). The FBG value at the time they met criteria for DM was similar in the two groups (156 ± 45 vs 152 ± 38 mg/dl). In PaCDM, 25/47 (53%) met criteria for DM ≥6 months before PaC diagnosis. PaCDM subjects were more likely to lose weight at onset of DM (28/44 vs 9/33, p = 0.004). Whereas PaCDM subjects lost on average 2.4 ± 4.2 kg at onset of DM, type 2 DM subjects gained 0.5 ± 5.0 kg at onset of DM.

Conclusion: PaCDM is often associated with modest weight loss at onset of DM. Otherwise PaCDM and type 2 DM have very similar clinical profiles and cannot be distinguished based on traditional risk factors for type 2 DM.

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The Outcome of Anastomotic Stenting for Pancreaticogastrostomy and Choledochojejunostomy Following Pancreaticoduodenectomy: A Single-Institution Experience

K. Kamei, T. Yasuda, Y. Nakata, H. Kitaguchi, H. Ishikawa, S. Haji, T. Ueda, T. Nakai, Y. Takeyama. Department of Surgery, Kinki University School of Medicine, Osaka-sayama, Japan.

Aim: Anastomotic leakage after pancreaticogastrostomy (PG) and choledochojejunostomy (CJ) is a persistent problem of pancreaticojejunostomy (PD). To avoid these complications, pancreatic and billiary stenting are widely used, but the efficacy is still unclear. In this study, we compare the outcomes of anastomotic stenting for PG and CJ in our institution.

Methods: A total of 92 patients undergoing PD from April 2003 to March 2009 were investigated. PG was performed with invagination of the pancreatic stump. Of the 92 patients analyzed, 54 patients were treated by internal (lost) stenting after PG (group I), 1 patient was treated by external stenting and 37 patients were treated without stenting (group II). Of the 92 patients, 79 patients were treated by external stenting after CJ (group III), and 13 patients were treated without stenting (group IV). We compared the morbidity, mortality, operative time, blood loss, time interval of oral intake, time interval of removing drainage tube, and postoperative hospital stay.

Results: We could not find the significant defferences in operative time and blood loss. Time interval of oral intake, time interval of removing drainage tube, and postoperative hospital stay were significantly shorter in group II and IV than those in group I and III. Pancreatic fistula (grade B and grade C by ISGPF definition) occurred in 5 patients (9.3%) in group I, while it owas seen in 3 patients (8.1%) in group II. Bile leakage occurred in 2 patients (2.5%) in group III, while 1 parient (7.7%) developed in group IV, but not significant. There was no patient in whom an obstruction due to an internal stent was suspected during hospital stay.

Conclusion: PG and CJ without stenting is safe and effective treatment after PD, with an acceptable morbidity.

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Frequent and Significant K-Ras Mutation in the Pancreas, Bile Duct and Gallbladder of Autoimmune Pancreatitis

T. Kamisawa,1 H. Anjiki,1 K. Takuma,1 N. Egawa,1 S. Horiguchi,2 M. Kurata,3 G. Honda,3 K. Tsuruta,3 T. Sasaki.4 Departments of 1Internal Medicine, 2Pathology, 3Surgery, and 4Chemotherapy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.

Aims: To assess relationship between autoimmune pancreatitis (AIP) and pancreatic cancer, we analyzed K-ras mutation in the pancreatobiliary tissues of AIP patients.

Methods: Analysis of K-ras mutation and an immunohistochemical study were performed on the pancreas of 8 AIP patients and 10 patients with chronic alcoholic pancreatitis, and on the common bile duct and gallbladder of 9 AIP patients. K-ras mutation was analyzed in the pure pancreatic juice from 3 AIP patients.

Results: K-ras mutation at high amounts (2+ or 3+) was detected in the pancreas of all 8 patients and in the pancreatic juice of the other 2 patients. The mutation in codon 12 of the ras gene was GAT in all 10 patients. K-ras mutation at high amounts was detected in the common bile duct of 5 AIP patients and in the gallbladder epithelium of 4 AIP patients. The K-ras mutation was detected in the fibroinflammatory pancreas, bile duct and gallbladder with abundant infiltrating IgG4-positive plasma cells and Foxp3-positive cells of AIP patients with elevated serum IgG4 levels.

Conclusions: Significant K-ras mutation occurs most frequently in the pancreatobiliary regions of AIP patients. AIP may be a risk factor of pancreatobiliary cancer.

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Invasion of the Splenic Artery Is a Crucial Prognostic Factor in Carcinoma of the Body and Tail of the Pancreas

M. Kanda, T. Fujii, T.T. Shain, A. Kanzaki, S. Yamada, H. Sugimoto, S. Nomoto, S. Takeda, A. Nakao. Department of Surgery II, Graduate School & Faculty of Medicine, University of Nagoya, Nagoya, Japan.

Background: There are no detailed reports focused on the correlation between invasion of the splenic vessels and prognosis in carcinoma of the body and tail of the pancreas.

Materials and Methods: This study included fifty-three patients with invasive adenocarcinoma of the body and tail of the pancreas underwent pancreatectomy from October 1981 to December 2008. We investigated the correlations between prognosis and pathological factors, in particular invasion of the splenic vessels.

Results: The median survival time was 19.5 months, and the 1- and 3-year survival rates were 58.2% and 14.9%, respectively. Eighteen patients with invasion of the splenic artery (SA) had a significant association with a poor prognosis (p = 0.0046), whereas twenty-four patients with invasion of the splenic vein (SV) had no significant correlation with prognosis. Additionally, invasion of the SA significantly correlated with tumor size, anterior serosal infiltration and SV invasion (p = 0.0249, p = 0.0304 and p = 0.0403, respectively). In univariate analysis, SA invasion, lymph node metastasis and anterior serosal infiltration were identified as significant poor prognostic factors. In multivariable analysis, only SA invasion was an independent prognostic factor (p = 0.0119).

Conclusion: Our results indicated that invasion of the SA, but not of the SV, is a crucial prognostic factor in carcinoma of the body and tail of the pancreas.

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A Case of Collision Cancers Occurring in the Bile Duct and Pancreas

T. Kaneko,1 K. Sugimori,1 C. Sato,1 M. Ueda,1 Y. Nagano,1 K. Numata,1 T. Sasaki,2 K. Tanaka.1 1Gastroenterological Center and 2Department of Pathology, Yokohama City University Medical Center, Yokohama, Japan.

A 71-years-old woman admitted for the increase of alkaline phosphatase levels in her blood test and dilatation of the common bile duct on ultrasonography (US). On abdominal computed tomography (CT), the wall of the middle and lower bile duct was thick and a low density mass was detected in the head of the pancreas. Endoscopic retrograde cholangiography (ERC) revealed stenosis of the middle and lower bile duct. Biopsies from this lesion showed adenocarcinoma. Endoscopic retrograde pancreatography (ERP) showed irregular of the wall of the main pancreatic duct close to the bile duct lesion. On endoscopic ultrasonography (EUS), no mass was detected in the head of the pancreas. Based on the diagnosis of bile duct cancer, pancreaticoduodenectomy was performed. Resected material showed two tumors in the middle and lower bile duct and the head of pancreas. Histopathologically, well to moderately differentiated tubular adenocarcinoma of the middle and lower bile duct had infiltrated the pancreas, well to poorly differentiated tubular adenocarcinoma with pancreatic intraepithelial neoplasia (PanIN) was found in the head of the pancreas. We diagnosed this as a collision of two cancers because no cell transference was found between the two tumors. According to the literature reviewed, this is rare neoplastic association.

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Solid-Pseudopapillary Neoplasm of the Pancreas: Experiences of Four Cases

S. Kanemitsu, Y. Nagao, N. Minagawa, T. Torigoe, A. Higure, K. Okamoto, K. Yamaguchi. Department of Surgery 1. School of Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan.

Background: Solid-pseudopapillary neoplasm (SPN) is a rare pancreatic neoplasm of low malignancy.

Objects: Four Japanese patients with SPN were retrospectively reviewed.

Results: The four patients were three females and a male and ranged 16-46 years old with a mean of 31 years. The four tumors were 6-12 cm in the greatest diameter with a mean of 7.9 cm. They were located in the body-tail of the pancreas in three patients and in the head in the other. Radiological findings revealed a sharply demarcated and solid and cystic mass in two, a unilocular cystic mass in one, and a multinodular mass in the remaining one. Histological examination showed proliferation of uniform polygonal cells in solid monotonous or pseudopapillary growth pattern in all the four lesions. Three of them had lymphatic permeation, perineural invasion, or deep invasion into the surrounding adipose tissue of the pancreas, respectively, suspecting aggressive malignant potential. All the four patients have been doing well without local recurrence or distant metastasis at a median follow-up of 111 months (range, 7-296).

Conclusion: We reviewed four patients with SPN and they have been doing well despite histopathological findings suggesting malignant potential.

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Prediction of Invasive Carcinoma in Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas

A. Kanno, K. Satoh, T. Shimosegawa. Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai City, Miyagi, Japan.

Background: The prognosis of BD-IPMN depends on the occurrence of invasive carcinoma.

Objective: To identify the factors which predict the development of invasive carcinoma in BD-IPMN patients.

Patients and Method: Invasive pancreatic carcinoma developing in patients with branch duct intraductal papillary mucinous neoplasms (BD-IPMN) could be classified into invasive IPMN group (invasive carcinoma derived directly from IPMN lesions) and concomitant group (common type of invasive carcinoma concomitant with BD-IPMN). The relation between the incidence of the respective types of invasive carcinoma in BD-IPMN and the clinicopathological parameters was retrospectively analyzed.

Results: There were 12 cases of invasive IPMN and 7 cases of concomitant cancer in 159 patients with BD-IPMN. Diameter of dilated branch or MPD, size of mural nodule and serum CEA level were factors associated significantly with invasive IPMN by univariate analysis. Among these factors, size of mural nodule > 6.5 mm (Odds ratio 19.4; P = 0.0313) and serum CEA level > 5 ng/ml (Odds ratio 6.6; P = 0.0463) were found to be the factors independently associated with invasive IPMN. On the other hand, both univariate and multivariate analyses revealed that elevated CA 19-9 levels were associated with the occurrence of concomitant ductal carcinoma in BD-IPMN (Odds ratio 8.54; P = 0.0174).

Conclusion: Our results suggested that careful imaging studies of the entire pancreas in addition to tumor lesions and measurement of serum CEA and CA19-9 would be required to find out the development of the two types of invasive carcinoma in BD-IPMN.

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Induction of Insulin-Producing Cells From Hepatic Cells In Vitro

Y. Kanoh,1 D. Tomotsune,1 S. Shirasawa,2 S. Yoshie,1 T. Yokoyama,2 I. Hinako,1 J. Ito,1 S. Mae,1 S. Takei,1 I. Takashimizu,1 K. Matumoto,3 M. Mizuguti,3 K. Sasaki.1 1Department of Histology and Embryology, Shinshu University School of Medicine; 2Laboratory for Health Sciences, Bourbon Institutes of Health, Bourbon Corporation; 3Nissui Pharmaceutical Corporation.

Type 1 diabetes mellitus can be ameliorated by pancreatic islet cell transplantation, but this treatment is restricted by the scarcity of islet cell source due to limited replication capacity of pancreatic cells. In the present study we tried to transdifferentiate the cultured hepatic cells to the pancreatic cells by several agents that induce hepatic dysfunction.Two marker plasmids containing a fluorescent gene with liver specific promoter (Albumin-GFP) or pancreas specific promoter (Elastase-DSRED) respectively were constructed and introduced into the human hepatoblastoma cell (HepG2). Using this cell line, we analyzed the phenotypic change of HepG2 to some pancreatic cells.Transdifferentiation of the HepG2 to pancreatic lineage was investigated by reverse transcriptase polimerase chain reaction (RT-PCR), immunostaining and fluorescence analysis. Three of tested agents could convert the green fluorescence of the HepG2 cells to red within two weeks after treatment,indicating the induction of elastase gene expression. RT-PCR analysis demonstrated expression of pancreatic gene markers such as insulin, amylase, elastase. Immunostaining confirmed the expression of amylase, glucagon and insulin. To check whether a similar transdifferentiation mechanism is also operating in normal cell, we induced mouse ES cells to liver cells and tired to transdifferentiate the liver cells to pancreatic cells. Induction of liver cells from the mouse ES cells was performed by treatment of Activin A and retinoic acid. By culturing in Lanford medium, the induced cells showed GFP fluorescence, indicating the albumin gene expression and differentiation into liver cells. This transdifferntiation method may lead to a new source of βcells that can be used for transplantation in diabetes.

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Antineoplastic and Immunomodulatory Effects of Protein-Bound Polysaccharide May Support the Treatment of Pancreatic Cancer

S. Karakhanova,1 M. Löhr,2 R. Jesnowski.3 1Dept. of Dermatology, Heidelberg Univ., Heidelberg, Germany, 2CLINTEC, Karolinska Institute, Stockholm, Sweden, 3CCU Molecular Gastroenterology, DKFZ, Heidelberg, Germany.

Background: Polysaccharide-K (PSK) is a protein-bound polysaccharide derived from the fungus Coriolus versicolor. It has been used successfully as a chemoimmunotherapy agent in the treatment of various cancers in Asia for over 30 years. However, experience concerning the effects of PSK in pancreatic carcinoma is limited. PSK not only boosts the immune system of patients but also has direct antineoplastic effects. It reduces invasiveness and metastasis. Moreover, it augments apoptosis induced by chemotherapy.

Methods: We analyzed direct effects of PSK on the proliferation of pancreatic tumor cells either alone or in combination with 5-FU or gemcitabine by WST-1 assays. Gene expression was analyzed using RT-PCR and activity of MMPs was analyzed using zymography. Proliferation and IFN-γ secretion of CD4 subpopulations was analyzed by thymidine incorporation and ELISA, respectively.

Results: PSK dose dependently decreased the proliferation of all pancreatic tumor cells investigated to 50-60 % at 250 μg/ml PSK. PSK did not exert any additive effect on cell killing when used in combination with either 5-FU or gemcitabine. PSK did not change MMP expression. PSK dose-dependently stimulated the proliferation of activated T-effector cells, whereas proliferation of Treg cells was decreased. PSK markedly increased IFN-γ secretion of cocultivated T-effector and Treg cells.

Conclusion: PSK may support the treatment of pancreatic cancer.

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Pancreatic Cancer Is a Significant Risk Factor in the Development of NAFLD/NASH After Pancreaticoduodenectomy: Impact of High -Dose Pancreatic Enzyme Supplementation

H. Kato, S. Isaji, Y. Murata, Y. Nobuoka, Y. Azumi, M. Kishiwada, T. Hamada, S. Mizuno, M. Usui, H. Sakurai, M. Tabata. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University, Tsu, Japan.

The aim of this study is to identify the significant risk factors on the development of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NAFLD) after pancreaticoduodenectomy (PD) and to reveal the efficacy of high-dose pancreatic enzyme supplementation.

From 2005 to 2008, 54 patients (pancreatic carcinoma: 27, IPMN: 13, bile duct carcinoma: 7, and others: 7) were enrolled. We defined the CT value of less than 40 HU as NAFLD, and NASH was confirmed by liver biopsy. To determine the significant risk factors of NAFLD, several perioperative variables were compared between the patients with or without NAFLD.

NAFLD was found in 37.0% (20/54) from one to 12 months (mean: 7.7 months) after PD and 2 patients were diagnosed as NASH. Pancreatic carcinoma, pancreatic resection line and diarrhea were selected as the significant risk factors by multivariate analysis. The 20 patients with NAFLD were divided into the 2 groups according to the dosage of pancreatic enzyme supplementation: high dose group in 12 and conventional dose group in 8. The remission rate of NAFLD was significantly higher in high dose group than in conventional dose group: 91.7% vs, 12.5% (p < 0.001).

Pancreatic carcinoma is a significant risk factor of NAFLD/NASH after PD. High-dose pancreatic enzyme supplementation should be required for the patients who have the risk factors of NAFLD.

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Usefulness of Endoscopic Features in the Diagnosis of Pancreatic Arteriovenous Malformation

S. Kato, S. Umezawa, N. Kobayashi, K. Kubota, A. Nakajima. Gastroenterology Division, Yokohama City University Hospital.

Background: Pancreatic arteriovenous malformations (PAVMs) are extremely rare. The suspected presence of a PAVM is typically based on enhanced CT or color Doppler US imaging, and confirmatory diagnosis is achieved with abdominal angiography. However, endoscopic findings of PAVMs have not yet been fully elucidated or documented.

AIM: To calarify endoscopic features potentially useful in the diagnosis of PAVMs.

Method: Retrospective case series. We clinicopathologically studied four cases with PAVMs, especially focused on the endoscopic findings.

Results: Endoscopic features were different in each case: case 1; An elevated mucosa with dilated reddish vessels in the duodenal wall; case 2; A refractory bleeding duodenal ulcer particularly when located in the postbulbar portion; case 3; Gastric varices; and case 4; Esophageal varices. An elevated mucosa with dilated vessels in the duodenal wall and a postbulbar duodenal ulcer are thought to be caused by ischemia of duodenal mucosa. Histological finding in case 1 revealed multiple infarctions of abnormal vessels in the duodenal mucosa. PAVMs could be one of the causes of portal hypertension resulting from an increased inflow into the portal system. Therefore, esophageal or gastric varices can be seen in patients of PAVM.

Conclusion: PAVM should be considered as a differential diagnosis in patients with recurrent gastrointestinal bleeding or unexplained abdominal pain. Endoscopic features associated with local ischemia of duodenal mucosa or unexplained portal hypertension enhance the diagnosis of PAVM.

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Radiation Therapy for Pain Management in Pancreatitis. A Meta-Analysis

M.S. Kaufman,1 R. Concha-Parra,1 S. Das,2 F.G. Gress.1 1Division of Gastroenterology and Hepatology, SUNY Downstate Medical Center, Brooklyn, NY; 2SAMSI, Duke University, Durham, NC.

Background: Chronic abdominal pain due to pancreatitis is often difficult to manage. Current treatment options include analgesics, pancreatic enzymes and celiac plexus block. Radiotherapy has anti-inflammatory properties, which may be useful for pancreatitis management. However, only a few experimental studies with radiotherapy have been performed and its use remains controversial.

Aim: To evaluate the efficacy of radiotherapy in alleviating abdominal pain secondary to pancreatitis.

Methods: Using Medline, Pubmed and Embase databases through June 2009, a search of literature was conducted for trials published in all languages evaluating the efficacy of radiotherapy for management of abdominal pain in pancreatitis. A Bayesian Hierarchical model for Meta Analysis was developed.

Results: 6 relevant studies were identified, comprising a total of 174 patients. Radiotherapy was effective in alleviating abdominal pain in 54% of patients (95% CI 0.4660, 0.6131).

Conclusion: Analyzed studies reported various levels of complete pain relief, ranging from 18-80%. Our meta-analysis demonstrates that radiotherapy results in the reduction of abdominal pain due to pancreatitis in at least 54% of patients. Logistic regression analysis reveals that radiation levels are positively associated with pain relief. Therefore, radiotherapy is promising for its ability to control intractable pain and may improve the quality of life in patients with pancreatitis. Further prospective randomized controlled trials are warranted.

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A Prospective Diagnostic Accuracy Study of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT), Multidetector Row Computed Tomography (MDCT) and Magnetic Resonance Imaging (MRI) in Primary Diagnosis and Staging of Pancreatic Cancer

S.P. Kauhanen,1,2 G. Komar,1 M.P. Seppänen,1 K.I. Dean,3 H.R. Minn,1,4 S.A. Kajander,1 I. Rinta-Kiikka,5 K. Alanen,6 R.J. Borra,1,3 P.A. Puolakkainen,2 P. Nuutila,1,7 J.T. Ovaska.2 1Turku PET Centre, Turku University Hospital, Turku, Finland; 2Department of Surgery, Turku University Hospital, Turku, Finland; 3Medical Imaging Centre of Southwest Finland, Turku, Finland; 4Department of Oncology and Radiotherapy, Turku University Hospital, Turku, Finland; 5Department of Radiology, Tampere University Hospital, Tampere, Finland; 6Department of Pathology, Turku University Hospital, Turku, Finland; 7Department of Medicine, University of Turku, Turku, Finland.

Objective: To prospectively compare the accuracy of combined positron emission tomography/computed tomography using 18F-fluorodeoxyglucose (FDG-PET/CT), multidetector row computed tomography (MDCT) and magnetic resonance imaging (MRI) in the evaluation of patients with suspected pancreatic malignancy.

Summary Background Data: FDG-PET/CT imaging is increasingly used for staging of pancreatic cancer. Preliminary data suggest a significant influence of FDG-PET/CT on treatment planning, although its role is still evolving.

Methods: 38 consecutive patients with suspicion of pancreatic malignancy were enrolled. Patients underwent a protocol including FDG-PET/CT, MDCT and MRI combined with magnetic resonance cholangiopancreatography (MRCP), all of which were blindly evaluated. The findings were confirmed macroscopically at operation and/or by histopathological analysis (n = 29) or follow-up (n = 9). Results of TNM classification of different imaging methods were compared to clinical TNM classification.

Results: Pancreatic adenocarcinoma was diagnosed in 17 patients, neuroendocrine tumor in three, mass-forming pancreatitis in four, cystic lesion in six and fibrosis in two. Six patients had a finding of a normal pancreas. The diagnostic accuracy of FDG-PET/CT for pancreatic malignancy was 89%, compared to 76% and 79% for MDCT and MRI, respectively. In the differential diagnosis of suspected malignant biliary stricture at endoscopic retrograde cholangiopancreaticography (n = 21), FDG-PET/CT had a PPV of 92%. In 17 patients with advanced pancreatic adenocarcinoma, FDG-PET/CT had a sensitivity of 30% for N- and 88% for M-staging. Both MDCT and MRI had sensitivities of 30% for N- and 38% for M-staging. Furthermore, the clinical management of 10 patients (26%) was altered after FDG-PET/CT.

Conclusion: FDG-PET/CT was more sensitive than conventional imaging in the diagnosis of both primary pancreatic adenocarcinoma and associated distant metastases. In contrast, the sensitivity of FDG-PET/CT was poor in detecting local lymph node metastasis. We recommend the use of FDG-PET/CT in the evaluation of diagnostically challenging cases, especially in patients with biliary strictures without evidence of malignancy in conventional imaging.

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Prospects of Tailor-Made Chemotherapy Based on Proteomics Technology

K. Kawaguchi, F. Motoi, N. Fujikawa, K. Ariake, S. Yokoyama, N. Omura, H. Otsuka, T. Rikiyama, Y. Katayose, S. Egawa, M. Unno. Division of Hepato-Biliary Pancreatic Surgery, Tohoku University, Sendai, Japan.

Background and Aims: Gemcitabine (GEM) is widely used as a first line agent for the treatment of pancreatic cancer. In some patients, it provides a long-term survival, while there are many non-responders. Recent advances in proteomics technology made it possible to quantitate trace proteins such as transporters and metabolic enzymes at high sensitivity enough to reflect the function of proteins in living organisms. In this study, we exhaustively quantitated the protein profiles of GEM related transporters and metabolic enzymes in pancreatic cancer cell lines and resected specimen using LC-MS/MS technique. We created the GEM sensitivity equation based on the profiles and the IC50 values of cell lines. This equation was validated using surgical specimens of pancreatic cancer.

Materials and Methods: We used twelve pancreatic cancer cell lines for profiling. Surgical specimen from six patients from March 2004 to January 2006 were classified Gemcitabin sensitivity group and resistant group according to the survival period after beggining of adjuvant GEM.

Results: dCK/(MRP1 × MRP4) showed high correlation with IC50 values. In surgical specimen, average value of equation in sensitivity group was 86.3, while that in resistant group was 3.8. The results support the validity of this equation.

Conclusion: Applying this equation, we can predict GEM sensitivity and tailor-made chemotherapy can be implemented.

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A Diagnostic Strategy to Differentiate Autoimmune Pancreatitis From Pancreatic Cancer and Mass-Forming Pancreatitis

Y. Kawaguchi, Y. Tsukune, K. Tajima, M. Fujisawa, I. Okita, H. Itoh, S. Kojima, T. Mine. Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Japan.

Aim: Autoimmune pancreatitis (AIP) shows similar presentations to pancreatic cancer (PC) and mass-forming pancreatitis (MP). Some AIP patients are incorrectly diagnosed as PC or MP. Since AIP can be treated effectively with corticosteroid, differentiating AIP from PC or MP is necessary to avoid unnecessary operations. The aim of this study is to compare pancreatography of these diseases as a diagnostic strategy.

Methods: This study consisted of patients with 23 AIP, 23 PC and 12 MP, who underwent endoscopic retrograde cholangiopancreatography. We compared the images of the main pancreatic duct (MPD), among PC, MP and AIP, retrospectively.

Results: The length of the narrowed portion of AIP patients tended to be long significantly, compared with PC and MP patients (p < 0.001). The upstream part of narrowed portion of the MPD in AIP patients tended to be not dilated significantly, compared with PC and MP patients (p < 0.001). The branches of the narrowed portion of the MPD in AIP patients tended to be found significantly, compared with PC and MP patients (p < 0.001, p < 0.05).

Conclusions: PC and MP can be distinguished from AIP based on the length, the upstream diameter and the branches of the narrowed portion of the MPD by pancreatography. However, in localized AIP cases, we should pay attention to differential diagnosis with PC.

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Insig2 Was Overexpressed in Pancreatic Cancer and Its Expression Was Induced by Hypoxia

T. Kayashima,1 K. Nakata,1 K. Ohuchida,1,2 K. Mizumoto,1,3 M. Tanaka.1 1Department of Surgery and Oncology, and 2Department of Advanced Medical Initiatives, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; 3Kyushu University Hospital Cancer Center, Fukuoka, Japan.

Backgrounds/Aims: Hypoxic microenvironment is characteristic in pancreatic cancer. Hypoxia induces various genes involved in malignant features such as invasion and metastasis in pancreatic cancer. Insulin-induced gene-2 (Insig2) has recently been found to be related with cellar invasion in colon cancer. However, there have been no reports regarding its expression and its relation with hypoxia in pancreatic cancer.

Materials and Methods: We evaluated Insig2 expression in cultured pancreatic cancer cells exposed to hypoxic condition and invasive ductal carcinoma (IDC) cells obtained from 26 patients, normal pancreatic epithelial cells from 5 patients, and pancreatic intraepithelial neoplasia (PanIN) cells from 4 patients using laser-microdissection.

Results: All 16 pancreatic cancer cell lines and 2 primary cultures of fibroblasts isolated rom pancreatic cancer expressed Insig2 mRNA. In analyses of microdissected tissues, all samples from IDC tissues expressed higher levels of Insig2 mRNA than those of normal pancreatic (p = 0.06) and PanIN (p = 0.09) cells. Under hypoxic condition (1% O2), pancreatic cancer cells showed over two-fold levels of Insig2 mRNA compared with normal condition (21%O2).

Conclusions: The present data show that invasion-related gene Insig2 may be associated with malignant potential of pancreatic cancer under hypoxia.

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Activated Protein C in Severe Acute Pancreatitis: A Double-Blind Randomized Human Pilot Study

E. Kemppainen, V. Pettilä, L. Kyhälä, L. Kylänpaa, M. Tallgren, H. Repo, P. Puolakkainen. Departments of Surgery, Medicine and Intensive Care, Helsinki University Central Hospital, Finland.

Introduction: Previous human studies have shown low activity of activated protein C in severe acute pancreatitis. This, together with the findings in animal models suggests that activated protein C (APC) may protect against pancreatic injury and ameliorate the disease. We, therefore, evaluated the safety of APC in SAP, and its effect on multiple organ dysfunction measured by the SOFA and on organ-failure-free days.

Design: Prospective double-blind randomized pilot study.

Setting: One university hospital tertiary ICU with 8 beds.

Patients: Inclusion criteria: 1. admitted to hospital <96 h from onset of pain, 2. a 3-fold increase in serum amylase over normal upper range or/and CT verification of SAP, 3. one or more organ dysfunction (OD), 4. <48 hours from the first OD. Of a total of 215 adult patients with SAP screened between June 2003 and August 2007, 158 fulfilled the study inclusion criteria. After exclusions 32 patients were randomized to the study.

Intervention: APC (N = 16) was administrated intravenously for 96 hours with a dose of 24 µg/kg/min or placebo (N = 16) with a similar infusion rate.

Measurements and Main results: No serious bleedings were detected clinically or by CT- scans in either group. No significant difference in SOFA score change between the APC and placebo groups was found [difference in means (DIM) −2.3, 95% CI −5.2-0.7]. No differences in ventilator free days, in renal replacement therapy-free days, in vasopressor-free days, or in days alive outside hospital were detected. Treatment with APC was associated with increases in serum levels of both total and conjugated bilirubin.

Conclusions: No differences in bleedings or in the evolution of MOD were detected between APC and placebo. Instead we found an increase in serum bilirubin in the APC group compared to the placebo group in patients with SAP.

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IgG4 Immunostaining of Duodenal Papillary Biopsy Specimens May Be Useful for Supporting a Diagnosis of Autoimmune Pancreatitis

M.H. Kim, S.H. Moon, D.H. Park, T.J. Song, J. Eum, S.S. Lee, D.W. Seo, S.K. Lee. Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Aim: Autoimmune pancreatitis (AIP) is now considered to be part of an IgG4-related systemic fibroinflammatory disease. We evaluated whether IgG4 immunostaining of duodenal papillary biopsy specimens is useful for supporting a diagnosis of AIP.

Methods: We obtained prospectively 2 forcep-biopsy specimens from the major duodenal papilla (MDP) of 19 symptomatic AIP patients during ERCP. Specimens were considered as positive for IgG4 immunostaining if there were >10 IgG4-positive cells/HPF. As a control, biopsy specimens obtained from MDP of patients with pancreatic cancer (n = 35), cholangiocarcinoma (n = 20), ampullary cancer (n = 11), ordinary chronic pancreatitis (n = 18), and AIP on remission (n = 16) were also examined immunohistochemically.

Results: Positive IgG4 immunostaining of MDP was found in 10 (53%) of 19 symptomatic AIP patients, while none (0/100) of control group including pancreatic cancer. Among symptomatic AIP patients (n = 19), 5 (83%) of 6 patients with elevated serum IgG4 levels showed positive IgG4 immunostaining of MDP, whereas 5 (38%) of 13 patients with normal serum IgG4 levels. Nine of 19 symptomatic AIP patients also underwent pancreatic biopsy, and positive IgG4 immunostaining of MDP was confined to patients with positive pancreas IgG4 staining (4/6; 67%), whereas none with negative pancreas IgG4 staining.

Conclusion: Positive IgG4 immunostaining of MDP was 100% specific and moderately sensitive in the diagnosis of AIP.

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Measurement of Serum IgG in Addition to IgG4 May Be Useful in Improving Sensitivity Without Sacrificing Specificity in the Diagnosis of Autoimmune Pancreatitis

M.H. Kim, T.J. Song, S.H. Moon, D.H. Park, J.B. Eum, S.S. Lee, D.W. Seo, S.K. Lee. Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Background: In the serologic criterion for the diagnosis of autoimmune pancreatitis (AIP), the HISORt criteria use elevation of serum IgG4 only, whereas revised Japanese criteria include high serum IgG or IgG4, or the presence of autoantibodies. This study was performed to find out which combinations of serologic tests could be effectively used in the diagnosis of AIP.

Methods: Serum IgG, IgG4 and antinuclear antibody (ANA) were measured in 78 patients with AIP. To evaluate specificity in differentiating AIP from pancreatic cancer, serum IgG and IgG4 were measured in 100 patients with pancreatic cancer.

Results: In patients with AIP, the sensitivity of total serum IgG (≥1800 mg/dL) was 46.2% (36/78), and that of IgG4 (≥135 mg/dL) was 51.3% (40/78). Seventeen patients (17/78, 21.8%) showed elevated IgG4 with normal IgG, whereas 13 patients (13/78, 21.8%) showed elevated IgG with normal IgG4. The sensitivity increased to 67.9% (53/78) when positive result was defined as any elevation of either IgG or IgG4, and it was significantly higher than that of IgG4 alone (p <0.05). The specificity of serum IgG and IgG4 in differentiating AIP from pancreatic cancer was equivalent. Presence of ANA (≥1:80) without IgG and/or IgG4 elevation was found in only one patient.

Conclusions: Measurement of serum IgG in addition to IgG4 may be useful in improving sensitivity without sacrificing specificity in the diagnosis of AIP, but serum ANA may not.

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Outcomes and Risk Factors for Post-ERCP Pancreatitis

Y.J. Kim,1,2 Y.T. Kim,2 J.K. Park,2 S.C. Park,1 S.H. Lee.3 1Department of Internal Medicine, Korea Institute of Radiological & Medical Science, Korea Cancer Center Hospital, Seoul, Korea; 2Department of Internal Medicine and Liver Research Institute Seoul National University College of Medicine, Seoul, Korea; 3Department of Internal Medicine, Seoul National University Bundang Hospital, Gyenggi-do, Korea.

Aims: The purpose of this study was to identify the outcome and most important risk factors for post-ERCP pancreatitis.

Patients and Methods: Patients with pancreatitis from ERCPs that were performed between September, 2004 to May, 2008, at Seoul National University Hospital and Bundang Seoul National University Hospital were analyzed retrospectively. Outcome measures were severity of pancreatitis, need for surgery and mortality. Risk factors were difficult cannulation, pancreatic opacification, underlying disease, etc.

Results: 210 cases of pancreatitis were identified among 4579 ERCPs. 43 cases needed hospitalization more than 10 days and were classified as severe group, the others were non-severe group. 2 out of those 43 cases were necrotizing pancretitis and required intervention, but there was no mortality case. Malignancy constitutes 41.9% of severe group cases significantly higher than 27.7% of non-severe group (p = 0.027). Repeated ERCP within 1 week resulted in 14% of severe pancreatitis as opposed to 4.2% of non-repeated ERCP.(p = 0.018) In addition, severe pancreatitis came about more frequently when biliary obstruction was incompletely resolved after ERCP. There was no significant difference in other parameters between the two groups.

Conclusion: Post-ERCP pancreatitis follows benign course and malignancy, incomplete drainage of biliary obstruction and repeated ERCP are the risk factors for severe ERCP-related pancreatitis.

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Role of CA-19-9 in Treatment of Pancreatic Cancer: Do We Have Better Marker Than CA-19-9?

Y.J. Kim.1 K.Y. Yang,1 J.K. Seo,1 J.K. Park,1 J.K. Ryu,1 Y.-T. Kim,1 Y.B. Yoon.1 S.H. Lee,1 J.H. Hwang,1 J.B. Jeong,1 J.-Y. Jang,2 S.-W. Kim.2 Department of 1Internal Medicine, 2Surgery. Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Purpose: CA 19-9 is commonly used marker in diagnosis and treatment of pancreatic cancer. However, its value has not been clearly established as a prognostic and predictor marker. Also, CA 19-9 level could be affected by biliary tract obstruction which occurred quite often in diagnosing pancreatic cancer. The previous studies have limitation as they have not considered distinctive two groups (CA-19-9 level with or without jaundice). Therefore, the aim of study was to investigate the value of CA19-9 level as a prognostic factor and an early indicator of response in treatment of pancreatic cancer without biliary tract obstruction.

Methods: Four hundred and sixty pancreatic cancer patients who were diagnosed between May 1st 1996 and April 30th 2008 were enrolled and they had total bilirubin level under 1.2mg/ml. All the patients were checked their CA-19-9 level before and after the treatment. We analyzed the difference in prognosis between those with CA 19-9 level higher and lower than 575 U/ml (median CA-19-9 level in study patients) and in treatment response between the groups with or without 50% decrease of CA 19-9 level.

Results: Median survival period was 7.2 months among all the pancreatic cancer patients. Median survival period of those whose CA 19-9 level on diagnosis was under 575 U/ml (n-230) was 9.9 months (95% CI; 8.0-11.7), longer than 6.4 months (95% CI; 5.4-7.3) of those over 575 U/ml (n = 230). (p < 0.001) When we analyzed the patients with the upper limit of normal CA 19-9 level, which is 39 U/ml, there was a difference in survival period between those over and under the level. Median survival period of those whose CA 19-9 level decreased by more than 50% after the first treatment (n = 93) was 14.4 months (CI; 13.0-15.8) and longer than 8.3 months (95% CI; 6.9-9.8) of those whose CA 19-9 level did not. (p < 0.001) When we analyzed the patients according to treatment type, among those who received only palliative chemotherapy, those with higher initial CA 19-9 level showed survival period longer than those with lower level. (9.3 vs 7.0 months) In addition, those with CA 19-9 level decreased by more than 50% after the chemotherapy showed survival period longer than those with less than 50%. (13.5 vs 7.8 months, p = 0.0065) However, among the 68 patients who received surgical resection, there was no survival period difference between those with higher and lower initial CA 19-9 level (17 vs 14.8 months) and postoperational decrease of CA 19-9 level did not affect the survival period. (decrease group 16.2 vs not decrease group 17.3 months).

Conclusion: Pre-treatment CA 19-9 level is a predictor factor for survival period of pancreatic cancer patients and the decrease of the level after the palliative chemotherapy helps predict the treatment response and the prognosis.

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Clinical Analysis of the Metastatic Pancreas Neoplasms

A. Kimijima,1 T. Hatori,1 I. Fujita,1 T. Imaizumi,2 M. Yamamoto.1 1Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan; 2Department of Surgery, Tokai University School of Medicine.

Background: The metastatic pancreas neoplasm is seen in 3% of the pancreaic neoplasm in Japan. The aim of this study is to evaluate the clinical features of the metastatic pancreas neoplasms.

Methods: 13 patients (14 cases) who underwent pancreatectomy for a metastatic pancreas neoplasms between 1998 and 2008 were chosen in this study.

Results: The mean age was 65.9 years old, gender was 8 male and 5 female. 12 patients had a past history of surgery for renal cell carcinoma, and one patient underwent pancreatectomy prior to the diagnosis of lung cancer as a primary lesion. Nine patients had a solitary metastasis and five patients had multiple metastases. Pylorus-preserving pancreaticoduodenectomy was performed in three patients, distal pancreatectomy, in five patients, pylorus-preserving total pancreatectomy, in one patient, duodenum-preserving total pancreatectomy in one patient, partial resection in two patients. One patient underwent pancreatectomy twice: distal pancreatectomy and total pancreatectomy of the remnant pancreas. The mean period to pancreatectomy was 15.8 years (3-27 years). Lymphnode metastasis was detected in one patient with the granules cell type renal cell carcinoma. The prognosis after surgery was good except one patient who died of lung cancer in 13 months after pancreatectomy.

Conclusions: Metastatic pancreas neoplasms arising from renal cell carcinoma should be resected to obtain a good prognosis. And organ preserving procedure is indicated for these patients.

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Two Cases of Total Remnant Pancreatectomy Due to Metachronous Cancer of Pancreas

Y. Kimura, Y. Kihara, S. Yamanaga, H. Yokomizo, T. Hirata. Department of Surgery, Kumamoto, Red Cross Hospital, Kumamoto, Japan.

Case 1: A 62 years old woman, had periodic check up, and the cystic tumor at the tail of pancreas and main pancreatic duct dilatation were detected. In JUN 2006, distal pancreatectomy was performed due to intraductal papillary mucinous neoplasm (IPMN). Histological exploration offered a diagnosis that the tumor was intraductal paillary-mucinous tumor with minimal invasion. 20 months after the operation, CT scan revealed a low dense amorphous area in the remnant pancreas. Total pancreatectomy was performed, the histological finding showed invasive cancer derived from IPMN. At first operation, intraductal papillary mucinous adenoma was positive at the proximal pancreatic margin.

Case 2: A 67 years old man was performed distal pancreatectomy due to pancreas body cancer in July 2006. 24 months after operation, he was suffered from obstructive jaundice. Explorations revealed pancreas head cancer and no distant metastasis. Total pancreatectomy was performed and histological finding showed two parts of invasive cancer in resected pancreas. It implicates two possibilities; 1. Recurrence of the pancreas body cancer, 2. Multicentric tumorigenesis.

Both were rare cases, which showed a metachronous invasive cancer of the pancreatic head and the remnant pancreas head cancers were surgically removed. At operation, it was difficult to approach to superior mesenteric vein (SMV), because of inflammation due to distal pancreatectomy. We recommend an approach SMV and gastroduodenal artery, not from the front left side, but from right side, which was intact.

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Metformin Inhibits Growth of Human Pancreatic Cancer Cells In Vitro and In Vivo

K. Kisfalvi,1 J. Sinnett-Smith,1 G. Eibl,2 E. Rozengurt.1 1Department of Medicine; 2Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA.

Epidemiological studies linked Type 2 diabetes and obesity (characterized by insulin resistance and compensatory hyperinsulinaemia) with increased risk of pancreatic cancer. Recently we identified a novel crosstalk in human pancreatic cancer cells by which insulin strikingly enhances G-protein-coupled receptor (GPCR) signaling, including cell proliferation, through an mTOR-dependent pathway.

Metformin, the most widely used anti-diabetic drug, activates AMP kinase, which negatively regulates mTOR. Moreover, epidemiological data showed that metformin lowers the risk of pancreatic cancer in Type 2 diabetic patients. Whether metformin has any direct effect on pancreatic cancer cells, however, is unknown.

Results: In vitro: Metformin (0.1-5mM) dose-dependently reduced cell proliferation of PANC-1, MiaPaCa-2 and BxPc-3 cells and eliminated the synergistic enhancement of insulin on GPCR agonists-induced DNA synthesis, anchorage-dependent and independent growth. Selective AMPK inhibitor dose-dependently reversed the effect of metformin. In vivo: Metformin (250 mg/kg, i.p, once/day, for 25 days) significantly decreased the growth of PANC-1 and MiaPaCa-2 xenografts in nude mice (p < 0.005). Furthermore, in PANC-1 xenografts metformin dose-dependently inhibited the tumor growth, maximum effect was achieved at 200 and 250 mg/kg.

Conclusion: Metformin significantly inhibits the growth of pancreatic cancer cells in vitro and in xenografts in mice. Thus, metformin could be a potential candidate in the treatment of pancreatic cancer.

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Therapeutic Effect of Endoscopic Naso-Pancreatic Duct Drainage for Diabetes Mellitus Associated With Autoimmune Pancreatitis: A Unique Case of Pancreatic Stones Successfully Treated With Endoscopic Technique

N. Kishikawa, T. Nomura, S. Matsuda, T. Ikuta, K. Kanno, M. Mizooka, T. Saiki, S. Tazuma. Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan.

It is known that autoimmune pancreatitis (AIP) is associated with unique features of main pancreatic duct such as diffuse strictures. This change may cause an increase in intraductal pressure. However, it is yet to be clarified whether such a change modulates the pancreatic endocrine and/or exocrine function. We experienced an AIP case with diabetes mellitus (DM), for which endoscopic naso-pancreatic duct drainage (ENPD) was effective. A 67-year-old male undergoing insulin therapy for DM associated with AIP was admitted for the treatment of the pancreatic stones. He has a history of ESWL therapy for pancreatic stones twice in the past two years. Accompanied with these stone extractions, the insulin dosage required per day decreased from 14 to 12 units and from 38 to 28 units respectively. At this admission, abdominal CT scan showed several calculous fragments within the pancreatic head. The images of MRCP demonstrated a dilated and beaded pancreatic duct with a filling defect in the proximal pancreatic duct. To remove the intraductal stone endoscopic retrograde pancreatography (ERP) was performed and the stone was successfully removed endoscopically. Subsequently, ENPD tube was placed for follow-up pancreatogram to confirm stone-free. Afterward, the daily insulin requirement drastically decreased from 26 to 12 units following placement of the ENPD tube, but retrieved to 28 units after the removal of it. Literature shows that the increase in pancreatic ductal pressure results in tissue ischemia and necrosis, presumably leading to DM. Thus, we conclude that the tube stent is a potential therapeutic strategy in the treatment of DM in AIP.

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Impact of Gemcitabine-Based Neoadjuvant Chemoradiotherapy as Preoperative Treatment for Locally Advanced Unresectable Pancreatic Adenocarcinoma

M. Kishiwada, H. Kato, Y. Nobuoka, Y. Azuni, T. Hamada, S. Mizuno, M. Usui, H. Sakurai, M. Tabata, S. Isaji. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University, Tsu, Japan.

Pancreatic adenocarcinoma with involvement of the superior mesenteric artery and/or celiac axis (UICC-T4) was commonly considered unresectable. For selected patients with locally advanced pancreatic adenocarcinoma, gemcitabine-based neoadjuvant chemoradiotherapy (NCRT) may offer the potential for margin-negative (R0) resection, resulting in improvement of prognosis. We assessed the outcome of patients who received NCRT for UICC-T4 histologically-proven pancreatic adenocarcinoma.

From February, 2005 to June, 2009, 28 patients with UICC-T4 determined by contrast-enhanced triphasic MDCT had been enrolled for gemcitabine-based NCRT: 3-dimensional conformation radiotherapy (45 Gy for 5 weeks) and weekly intravenous infusion of gemcitabine (800 mg/square m) for 5 weeks including one-week break. The patients underwent restaging 4 to 6 weeks after NCRT and were taken to surgery.

Completion rate of NCRT was 89.3% (25/28). The 6 patients (21.4%) were precluded from surgery due to distant metastasis at the time of restaging. The rates of resection and R0 resection were 46% (13/28) and 31% (4/13), respectively. The median survival time was 10.9 months in the entire group, and it was significantly longer in the 13 patients with resection than in the 15 patients without resection (16.0 months vs. 9.7 months, P < 0.01).

Even for the UICC-T4 tumors, NCRT can select the patients who are likely to benefit from aggressive resection.

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En Bloc Resection Including Superior Mesenteric Artery and Vein for Locally Advanced Pancreatic Carcinomas (Long-Term Results and Clinicopathological Study)

H. Kitagawa, T. Ohta, H. Nakagawara, H. Tajima, Y. Hayashi, I. Ohnishi, H. Takamura, T. Tani, M. Kayahara, K. Miwa. Department of Gastroenterologic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.

Objective: To assess the long-term results and clinicopathological findings after en bloc resection including superior mesenteric artery and vein (ARPD), a newly designed surgical procedure for locally advanced carcinomas of the pancreas head.

Summary Background Data: Curative resection has been shown to be one of the key factors influencing survival of the carcinomas of the head of the pancreas. However local recurrence is very common as Esposite and his colleague advocated that "Most pancreatic cancer resections are R1 resection". In 2002, We developed a new method for en bloc resection of the pancreas head including the superior mesenteric artery (SMA) and vein (SMV) for pancreatic head carcinoma with portomesenteric invasion, called "augmented regional pancreatoduodenectomy (ARPD)"1). Technical and general eligibility criteria for ARPD were as follows: (1) presumable achievement of R0-status; (2) tumor infiltration proximal to the SMV and SMA; (3) tumor respecting the hapatic artery, splenic artery and celiac trunk and neither hepatic nor paraaortic nodal metastasis in preoperative examination.

Method: Between 2002 and 2005, 16 patients underwent ARPD. Tumor stage and grade were classified according to the sixth edition of the tumor-node-metastasis classification of the International Union against Cancer.

Results: Stage II, III and IV disease were present in 5, 8 and 3 patients respectively. N0 and N1 were present in 3 and 10 patients respectively. Paraaortic lymph node metastases were observed postoperatively in 3 patients (Stage IV). Distant metastasis and dissemination was not observed in all patients. The length of arterial and venous resection were 48 mm (30-70) and 51 mm (20-80) respectively. The reconstruction time of artery and vein were 40 min (16-55) and 40 min (20-80) respectively. Fifteen patients were used venous grafts for artery and venous reconstruction. No pancreatic fistula and thrombosis of the SMV and SMA was observed.

The postoperative death was observed in two patients. One was after full dose radiotherapy, severe abdominal infection due to failure in duodenojejunostomy was complicated. The other was complicated with sepsis due to abdominal abscess and rupture of aortic aneurysm who was old age and accompanied with severe arterial sclerosis. Tumor involved SMV and SMA pathologically in 14 (88%) and 8 (50%) patients respectively. The surgical margins were histologically negative in 13 patients (81%). Median survival was 14 months. The overall 3- and 5-year survival probabilities were 25% and 19% respectively. Three patients survived more than 5 years.

Conclusions: This procedure (ARPD) has advantages in obtaining enough margin at the uncinate and posterior site for patients of pancreatic head carcinoma with SMA or SMV involvement.

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Evaluation of Local Pharmacokinetics of 5-Fluorouracil in Dog Pancreas by EUS-Guided In Vivo Microdialysis

M. Kitano, H. Sakamoto, T. Komaki, K. Das, H. Imai, K. Kamata, M. Kudo. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kinki University School of Medicine, Osaka-Sayama, Japan.

Aim: In vivo microdialysis using a probe with a semi-permeable membrane has been used in vivo to measure dynamic temporal variations in the interstitial concentrations of non-protein-bound substances that are unstable in the systemic circulation. We evaluated the technical feasibility and possible complications of EUS-guided in vivo microdialysis of the pancreas using a specially developed microdialysis-probe that was placed in the pancreatic parenchyma through a EUS-FNA needle.

Methods: Under anaesthesia, EUS emaninations were performed in 8 beagle dogs. Under the guidance of an echoendoscope inserted into the stomach of each dog, the pancreatic parenchyma was punctured using a 19-gauge needle. A specially developed microdialysis probe threaded through the lumen of the 19-gauge needle was positioned in the pancreas. The probe was constantly perfused with saline at a flow rate of 1.0 μl/min. The concentration of 5-fluorouracil (5-FU) in the microdialysate was measured at 10-min intervals, once before and for 8 times after a single (20 mg/kg) bolus intravenous infusion of 5-FU.

Results: Following the administration of 5-FU, the concentration of 5-FU in all macrodialysate samples exceeded the cut-off value by more than 100-fold. The 5-FU levels in the microdialysate increased rapidly, peaked by 10 min (13.9 μg/ml), and gradually declined thereafter. No local bleeding or accumulation of fluid around the pancreas was observed.

Conclusion: EUS-guided pancreatic microdialysis is feasible and has multiple potential clinico-therapeutic applications, including monitoring pharmacokinetics focally and detecting novel biomarkers that are unstable or undetectable in the plasma.

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EUS-Assisted Drainage of Pancreatic Duct for Obstructive Pancreatitis

M. Kitano,1 H. Sakamoto,1 T. Komaki,1 K. Das,1 H. Imai,1 K. Kamata,1 Y. Takeyama,2 M. Kudo.1 1Division of Gastroenterology and Hepatology, Department of Internal Medicine, and 2Department of Surgery, Kinki University School of Medicine, Osaka-Sayama, Japan.

Aim: Stenosis of pancreatic duct due to stricture of anastomosis sometimes occurs after pancreaticogastrostomy reconstruction, resulting in abdominal pain and aggravation of diabetes as a result of ductal hypertension. We report a novel endoscopic drainage assisted by EUS for decompression of obstructive pancreatitis.

Methods: Three patients with obstructive pancreatitis underwent EUS-assisted drainage of pancreatic duct. Etiology of pancreatitis was due to stricture of anastomosis of pancreaticogastrostomy (n = 2) and alcoholic pancreatitis (n = 1). All cases had dilatation of pancreatic duct, and either abdominal pain or hyperglycemia. Deep cannulation of pancreatic duct by conventional ERCP were unsuccessful in those 3 cases. Thus, the pancreatic duct was punctured by 19-gauge needle through the gastric wall under guidance of EUS. After successful ductal visualization by contrast injection fluoroscopically, a guidewire was introduced into the pancreatic duct, and guided into the duodenal or gastric lumen through the papilla or anastomosis. Then, a duodenoscope was introduced and a pancreatic stent was inserted over the guidewire across the stricutre by rendezvous method. When the guidewire did not pass the stricture, a pancreatic stent was inserted directly through the gastropancreatic fistula after dilating it.

Results: Pancreatic stenting was successful through the stricutre or gastropancreatic fistula, and resulted in pain relief and improvement of hyperglycemia in all cases. One case temporally had pancreatic ductal leak at the site of puncture, which was managed conservatively. The pancreatic stents were kept after exchanging to lager size periodically.

Conclusion: EUS-assisted drainage of pancreatic duct can become a method of therapy where conventional ERCP fails because of unpassable strictures or post-surgical altered anatomy.

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Intraductal Papillary Mucinous Neoplasms of the Pancreas Showing Penetration of the Other Organs

G. Kobayashi, N. Fujita, Y. Noda, K. Ito, J. Horaguchi, T. Obana, S. Koshida, Y. Kanno, Y. Kato, Y. Yamashita, T. Ogawa. Department of Gastroenterology, Sendai City Medical Center, Sendai City, Japan.

Background: Intraductal papillary mucinous neoplasm of the pancreas (IPMN) is characterized by slow, expansive progression, and some tumors of this type occasionally penetrate other organs.

Objective: To assess the mechanism of penetration into other organs in IPMN.

Patients: A total of two hundred seventy nine patients with IPMN who underwent endoscopic retrograde cholangiopancreatography (ERCP) at our center.

Main outcome measurements: Clinical prevalence and organs penetrated by the IPMN and analysis of the mechanism of penetration as shown by immunohistopathological study.

Results: Among the subjects, penetration of other organs was observed in 18 patients (6.5%) and into 29 organs. There were seven patients (39%) in whom multiple organs were penetrated. Of the sixteen patients including seven patients who had undergone endoscopic biopsies from fistula, the expression of MUC5AC, MUC2, and MUC1 positive cells were confirmed in 100%, 94% and 38%, respectively. Of the nine patients who had undergone surgery or autopsy, 89% had intestinal-type tumor with MUC2(+), including colloid carcinoma (33%), and 67% showed mechanical penetration without invasion along the tract histologically.

Conclusions: There were two processes in the development of fistulas between the pancreas and other organs in IPMN. Fistula formation due to increased pressure in the mucin filled pancreatic duct was more frequent than direct cancer invasion.

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Mixed Acinar-Endocrine Carcinoma of the Pancreas With Intraductal Growth Into Main Pancreatic Duct: Report of a Case

S. Kobayashi,1 T. Asakura,1 N. Ohike,2 T. Enomoto,1 J. Sakurai,1 S. Koizumi,1 T. Watanabe,1 H. Nakano,1 T. Ootsubo.1 1Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kowasaki, Kanagawa, Japan; 2Department of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan.

The patient was a 75 year-old man. A tumor mass in the pancreatic tail was found 6 months earlier. Computed tomography revealed a mass of 7 cm diameter, and enhancement with contrast medium was observed at the periphery and partially inside the mass, but not in most of the tumor. Endoscopic retrograde cholangiopancreatography revealed a filling defect in the main pancreatic duct. Distal pancreatectomy was performed because of the possibility of malignant tumor. The tumor consisted of a lobular invasive growth component and a component with intraductal growth into the main pancreatic duct, and histologically, the tumor cells had solid acinar to partially trabecular/tubular patterns. Trypsin (an acinic cell marker) expression was widely observed, followed by expression of chromogranin A (an endocrine cell marker) in about 30% of the tumor cells. The tumor was diagnosed as mixed acinar-endocrine carcinoma according to the WHO classification.

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A Case of Pancreatic Neuroendocrine Tumor (NET) With Atypical Looking Which Diagnosed by EUS-FNA

Y. Kobayashi,1 K. Yamao,1 A. Sawaki,1 N. Mizuno,1 K. Hara,1 S. Hijioka,1 H. Imamura,1 K. Matsumoto,1 Y. Shimizu,2 Y. Yatabe.3 1Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan; 2Department of Gastrointestinal Surgery, Aichi Cancer Center Hospital, Nagoya, Japan; 3Department of Pathology and Genetics, Aichi Cancer Center Hospital, Nagoya, Japan.

A 37-year-old woman was presented at 2006 with malignant lymphoma and asymptomatic pancreatic lesion. She was received chemoteraphy for the malignant lymphoma and treated successfully. On November 2008, she was refered to our hospital for further examination of small pancreatic lesion less than 20 mm. CT revealed one cystic lesion in the body of pancreas. Tumor showed iso-contrast enhancement with comparison of pancreatic parenchyma in the arterial phase. On MRCP, the tumor showed hyperintensity and internal intensity was inequality. EUS morphology was mixed solid and cystic parts, and contrast enhanced EUS by SONAZOID showed strong echogenesity. SCN, SPT, and NET were speculated by CT, MRCP and EUS findings. The definite diagnosis was made by EUS-FNA. Cytology showed monotonous, small sized cells with granular chromatin and tumor cells appeared funis structure, immunocytochemical staining showed positivity for chromogranin A and synaptophysin. Cytologic diagnosis was NET and she underwent distal pancreatectomy. The final diagnosis was pancreatic NET (Benign behaviour; non-angioinvasive, no perineural invasion, 17 mm, 1.7% Ki67 positive cells.) The typical cytologic findings and immunocytochemical staining by EUS-FNA allowed the accurate diagnosis of the pancreatic NET which was presented with atypical image findings.

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Exocrine Specific Inactivation of PDX1 Results in Pancreatic Hypoplasia and Diabetes in Mice

S. Kodama,1 Y. Kawaguchi,1 T. Kuhara,1 K. Furuyama,1 A. Fukuda,1 M. Horiguchi,1 R. Doi,1 C.V.E. Wright.2 1Department of Surgery and Surgival Basic Science, Kyoto University, Japan; 2Department of Cell and Developmental Biology, Vanderbilt University, USA.

Introduction: Pancreatic duodenal homeobox gene 1 (pdx1) is a key pancreatic transcriptional factor involved in glucose homeostasis and critical for embryonic development of the pancreas: pdx1 knock out results in pancreas agenesis. However, our knowledge on its role in exocrine pancreas is limited.

The aim of this research is to clarify the function of pdx1 in exocrine of pancreas.

Methods: Using Elastase-Cre mediated conditional inactivation, we analyzed phenotypical and physiological characteristics of the exocrine specific pdx1-inactivated mice. At the same time, we traced the fate of the pdx1-inactivated cells using ROSA26r reporter strain.

Results: Elastase-Cre mediated, acinar specific pdx1 inactivated mice showed growth retardation with severe exocrine dysfunction and many of them could not survive after weaning. As expected, pancreas of the mutant mice is very small, due to the apoptotic cell death and decrease of the acinar cell proliferation. Interestingly, Elastase-Cre mediated PDX-1 mutant mice have reduced endocrine mass and disturbed islet structure resulting in glucose intolerance. This result suggests that there is interaction between exocrine and endocrine of the pancreas.

Conclusion: pdx1 is crucial for cell proliferation, maintenance of the exocrine pancreas during organogenesis. Interaction between exocrine and endocrine pancreas may be important for pancreatic endocrine development.

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Soluble Adenylate Cyclase Mediates Cerulein (CER)-Induced Zymogen Activation in Rat Pancreatic Acinar Cells

T. Kolodecik,1 J. Buck,3 L. Levin,3 F. Gorelick.1,2 1Dept. Internal Med., Sec. of Digestive Diseases, Yale Univ. School of Med. New Haven CT; 2Veterans Affairs Conn Healthcare, West Haven CT; 3Dept. Pharmacology Weill Medical College of Cornell Univ., New York NY.

Supraphysiologic concentrations of CCK (or CER) stimulate acinar cell zymogen activation, an early pancreatitis response, and increase both calcium and cAMP. Two forms of adenylate cyclase, with distinct distributions and regulation, generate cAMP; membrane-associated and soluble (sAC). We hypothesized that the pH sensitive, sAC, might modulate zymogen activation. In isolated acinar cells, a specific inhibitor of transmembrane adenylate cyclases, 2', 5'-dideoxyadenosine, did not affect zymogen activation. However, inhibition of sAC with a specific inhibitor (KH7) increased CER stimulated chymotrypsin activation by 3.29-fold. Treatment with bicarbonate, a sAC activator, significantly decreased CER stimulated chymotrypsin and trypsin activation. To confirm that sAC was present in acinar cells, we used PCR; expression of both the full length (sACfl) and truncated (sACt) iso-forms of sAC was observed. To determine whether the cAMP effects of CER were acting through PKA, we used PKI, a specific PKA inhibitor. This agent had little effect on CER-induced zymogen activation. These data suggest that sAC is present in the pancreatic acinar cell and that its activation by CER results in an inhibition of zymogen activation in a PKA-independent manner. Based on these findings and our previous studies, we speculate that activation of distinct cAMP pools in the acinar cell might have distinct biologic effects.

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The Study on the Treatment of Pancreatic Steatorrhea and Pancreatic Diabetes for Patients With Pancreatic Insufficiency

A. Kon,1 Y. Tando,1 M. Yanagimachi,1 E. Mikami,2 A. Matsumoto,1 S. Chikazawa,1 H. Tanaka,1 T. Suda,1 T. Nakamura,3 T. Takeuchi.4 1Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; 2Department of Dietary Management Center, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; 3Department of Health Science, Hirosaki University School of Medicine, Hirosaki, Japan; 4Tokyo Womens Medical University, Tokyo, Japan.

Introduction: Pancreatic steatorrhea and pancreatic diabetes appear when patients developed pancreatic insufficiency due to chronic pancreatitis or the pancreatectomy. We performed the replacement therapy for the pancreatic insufficiency.

Subjects and Methods: We studied 17 cases with pancreatic insufficiency and average observation period is 8.9 years. We investigated the nutritional state, the frequency of hypoglycemia, changes of the insulin preparations, in addition we compaired insulin preparations of conventional therapy with the intensive therapy.

Results: The body weights and serum albumin levels were significantly improved. The frequency of hypoglycemia decreased. While the number of patients with conventional insulin therapy decreased,those with intensive insuline therapy increased. Insulin requiring dose increased significantly and HbA1c showed improvement.

Conclusion: Our results suggested that the nutritional state is improved with the long -term pancreatic enzyme preparations and that the change of insulin preparation showed excellent glycemic control.

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The Advantage of the Three-Dimensional Virtual Simulation Software for Safety Management of Pancreaticoduodenectomy

Y. Kondo, N. Kuroda, J. Yamanaka, Y. Iimuro, T. Hirano, T. Okada, Y. Asano, M. Satake, J. Fujimoto. Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.

Background: Pancreaticoduodenectomy (PD) is commonly accepted as the standard operation for pancreatic diseases. However, until recently, many reports have been suggesting that hepatic arterial (HA) variations make this procedure difficult and HA injuries cause serious postoperative complications. Therefore, we sought that to keep the HA blood supply is the critical for intra, peri and postoperative course of patients. Recently, we have reported the advantage of three-dimensional virtual simulation software (3D-virtual simulation) for safety management of hepatectomy. The aim of this study is to assess the advantage of 3D-virtual simulation, for preoperative analysis of HA, to undergo PD more safety.

Methods and Results: From June-2008 to June-2009, we underwent 31 cases of PD in our department. All patients were examined by 3D-CT and HA were reconstructed as the virtual imaging in preoperative state. Ten cases show HA variations, replaced or accessory HA or both. By using the virtual imaging of HA, we could preserve them and could keep their blood supply in all cases without complications.

Conclusions: As same as the more recent reports, HA variations are not rare at our department. Avoiding injury and preserving HA seems the crucial during peri- and post-operative course of patients. Our results demonstrate that 3D-CT/virtual simulation of HA bring advantage to undergo PD more safety.

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Identification of Genes Related With Radioresistance in Pancreas Cancer Cell Lines by cDNA Microarray

S. Kozono, K. Ohuchida, N. Ikenaga, K. Mizumoto, M. Tanaka. Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Objectives: Pancreatic cancer is a devastating disease that is characterized by a marked resistance to radiotherapy. In this study, we identified the gene expression involved in resistance to radiationtherapy in pancreatic cancer cell lines.

Methods: To identify genes that contribute to radioresistance, two pancreatic cancer cell lines, CFPAC-1 and Capan-1, were subjected to repeated exposures to radiation and we established two radioresistant cell lines derived from CFPAC-1 and Capan-1 cell lines. Subsequently, gene expression profilings using a cDNA microarray to indentify genes responsible for radioresistance were performed.

Results: We identified 27 genes that show differential expression between the radioresistant and parent pancreatic cancer cell lines. Microarray analysis identified 4 genes that were relatively overexpressed in two radioresistant cell lines compared with each parent cell lines, while 23 gene expressions are repressed. 4 overexpressed genes included S100A4 that was reported to be related with radiation exposure. Meanwhile, 23 down-regulated genes, which have not been reported to have relevance with radioresitance, included 7 down-regulated genes that were potentially involved in apoptosis, the cell attachment, the inhibition of cell proliferation and tumor suppression.

Conclusions: These genes may play an important role in the poor response to radiation therapy in patients with pancreatic cancer.

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Prevalence of Neoplasia in Small and Potentially Resectable Focal Pancreatic "Mass" Lesions Noted on CT/MRI in Non-Jaundiced Patients

N. Krishna, C. Meehan, B. Agarwal. Division of Gastroenterology, Saint Louis University, St. Louis, MO.

Background: Small and potentially resectable focal non-cystic pancreatic "mass" lesions are frequently identified on CT/MRI. The prevalence of neoplasia in these lesions is currently unknown especially in patients without obstructive jaundice (ObJ).

Patients and methods: This is a retrospective analysis of our prospective database. From 2002-07, we found 137 patients (without ObJ) who underwent EUS-FNA for evaluation of a focal pancreatic lesion, ≤25 mm and potentially resectable on CT/MRI. We then excluded patients 1) without an identifiable lesion on EUS (n = 11, none had malignancy during follow-up) and 2) when lesion was cystic on EUS exam (n = 17). Final diagnosis was based on surgical pathology or clinical follow (≥ 12 months). The median follow-up was 16 months (12-33 months).

Results: The mean age of 109 patients (56 males) was 63.4 ± 12.9 years. 55 patients had a final diagnosis of malignancy which included adenocarcinoma (n = 41), NE tumors (n = 12), malignant lymphoma (n = 1) and metastasis (n = 1). 19 of 29 (65.5%) lesions ≤15 mm, 23 of 36 (66.6%) 16-20 mm and 12 of 44 (27.3%) lesions 21-25 mm in size were benign. 3 of 29 (10.3%) lesions ≤15 mm, 11 of 36(30.5%) lesions 16-20 mm and 27 of 44 (61.4%) lesion 21-25 mm had an adenocarcinoma. NE tumor was the most common neoplasm amongst lesions ≤15 mm. EUS-FNA had 96.3% overall accuracy with 94.6% sensitivity and 94.6% NPV with no significant differences amongst the three size groups. In multivariate analysis, patient age and lesion size had a positive correlation and history of abdominal pain had a negative correlation with malignant diagnosis.

Conclusions: In non-jaundiced patient with potentially resectable pancreatic lesion ≤25 mm noted on CT/MRI, the probability of malignancy decreases with decreasing size. EUS-FNA has high accuracy and NPV for identifying neoplasia in these lesions.

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Association of Epidermal Growth Factor Receptor (EGFR) and Mitogen-Activated Protein Kinase (MAPK) With Cystic Neoplasms of the Pancreas

Y. Kuboki,1,2 K. Shiratori,1 T. Hatori,1 M. Yamamoto,1 M. Kobayashi,3,4 T. Furukawa.2,4 1Institute of Gastroenterology, 2International Research and Educational Institute for Integrated Medical Sciences, 3Department of Pathology, Tokyo Women's Medical University, 4Department of Surgical Pathology, Tokyo Women's Medical University Hospital, Tokyo, Japan.

Background and Aim: We investigated an association of EGFR, MAPK and AKT with the pancreatic cystic neoplasms.

Materials and methods: 39 serous cystic neoplasms (SCNs) and 33 mucinous cystic neoplasms (MCNs) were analyzed for expressions of native and active/phosphorylated forms of EGFR, MAPK and AKT by immunohistochemistry. EGFR mRNA copy number for 7 SCNs and 8 MCNs were analyzed by using quantitative PCR. Genomic DNA from SCNs and MCNs were isolated and directly sequenced to identify EGFR, KRAS, BRAF and PIK3CA mutations. EGFR gene amplifications were investigated in 6 SCNs using southern hybridization.

Results: Expression of EGFR, p-EGFR, MAPK, p-MAPK, AKT and p-AKT were observed in 100%, 53.8%, 100%, 69.2%, 0% and 0% of SCNs and in 12.1%, 0%, 33.3%, 27.3%, 0% and 0% of MCNs, respectively. EGFR transcriptions were significantly increased in SCNs than those in MCNs (p < 0.000221). KRAS somatic mutations were found in 2 MCNs but not in any SCNs. The amplification of EGFR gene was not detected in any SCNs.

Conclusion: EGFR and MAPK were actively involved in development of SCNs, which may indicate that the molecular targeting of EGFR and MAPK is rational for medical treatment of SCNs.

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Highly Active State of Autoimmune Pancreatitis With Mikulicz's Disease

K. Kubota, S. Umezawa, S. Kato, Ni Kobayashi, A. Nakajima. Division of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.

Objectives: Patients with autoimmune pancreatitis (AIP) sometimes present with Mikulicz's disease (MD), however the clinical features regarding these AIP patients with MD have not yet been fully elucidated. Our aim is to study the clinical differences between AIP with and without MD.

Methods: Twenty-eight consecutive AIP patients were divided into two groups, one with MD and one without it. The following factors having a possible association with the presence or absence of MD were investigated: gender; sex; serum IgG and IgG4 levels; the presence or absence of antinuclear autoantibodies, jaundice, diabetes mellitus, swollen duodenal papilla, diffuse pancreatic swelling, spontaneous remission and relapse.

Results: The MD and non-MD groups consisted of 5 AIP and 23 AIP patients, respectively. The results of univariate analysis revealed that AIP patients presenting with MD were significantly associated with a younger onset, female predominance, high serum IgG4 titer, and diffuse pancreas swelling (p < 0.05). In 4 of the MD patients, onset preceded pancreatitis and/or sclerosing cholangitis. Relapse and complication with adult-onset bronchial asthma were seen in 3 of the 5.

Conclusions: AIP patients presenting with MD tended to have different clinical features from the non-MD AIP patients, such as an earlier onset, female tendency, and diffuse pancreatic swelling with a high titer of serum IgG4. AIP with MD showed these characteristic features and tended to precede gastroenterological events.

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Efficient Secretion of Insulin From Β-Cells Requires Cell-To-Cell Adhesion

M. Kudo, T. Fujii, K. Teduka, Y. Kawamoto, T. Suzuki, K. Kawahara, T. Ishiwata, Z. Naito. Department of Integrative Oncological Pathology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.

Introduction: Recently, several reports have suggested that cell-to-cell adhesion affects β-cell functions such as insulin secretion, and the roles of gap junction communication and cell adhesion molecules such as epithelial (E)-cadherin in β-cell functions have been investigated. In this study, we investigated the effect of cell-to-cell adhesion on β-cell functions such as insulin secretion using the MIN6 cell line which secretes insulin.

Methods: MIN6 cells were cultured on a low-cellular-adhesiveness culture plate for 3-8 days to form MIN6 pseudoislet cells, which are three-dimensional isle like clusters. The expression levels and localization of cell adhesion molecules and molecules related to insulin synthesis / secretion were analyzed, and the amounts of insulin secreted from MIN6 cells and pseudoislet cells were determined.

Results: The expression levels of insulin, Foxa2, and PDX-1 of pseudoislet cells tended to be higher than those of monolayer cultured MIN6 cells. The E-cadherin immunoreactivity was low in monolayer cultured MIN6 cells, but E-cadherin immunoreactivities at the periphery and cell-to-cell adhesion parts of pseudoislet cells were markedly high. The total amount of insulin secreted from pseudoislet cells was significantly higher than that from monolayer cultured MIN6 cells.

Conclusion: These findings suggest that cell-to-cell adhesion plays an important role in β-cell functions.

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Neoadjuvant Chemoradiation With Gemcitabine and S-1 for Patients With Locally Advanced Pancreatic Cancer

M. Kurata,1 G. Honda,1 K. Tsuruta.1 T. Kamisawa,2 K. Karasawa.3 1Department of Surgery, 2Department of internal medicine, and 3Department of radiology, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan.

Aim: We addressed the safety and efficacy of Gemcitabine(GEM) and S-1 combined with radiotherapy and determined the profile of dose limiting toxicities and recommended Phase II dose (RPTD) in patients with locally advanced pancreatic cancer.

Patients and Methods: Chemotherapy consisted of 5 weekly infusions of GEM (starting at 200 mg/m2) and S-1 (80 mg/m2; day 1-5; week 1-5) combined with radiotherapy (50.4Gy in 28 fractions administered over 5 weeks) delivered 5 days per week. GEM and S-1 were given concurrently. Patients underwent restaging 4 weeks after completion of chemoradiation and, in the absence of distant metastasis, underwent intraoperative radiotherapy (IORT) after surgical resection or IORT alone.

Results: Thirteen patients were enrolled. Twelve patients completed chemoradiation. One patient had to stop the treatment due to Grade 3 thrombocytopenia. There were 10 temporary interruptions because of hematological toxicity G3 and anorexia G3. Bone marrow suppression was the primary and dose-limiting toxicity of this regimen. The RPTD of GEM/S1 was determined to be 200 mg/m2/80 mg/m2. Six patients had partial response and 7 had stable disease. Four patients received pancreaticoduodenectomy and IORT. Other 7 were taken IORT alone because of SMA invasion. One patient is waiting for treatment.

Conclusion: Preoperative chemoradiation with GEM and S-1 well tolerated, and was potentially effective in the neoadjuvant setting.

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Small Pancreatic Cancer With Giardiasis: A Case Report

A. Kurita, H. Maguchi, K. Takahashi, A. Katanuma, M. Osanai. Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan.

Context: The protozoan Giardia lamblia is a major cause of gastrointestinal disease worldwide. However, it is rarely found in the pancreas.

Case Report: A 59-year-old female with Type II DM was referred to our institution after imaging studies revealed a mass in the pancreatic head. The imaging had been performed to help evaluate recent rapid worsening of her diabetes.

Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture at the head of the main pancreatic duct. Cytology of brush sampling showed no malignant cells and similarly there was no evidence of malignancy in biopsies of the mass obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). However, numerous pear-shaped, binucleated, flagellated organisms morphologically consistent with trophozoites of Giardia lamblia were identified in both specimens. The patient was treated with metronidazole for 7 days. On repeat imaging one month later, the size of the pancreatic mass had not changed. A second EUS-FNA was performed and this time adenocarcinoma was confirmed. Pancreatoduodenectomy was performed and the pathological diagnosis was invasive ductal carcinoma of the pancreatic head limited to the pancreas. Tumor size was 15 × 12 mm and its final stage was Stage IA.

Conclusion: This rare case of pancreatic cancer occurring in association with Giardia infection caused diagnostic difficulties.

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Experience of Local Resection of the Head of the Pancreas Combined With Longitudinal Pancreaticojejunostomy: Frey's Procedure in the Managemnt of Patients With Chronic Pancreatitis

N. Kuroda, M. Satake, K. Suzumura, M. Takahashi, K. Ohashi, Y. Yoshida, Y. Asano, T. Okada, K. Oh, J. Fujimoto. Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.

Backgrounds: The Frey's procedure was designed to improve decompression of the head of the pancreas results in relief of intractable pain of the patients with chronic pancreatitis. In the present study, we analyzed the clinical outcome of this surgical procedure in the patients with chronic pancreatitis.

Methods: The operation was performed on 10 patients. 17% of the patients were alcoholics, 50% had pseudocysts and 100% had calcification. To relief from pre operative pain, narcotic intake was observed in all patients, opioid in 3 patients and NSAID in 7 patients.

Results: The Frey's procedure was performed on all of the patients. In one case, distal pancreatectomy was added because of intractable of calcification in the tail of pancreas. Pain relief was excellent in all patients and no narcotic intake was needed after the operation. Endocrine status in 10 patients was as follows: 30% were not diabetic preoperatively and postoperatively. 70% were diabetic preoperatively, but endocrine function was not worsened postoperatively. Exocrine function was not worsened in all patients.

Conclusions: The Frey's procedure seems to offer an effective means of reducing the intractable pain of chronic pancreatitis without adding the burden of endocrine and exocrine insufficiency.

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Circulating Levels of Srage and HMGB1 in Patients With Acute Pancreatitis

L. Kylänpää,1 O. Lindström,1 E. Tukiainen,1 P. Mentula,1 P. Puolakkainen,1 H. Repo.2 1Department of Surgery; 2Department of Medicine, University of Helsinki, Helsinki, Finland.

Background: Organ failure in acute pancreatitis (AP) is characterized by an overwhelming production of mediators of inflammation including high mobility group box chromosomal protein (HMGB) 1. Once release, HMGB1 binds to the receptor of advanced glycation end products (RAGE) and its soluble form (sRAGE). Recently, it has been reported that serum HMGB1 levels are elevated in patients with AP while, there are no reports of AP patient's circulating sRAGE levels.

Aim: To study in AP patients the plasma sRAGE and HMGB1 levels, followed-up for 12-days after hospitalization, in relation to the occurrence of organ failure and mortality.

Patients and methods: 38 patients with severe AP and organ failure (grade 2). A control group (127 patients) consisted of 38 patients with severe AP without organ failure (grade 1) and 89 patients with mild AP (grade 0). Plasma samples for determination of HMGB1 and sRAGE were collected on admission and on Day 1-2, 3-4, 7-12 post admission.

Results: The median of the highest sRAGE levels was higher in grade 2 patients (472 pg/ml, IQR 259-912) than in grade 0 plus grade 1 patients (349 pg/ml, IQR 209-544, p = 0.024). Among the patients with detectable HMGB1, the median of the highest HMGB1 levels was 117 ng/ml (IQR 56-212, n = 24) in grade 2 patients and 87 ng/ml (IQR 54-161, n = 62) in grade 0 plus grade 1 patients (p = 0.310).

Conclusions: We demonstrate that sRAGE, but not HMGB1, is significantly higher in AP patients who develop organ failure than in AP patients who recover without organ failure.

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Total Pancreatic Ductal Decompression Is a New Type of Surgery in Chronic Pancreatitis

V.N. Klymenko, A.V. Klymenko. Zaporozhye State Medical University, Zaporozhye, Ukraine.

Introduction: standard chronic pancreatitis surgical treatment such as longitudinal pancreatojejunostomy, Beger, Frey, Whipple procedures has some disadvantages because of insufficient proximal Wirsungeal decompression and overadicalism treating benign disease.

Objectives: To gain better chronic pancreatitis surgery results using saving parenchyma techniques.

Methods: We invented new operative technique-longitudinal total pancreatowirsungoduodenopapillotomy with formation of longitudinal total pancreatojejunoduodenostomy by Roux-en-Y in 27 patients (25 male, median age: 51 years). We examined all of them by US, ERCPG, CT-scan and fond them suffering from chronic pancreatitis with calculosis and strictures of Wirsungeal duct, enlargement of pancreas because of parenchyma cystic transformation and calcinosis, biliary and segmental portal hypertension, duodenostasis.

Results: There was no mortality in the group. In 12-24 months period there was a significant diminishing of pancreas head size in 92,5%. Abdominal pain discontinued in 96,2%. Glycemia improved in 88,8%. Dosage of enzymes intake strongly decreased in all the patients. 18 patients stopped having enzymes at all. All the patients had normal duodenal passage, size of portal vein, common bile duct, spleen and normal parameters of bilirubin, alkaline phosphatase and Y-glutamiltransferase.

Conclusion: Longitudinal total pancreatowirsungoduodenopapillotomy with formation of longitudinal total pancreatojejunoduodenostomy by Roux-en-Y is a saving pancreatic parenchyma technique that totally and instantaneously eliminates pancreatic and biliary hypertension, duodenostasis. This procedure maintains physiological passage of bile and pancreatic secretion and can be an alternative to Beger, Frey and Whipple procedures. The procedure gives one a possibility to check natural course of the disease by endoscopy of the main pancreatic duct with pancreatic tissue biopsy through orifice of pancreatojejunoduodenostomy.

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Exocrine Pancreatic Insufficiency in Patients With End-Stage Renal Disease

J. Griesche-Philippi,1 J. Otto,2 P. Maisonneuve,3 P.G. Lankisch.4 1Nephrologische Praxis, Lüneburg; 2Department of Internal Medicine, University of Göttingen, Göttingen; 3European Institute of Oncology, Milan, Italy; 4Clinic for General Internal Medicine, Medical Centre, Municipal Clinic of Lüneburg, Lüneburg, Germany.

Background and aim: Over three decades ago, several studies showed that up to 60% of patients with end-stage renal disease had exocrine pancreatic insufficiency (EPI) as demonstrated by the secretin-pancreozymin test (SPT). Because the SPT is now available only in very few places, we investigated whether and how often EPI can be demonstrated in hemodialysis (HD) patients by means of fecal elastase-1 (FE-1) assay.

Methods: The study included 50 patients. FE-1 was determined using two different methods (Bioserv Diagnostics and Schebo-Biotech), and stool weight and stool fat content were measured.

Results: Mild EPI (100-200 μg/g stool) was found in 5 (10%) patients. It was not correlated with age, gender, underlying nephrological disease, or HD duration. In no case was pancreatic enzyme substitution (FE-1 < 100 μg/g stool) required. Nine (18%) patients had mild diarrhea (200-300 g/day), and 10 (20%) had mild steatorrhea (7-15 g fat/day). In 6 (67%) and 5 (50%) patients respectively, the diarrhea and steatorrhea could be explained by the simultaneous administration of an ion exchanger (binding of bile acids).

Conclusion: EPI has become a rare and clinically insignificant problem in HD patients. This may be because dialysis places are no longer in short supply and patients with end-stage renal disease can be started on dialysis while their general and nutritional status is still good. Whether the equally rare but not readily explicable diarrhea/steatorrhea are clinically significant remains to be shown.

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Pancreatic Pseudocysts: Prognostic Factors for Their Development and Their Spontaneous Resolution

P.G. Lankisch,1 B. Weber-Dany,1 P. Maisonneuve,2 A.B. Lowenfels.3 1Municipal Clinic of Lüneburg, Lüneburg, Germany; 2European Institute of Oncology, Milan, Italy; 3New York Medical College, Valhalla, NY, USA.

Background: It remains unknown what conditions favour the formation, or the subsequent spontaneous resolution, of a pancreatic pseudocyst (PP).

Aim: To characterize the prognostic factors for their development and their spontaneous resolution.

Methods: In a prospective multicentre study the severity of disease in 369 patients with a first attack of acute pancreatitis (AP) was determined (clinically, prognostic factors, CECT within 96 hrs). US of the pancreas was performed at discharge and 3 and 6 months later.

Results: The risk factors for fluid collections at discharge (present: 124 [34%], group 1; absent: 245 [66%], group 2) were severe initial pain; signs of peritonitis; high Ranson, Imrie and Balthazar scores. At 3 months, a PP was found in 36 (10%) patients (group 1: 30, 24%; group 2: 6, 2%). Spontaneous resolution or decrease in size was found after 6 months in 11 (31%) and 8 (22%) patients, respectively. The milder the symptoms (nausea, vomiting, pain), the greater was the likelihood of spontaneous shrinkage or complete resolution. Ten of 11 cysts that were no longer demonstrable at 6 months had initially been <4 cm in diameter.

Conclusion: Patients with a severe first attack of AP and a fluid collection at discharge should be examined by US 3 months later to detect/exclude a PP. In patients with a PP and mild symptoms amenable to conservative treatment, any intervention should be postponed for a further 3 months because the pseudocyst may resolve spontaneously.

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Raised Serum Creatinine: Marker for Pancreatic Necrosis in Acute Pancreatitis? Results of a Prospective Multicentre Study

P.G. Lankisch,1 B. Weber-Dany,1 P. Maisonneuve,2 A.B. Lowenfels.3 1Municipal Clinic of Lüneburg, Lüneburg, Germany; 2European Institute of Oncology, Milan, Italy; 3New York Medical College, Valhalla, NY, USA.

Background and aim: Raised serum creatinine (SC) is considered an unfavourable prognostic parameter in acute pancreatitis (AP). Increased SC after 48 h was recently described as a marker for pancreatic necrosis (PN) in AP. The aim of this study was to test that statement.

Methods: In a prospective multicentre study carried out together with the Arbeitsgemeinschaft Leitender Gastroenterologen im Krankenhaus (ALGK; Joint Working Group of Senior Hospital Gastroenterologists), SC levels (abnormal ≥2 mg/dL) was determined on admission and 24/48 hours thereafter and compared with the findings of CECT in 465 patients with a first attack of AP obtained within 96 hours after admission.

Results: PN was present in 62 (13%) of the patients. SC on admission and after 24/48 h were evaluated versus the presence or absence of PN. Sensitivity rates varied between 14 and 23%, specificity between 95 and 97%, positive predictive values between 41 and 50%, and negative predictive values between 87 and 89%. Receiver operating characteristic curves revealed an area under the curve of between 0.604 and 0.669.

Conclusion: An increased SC concentration at any time during the first 48 h after admission to hospital is not a marker for PN in a first attack of AP. If SC is normal, however, necrotising pancreatitis is unlikely and CECT need not be performed, unless complications occur.

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The Role of Heat Shock Protein 70 in Pancreatic Stellate Cell

H.S. Lee, Y.D. Kwon, Y.M. Choi, H.J. Yim, S.W. Lee, J.H. Choi, C.D. Kim. Dept. of Gastroenterology, Ansan Hospital, College of Medicine, Korea University, Ansan, Korea.

Background: PSC plays a crucial role in pancreatic fibrogenesis in CP. PSC shows cellular transformation in response to various exogenous stress. HSP70 are expressed in the cell as a response to external stimulation such as nonlethal hyperthermia. HSP70 is also induced by pathophysiologic stress. Here, we investigate the role of HSP70 in PSC in terms of cell proliferation and cell transformation.

Methods: PSC were incubated in the 42C for 2 hr and recovered in 37C for 24 hr in order to induce HSP70 expression. PSCs were treated with PDGF, TGF-β and LPS in control state and heat treated state. PSC proliferation and transformation was evaluated with Brd-U assay and expression levels of α-SMA by western blotting, respectively. Simvastatin and quercetin were used in order to inhibit cell proliferation and HSP70 expression.

Results: Heat treatment induced HSP70 expression in PSC. PDGF and LPS induced significantly HSP70 expression in both quiescent and active form of PSC, but TGF-β fail to induce HSP70. PDGF treatment resulted in about 3 folds increase of PSC proliferation. LPS treatment also increased PSC proliferation but, in lesser degree. However, TGF-β did not induce PSC proliferation. Heat preconditioning, which induced HSP70 overexpression, did not affect cytokines induced α-SMA expression. Simvastatin suppressed HSP70 expression and proliferation induced by heat or PDGF. Quercetin completely inhibited PDGF-induced HSP70 expression and cell proliferation and partly inhibited heat-induced effects. However, heat preconditioning which induced HSP70 overexpression had no additional effect on PDGF induced cell proliferation.

Conclusions: Our findings show a correlation of HSP70 expression with PSC proliferation but not with cell transformation. Inhibition of HSP70 expression abolished the effect of PDGF on cell proliferation. These findings suggest that the modulation of HSP70 expression may be an effective therapeutic target for CP.

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EphA2 Is Regulated by EGF Via the Ras/MAPK Pathway in Pancreatic Cancer

P.A. Levin,1 T. Arumugam,1 D.J. McConkey,1 S. Reddy,2 C.D. Logsdon.1 1Department of Cancer Biology, 2Department of Gastrointestinal Medical Oncology, UT MD Anderson Cancer Center, Houston, TX.

Background: We have previously shown that the EphA2 receptor stimulates pancreatic cancer growth and metastases in mice. Recently, EGFR inhibitors have had some success in treating pancreatic cancer (PC). The objective of this study was to determine a possible relationship between EGFR and EphA2.

Methods: The effects of EGF on EPHA2 expression at the mRNA (QRT-PCR) and protein (Western blotting) levels were analyzed. To examine the role of endogenous EGF on EphA2 expression, a panel of 13 cell lines was treated with gefitinib, an EGFR inhibitor. Erk involvement in EphA2 regulation was analyzed by treating MPanc96 cells with 2 inhibitors specific for MEK1/2. In order to investigate regulation of EphA2 upstream of MEK1/2, MPanc96 cells were transfected with siRNA against mutant K-Ras.

Results: EGF treatment led to a dose- and time-dependent up regulation of EphA2 at the RNA and protein levels in PC cells. EphA2 protein levels decreased in 5 of 13 cell lines after gefitinib treatment. A reduction in EphA2 expression was correlated with a reduction of Erk, but not Akt or STAT3, phosphorylation. EphA2 RNA and EPhA2 protein levels decreased in a time- and dose-dependent manner after treatment with MEK1/2 inhibitors. Silencing of mutant K-Ras decreased EphA2 RNA and protein levels.

Conclusions: The data suggest that EphA2 levels are regulated by the RAS/MAPK pathway and that even in the presence of constitutively active K-Ras, EGFR plays an important role in regulating EphA2 receptor expression in some cells.

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Three-Dimensional Cultures Are the Prefered Models for the Growth Effects of Fatty Acids in Pancreatic Cancer Cells

A. Li, S. Kang, J. Park, H.A. Reber, O.J. Hines, G. Eibl. Hirshberg Laboratory for Pancreatic Cancer Research, UCLA Center of Excellence in Pancreatic Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Introduction: We have previously reported that in contrast to the n-6 PUFA arachidonic acid (AA) the n-3 PUFA eicosapentaenoic acid (EPA) decreased pancreatic cancer (PaCa) growth. However, the observed effects using standard two dimensional (2D) culture conditions were only modest. It has become recognized that the phenotype of cancer cells changes in more relevant three-dimensional (3D) assays. The aim of the present study was to assess the effects of AA and EPA on PaCa cell growth using 3D growth assays.

Methods and Results: The human PaCa cell lines MIA PaCa-2 with (MP2+COX2) or without (MP2-COX2) COX-2 expression, and BxPC-3 (COX2+) were used. Culture dishes were coated with Matrigel. Exposure of MP2+COX2 cells to AA in the 3D assay increased growth by more than 12-fold in 3D but 1.3-fold in 2D. EPA decreased growth in 3D assays by 17-fold but only by 2.8-fold in 2D assays. Similar effects were seen in the MP2-COX2 cells and BxPC-3 cells. Confocal microscopy analysis revealed that EPA treatment decreased the proliferative index and reduced Akt phosphorylation in PaCa cells.

Conclusion: In pancreatic cancer cells the growth enhancing effects of the n-6 as well as the growth inhibitory effects of the n-3 were significantly more pronounced in 3D compared to standard 2D culture assays. Our data indicate that 3D assays be the preferred method to evaluate growth effects of fatty acids in pancreatic cancer cells.

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CXCL5 Correlates With Survival and Mediatates Pancreatic Cancer Growth

A. Li, J. King, A. Moro, M.D. Sugi, D.W. Dawson, J. Kaplan, G. Li, X. Lu, V.L.W. Go, H.A. Reber, G. Eibl, O. Joe Hines. UCLA Center for Excellence in Pancreatic Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Angiogenesis is a mandatory component for the progression toward and maintenance of a malignant phenotype. Array analysis of pancreatic cancers (PaCa) finds that the angiogenic factor CXCL5 is one of the most differentially expressed genes. In this study, we analyzed the clinical significance of CXCL5 utilizing resected PaCa samples, and the role of CXCL5 inhibition in PaCa growth in vivo.

Methods and Results: Real time PCR showed that CXCL5 mRNA level was increased in cancer compared to normal pancreas tissue in 14 out of 17 (82.4%) patients. A majority (66.7%) of the high CXCL5 mRNA expression cancers were poorly differentiated. Tumors with elevated CXCL5 mRNA were two-fold larger by volume. Immunohistochemistry confirmed most of cancer specimens (77.3%) overexpressed CXCL5 compared to normal tissue. Tissue microarray analysis of 153 archived PaCa samples revealed that 136 of 153 specimens tested positive for CXCL5. A clear survival advantage was identified for patients with low CXCL5 tumor expression (mean survival 64 ± 8 [95% CI 48.9-79.1] vs. 38 ± +/−5 mons [95% CI 29.2-47.8], P = 0.002). siRNA treatment against CXCL5 slowed tumor growth (44%) in a murine pancreatic cancer xenograft and decreased tumor CXCL5 by 47.3% (p = 0.002) and serum CXCL5 by 57.3% (p = 0.001).

Conclusion: These findings indicate that CXCL5 expression correlates with patient survival following resection of PaCa. Blockade of CXCL5 may serve as a critical adjunct to therapy against pancreatic cancer.

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Delivery of Enzymes Into the Duodenum of Subjects With Severe Pancreatic Exocrine Insufficiency (EPI) From a Non Enteric Coated Enzyme Preparation Administered With Omeprazole

J. Lieb,1 C. Curington,1 R. Coston,1 M.J. Dumoulin,2 I.T. Shaw,2 P. Toskes.1 1Division Gastroenterology, University of Florida, Gainesville, FL; 2Axcan Pharma Inc., St-Hilaire, QC, Canada.

Aim: To demonstrate adequate delivery of lipase, trypsin, and amylase into the duodenum by VIOKASE®16.

Methods: Twelve subjects with severe EPI (fecal elastase <100 mcg/g stool) participated in an open-label, randomized, single center, crossover trial. Each subject had two separate gastro-duodenal perfusion procedures with 14C-PEG as a marker. Subjects were randomized to receive both Ensure Plus liquid meal alone and Ensure Plus with 3 tablets VIOKASE®16. All subjects were on omeprazole (20 mg/day) starting 5 days prior to and throughout the study. The primary efficacy endpoint was the amount of lipase released and recovered in the duodenum after administration of VIOKASE®16 under fed conditions. Secondary endpoints were trypsin and amylase delivery.

Results: Enzyme data are expressed as the sum of Ensure Plus with VIOKASE®16 minus the sum of Ensure Plus over the 2 hour perfusion period. Cumulative activity of lipase, p = 0.0034; trypsin, p = 0.0017 and amylase, p = 0.0188 is statistically significant. % recovery for each enzyme was: lipase 64.1, trypsin 29.2 and amylase 21.3. VIOKASE®16 was well tolerated with no related adverse events.

Conclusion: In subjects with severe EPI (on omeprazole) lipase, trypsin and amylase were released in clinically relevant amounts into the duodenum after ingestion of VIOKASE®16 with a liquid meal. The remarkable recovery of lipase suggests proton pump inhibition may enhance delivery of VIOKASE®16.

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Generation of Human, Mouse, and Rat Pancreatic Stellate Cell Lines for Studying Transcriptional Control of Extracellular Matrix Synthesis

A. Liebl, A. Mathison, J. Bharrucha, V. Shah, G. Lomberk, R. Urrutia. Mayo Clinic. Rochester, MN.

Pancreatic Stellate Cells (PSC) are abundant in chronic pancreatitis and cancer. However, little is known on molecular pathways that are critical for the function of these cells in pancreatic diseases. Thus, well-characterized stellate cell lines need to be available. We report the generation of PSC lines from human, rat, and mouse. Rodent PSC isolated by differential gradient centrifugation were characterized by vitamin A-storing droplets and known molecular markers. Primary human PSC were isolated upon outgrowing from pancreatic tumors. Both human and rodent PSC were transformed by retroviral infection with SV40 and cloned by limiting dilution. Cloned lines were treated with their physiologically relevant growth factors (TGFβ and PDGF-D), and their biosynthetic response of extracellular matrix genes measured by Q-PCR arrays. Their potential application for transcriptional studies was demonstrated by their expression of key chromatin proteins including Sin3a, HDACs, CBP, p300 and HP1 as detected by PCR, western blot, and immunofluorescence. Together, these results strongly support that: 1. Cloned cells from all three species maintained a differentiated stellate cell phenotype, 2. Their response to TGFβ and PDGF-D demonstrate their applicability to investigations on ECM, and 3. The presence of well-characterized chromatin cofactors make them a useful tool for transcriptional studies. Thus, these PSC represent a unique toolkit for advancing our knowledge on the biology and physiopathology of ECM in chronic pancreatitis and cancer.

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Disturbed Tissue Factor Regulation Associates With Organ Failure and Predicts Death in Acute Pancreatitis

O. Lindström,1 E. Tukiainen,1 L. Kylänpää,1 P. Mentula,1 P. Puolakkainen,1 U. Wartiovaara-Kautto,2 H. Repo,2 J. Petäjä.3 Department of 1Surgery; 2Medicine; 3Pediatrics, University of Helsinki, Helsinki, Finland.

Background: Being a central link between inflammation and coagulation, tissue factor (TF) and its inhibitor (TFPI) might associate with the severity of acute pancreatitis (AP). Organ failure might involve perturbations in TF/TFPI physiology.

Patients and methods: 9 AP patients with organ failure and 24 control patients, of whom 11 patients had mild AP and 13 severe AP without organ failure. Plasma samples were collected on admission. TF induced thrombin generation in plasma samples was studied using the thrombogram method. In vivo thrombin generation was estimated by prothrombin fragment F1+2. Free and total TFPI were measured.

Results: There was no significant difference in F1+2 levels between patient groups. The thrombograms of all patients were disturbed in their shape. In 11 patients the standard TF stimulation did not trigger thrombin generation at all ("flat curve"). All deaths (n = 4) in the patient series occurred to patients who presented with "flat curve". Free TFPI and free/total TFPI ratios were significantly higher in patients with "flat curve". Also in non-survivors these values were significantly higher. Using "flat curve" alone, sensitivity /specificity of predicting death were 100/36 %. Combining this with free TFPI (cut off 25) increased the specificity to 50 %.

Conclusion: Failure of TF initiated thrombin generation in the thrombogram assay explained by high levels of circulating free TFPI associates with organ failure and mortality in AP.

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Confocal Laser Endomicroscopy of the Pancreatobiliary Ducts

M. Löhr,1 F. Swahn,1 L. Enochsson,1 S. Ghazi,2 R. Segersvärd,1 U. Arnelo.1 Divisions of 1Surgical Gastroenterology and 2Pathology, Dept of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden.

Introduction: Unclear strictures within the pancreatic or biliary ducts are difficult to accurately discriminate as malignant or benign. Confocal laser endomicroscopy (CLE) is a new intraductal diagnostics tool allowing in-vivo real time microscopy. At Karolinska we have used the probe based CLE Cellvizio-GI System (Mauna Kea Technologies) in clinical practice since September 2008. We present a consecutive series of intraductal CLE cases until May 2009.

Methods: Twelve patients (5 M/7 F, median age 64 y) were examined with CLE (8 biliary, 4 pancreatic) introduced by a peroral cholangioscope (SpyGlass System). Targeted biopsies and brush-cytology were taken from the same area. Every CLE investigation were recorded and demonstrated blinded to experienced gastroenterologists.

Results: Two out of 3 cholangiocarcinoma and 3 out of 3 IPMN patients were consistent with CLE appearance. In 5 unclear stricture patients we found no evidence of malignancy neither with CLE, nor on histology or imaging during 3 months of follow-up (PSC n = 2, CBD-stone stricture n = 1, chronic pancreatitis n = 1, cholangitis in a transplanted liver n = 1). One patient with chronic pancreatitis and a cyst showed normal duct pattern on CLE.

Conclusion: Probe-based CLE expands the possibilities to combine endoscopy and real-time microscopy within the pancreatobiliary tract. Two indications stand out: Strictures of uncertain dignity and premalignant/intraductal neoplasia in the pancreas.

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Heterotrimeric G-Protein Gα15/16 Activates RhoC GTPase and Increases the Metastatic Phenotype in Panc-1 Cells

M.M. Lucey, K.L. van Golen. Laboratory of Cytoskeletal Physiology, The Center for Translational Cancer Research, Dept. of Biological Sciences, The University of Delaware, Newark, DE.

Heterotrimeric G-proteins play diverse roles in cellular signaling and have recently been shown to regulate cellular motility and invasion via activation of the Rho GTPases, specifically through Gα12/13 and Gq subunits. The Rho GTPases comprise a subfamily of the Ras Superfamily of monomeric G-proteins, which act as molecular switches to regulate reorganization of the actin cytoskeleton. One member of the Rho subfamily, RhoC GTPase, is overexpressed and specifically implicated in metastasis of many tumor types including pancreatic cancer. However, the molecular mechanisms by which RhoC is activated during metastasis have not been demonstrated. During a cDNA microarray screen of laser capture microdissected patient samples, normal pancreatic ductal epithelial cells were compared with chronic pancreatitis and pancreatic adenocarcinomas. Expression of the Gq class heterotrimeric G-protein, Gα15/16, was found to be expressed 13- and 3-fold over normal and pancreatitis, respectively in the adenocarcinomas. In the current study we examined whether this unique Gq protein could activate RhoC GTPase. When constitutively active Gα15/16 was introduced into Panc-1 pancreatic cancer cells, which express RhoC; cell morphology and actin reorganization was drastically altered. Also, RhoC-mediated invasion and motility increased significantly. Conversely, when the dominant negative form of Gα15/16 was transfected into Panc-1 cells,a decrease in cellular processes were seen, along with a decrease inRhoC-mediated invasion and motility. Panc-1 cells transfected with a luciferase construct alone, or with either the dominant negative Gα15/16, or constitutively active Gα15/16 were injected through the tail vein of nude mice. Cells containing the constitutively active Gα15/16 saw an increase in gross mets compared to both the wild type Panc-1 cells, and the dominant negative Gα15/16 containing Panc-1 cells. This data implicates expression and activation of Gα15/16 in the activation of RhoC GTPase and an increase in the metastatic phenotype in pancreatic cancer cells.

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Paclitaxel as a Salvage Chemotherapy in Patients With Gemcitabine-Refractory Pancreatic Cancer

S. Maeda, F. Motoi, K. Kawaguchi, T. Onogawa, T. Morikawa, A. Okaue, T. Takadate, T. Rikiyama, Y. Katayose, S. Egawa, M. Unno. Division of Hepato-Biliary-Pancreatic Surgery, Tohoku University, Sendai, Japan.

Background and Aims: Gemcitabine (GEM) and S-1 are regarded as standard agents for pancreatic cancer in Japan. Paclitaxel (PTX) has a different mechanism of action from the two. We evaluated the efficacy and the feasibility of PTX as a salvage treatment for pancreatic cancer.

Patients and Methods: Thirty-two Patients with recurrent or unresectable pancreatic cancer who failed to respond to a GEM-based regimen were enrolled in this study. PTX was administered at a dosage of 80 mg/m2 once weekly for three weeks followed by one week rest in out-patient basis and was continued until disease progression defined by RECIST criteria. Adverse events were evaluated by CTCAE v3.0.

Results: The median number of administration per patient was 9 (range 1-35). Grade 3 hematological toxicities and non-hematological toxicities were recorded in 9 (28.1%) and 2 (6.3%) cases, respectively. No grade 4 toxicities were observed. The median survival time from the start of PTX treatment was 29.6 weeks (range 5-80 weeks). The response rate was 9.4% and the disease control rate was 50%. Patients with CA19-9 decline showed a trend toward better survival.

Discussion and Conclusion: Weekly administration of PTX as a salvage therapy in patients with gemcitabine-refractory pancreatic cancer is well tolerated and seems to be effective against GEM, S1-refractory disease.

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Endoscopic Pancreatic Stenting (EPS) for Pancreatic Duct Stricture in Chronic Pancreatitis

H. Maguchi, M. Osanai, A. Kurita, K. Takahashi, A. Katanuma, T. Kin, K. Yane, M. Ohtsubo, S. Hashigo. Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan.

Background: Endoscopic pancreatic stenting(EPS) is thought to improve the conditions of the patients with chronic pancreatitis CP) with the main pancreatic duct(PD) stricture. However, the appropriate stent size and length, and duration of stenting have been controversial. While some doctors recommend to use a thick stent or multi-stenting, and to maintain the stent for a long period, we suggest that using a thin stent is more reasonable because by nature the main PD has a smaller diameter than the bile duct, and there is a risk of the secondary pancreatitis due to obstruction of the branch duct in maintaining the stent for a long period. Furthermore, since CP itself is a progressive disease, EPS should be a temporary treatment. Therefore, we usually perform EPS using a thin stent, and remove it in a short period after placement.

Objective: To evaluate the efficacy of temporary EPS by using a 7 Fr stent in CP patient with PD strictures.

Methods: Eighty patients (60 male and 20 female) of CP (71 alcoholic, 4 idiopathic and 5 other) with PD stricture were treated by EPS from April 1997 to May 2008. A 7Fr stent was placed for 1 or 2 months and changed to endoscopic naso-pancreatic drainage (ENPD) after removal of the stent. We decided whether tube-free or repeated EPS should be indicated from the evaluation of the drainage function by ENPD pancreatography.

Results: EPS was successfully placed in all cases. Pancreatic conditions improved in all cases except 1 which had a duct stricture in the tail of the pancreas. Sessions of the EPS were single in 60 patients (75.9%), twice in 13 patients, 3 times in 4 patients and 4 times in 2 patients. There were no serious complications. In 51 cases (63.8% of all), we achieved follow-up for more than 1 year after removing the stent. Pancreatic symptoms recurred in 24 patients (47.1%), i.e., 14 patients (14/35, 40.0%) in the single EPS group and 10 patients (10/16, 62.5%) in the repeated EPS group. The main reason of the recurrence was continued drinking. While 18 (75.0%) of them recovered by the repeated EPS treatment, 5 cases required complementary surgical treatment due to stenosis of the duodenum in 3 and uncontrollable pseudocyst formation in 2.

Conclusion: EPS using a 7Fr for a short period has a potential as the first treatment method for CP patients with PD stricture in the head or body, and also as the second therapy if recurrence occurred. However, some problems remain with EPS, as to stent diameter, length, and stenting period, for which further studies are required.

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Antitumoral and Immunostimulatory Effects of a Bacterial Vaccine -Coleys Toxin

C. Maletzki,1,2 W. Obst,1 P. Bodammer,1 U. Klier,2 B. Kreikemeyer,3 J. Emmrich.1 1Division of Gastroenterology, Department of Internal Medicine, 2Section of Molecular Oncology and Immunotherapy, Department of General Surgery, 3Department of Medical Microbiology and Hospital Hygiene, Institute of Medical Microbiology, Virology and Hygiene, University of Rostock, Germany.

Background & Aims: This study addressed the question of whether Coleys Toxin (CT), a combination of heat-inactivated S. pyogenes and S. marcescens, is applicable as an active immunotherapeutic compound for treatment of pancreatic cancer (PaCa) in vitro and in vivo.

Material and Methods: Established human PaCa cell lines were treated with increasing concentrations of CT (0.5 × 106 - 12.5 × 106cfu) for 24 and 48 hours. Tumor cell proliferation and viability was assessed by BrdU incorporation assay and Calcein AM staining. Apoptotic tumor cells were detected by Sub-G1-peak analysis. In vivo, Panc02-tumor carrying C57Bl/6 mice were treated with CT (4 injections/twice a week, n = 7). Control mice received saline (n = 5). Tumor growth was monitored for 28 days, lymphocyte subpopulations were examined from blood samples.

Results: Treatment with CT resulted in a dose and time-dependent growth inhibition in 4/5 cell lines (responder: AsPC1, BxPC-3, MiaPaCa-2, T3M4, non-responder: Capan-1). These effects were accompanied by reduced cell viability and increasedd apoptosis. In vivo, CT induced a substantial delay of Panc02 tumor growth (day 28 (x-fold increase from therapy start): 6.8 ± 1.3 (CT) vs. 20.62 ± 4.2 (control), t-test: p < 0.05). The antitumoral effect was accompanied by raised levels of circulating CD11b+/CD62L+ granulocytes/monocytes, NK1.1+ NK-cells and γ/δ TCR+ T cells.

Conclusions: Data presented here show the antitumoral potential of CT and thus warrants further investigations on this historical, but still current immunotherapeutical approach.

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Tauroursodeoxicholic Acid Reduces Hallmarks of Acute Pancreatitis as Well as Endoplasmic Reticulum Stress in Rat

A. Malo, E. Seyhun, C. Kubisch. Dept. of Medicine, University of Munich, Germany.

Background: The accumulation of unfolded protein in the Endoplasmic reticulum (ER) early during acute pancreatitis (AP) initiates the unfolded protein response (UPR) and is important in pancreatic development. Incubation with the ER-chaperone tauroursodeoxicholic acid (TUDCA) showed a reduction in UPR and trypsin activation in pancreatic acini. However, our study now aimed to examine the effects of TUDCA on AP and the UPR.

Methods: Rats received an i.p. injection of 50 μg/kg caerulein (Cer) for AP induction. Controls received saline. One half of the rats received 250 mg/kg TUDCA two hours prior i.p. UPR components, including BiP expression, PERK phosphorylation, XBP1 splicing, and caspase 3 activation, were analyzed, as were effects on amylase secretion, trypsin activation, edema formation and myeloperoxydase (MPO) activation in lung tissue 30 min to 4 h after Cer injection.

Results: Cer caused an amylase increase, trypsin activation and edema starting 30 min after injection. MPO started to rise at 1 h. TUDCA preincubation alone let to a significant PERK phosphorylation. Cer injection after TUDCA was followed by a significant smaller increase in trypsin activity (2538vs.1068 fmol/mg), edema formation (87vs.81%) and MPO activity (10vs.6 mU/mg). Amylase did not change. Cer increased BiP, PERK phosphorylation, XBP1 splicing and caspase 3 activation. All of this was significantly less after TUDCA treatment.

Conclusions: Preincubation with an ER-chaperone let to a significant PERK phosphorylation. Further, it reduced several UPR elements and hallmarks of the AP. Future efforts should be directed at understanding these mechanisms in the pancreas.

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Inhibition of GSK3 Activity Leads to JNK Activation and Correlates With Pancreatic Cancer Cell Death

B. Marchand, I. Tremblay, M.-J. Boucher. Gastroenterology Unit, Fac. of Medicine, University of Sherbrooke, Canada.

Background: The glycogen synthase kinase-3 (GSK3) are ubiquitous serine/threonine kinases that were first identified for their role in glycogen metabolism. Depending on the cell context, we now know that they also play important roles in other processes such as cell proliferation, survival and transformation. We have previously demonstrated that prolonged inhibition of GSK3 activity induced human pancreatic cancer cell death. However, the mechanisms involved remained unknown.

Methods: Experiments were done in human pancreatic immortalized (HPDE) and cancer (MIA PaCa2, PANC1, BxPC3) ductal cells. GSK3 activity was inhibited using specific GSK3 inhibitors (SB216763, AR-A014418) or specific GSK3α/β siRNA and shRNA.

Results: 1- Only in pancreatic cancer cells, prolonged inhibition (48,72 h) of GSK3 activity increased Bim expression, decreased Bcl-2 expression, activated caspase-3 and-7 and induced PARP cleavage. 2- Inhibition of GSK-3 activity neither influence Akt nor Erk activities, two signalling pathways reported to mediate survival signal in pancreatic cancer cells. However, increased JNK phosphorylation and c-jun expression were observed suggesting that inhibition of GSK3 activity stimulated JNK activity. 3- Interestingly, concomitant treatment with the specific JNK inhibitor SP600125 blocked the SB216763-induced c-jun expression, bim expression, caspase activities and apoptosis.

Conclusion: Taking together, our data uncovered a new crosstalk between the GSK3 and JNK pathways which plays important role in pancreatic cancer cell survival.

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Beneficial Effects of Hyperbaric Oxygen Plus 3-Amino Benzamide in Acute Necrotizing Pancreatitis

M.R. Mas,1 A. Turan Isik,1 B. Comert,1 S. Aydın,2 N. Mas,3 S. Deveci,4 I. Tasci,1 L. Yamanel,1 E. Cinar,5 M. Tahir Ünal.1 Departments of 1Internal Medicine, 4Pathology, 5Infectious, Gulhane Medical Faculty, Ankara; 2Güven Hospital; 3Department of Anatomy, Afyon Kocatepe University, Afyon, Turkey.

Introduction: Infectious complications of acute pancreatitis (AP) cause significant mortality. Hyperbaric oxygen (HBO) administration decreases nitric oxide production, enhances bactericidal activity of neutrophils, augments angiogenesis and wound healing, and displays bactericidal activity on anaerob bacteria. 3-Amino Benzamide, a Poly (ADP ribose) synthase (PARS) inhibitor, is known to prevent intestinal injury and, thus, inhibit translocation of intestinal microorganism. In this study, effects of HBO and 3-AB treatments on bacterial translocation (BT), oxidative stress (OS), and natural course of the disease were evaluated.

Materials and Methods: Seventy-five Sprague-Dawley rats were randomly divided into five groups. Group I received sham. AP was induced in the remaining group via intraductal taurocholate infusion. Group II received saline, Group III 3-AB, Group IV 3-AB+HBO, and Group V HBO. 3-AB and saline were started right after the induction, whereas HBO six hours later. The rats were killed 48 hours after the induction of AP.

Results: Serum amylase and histopathological scores decreased in Groups III to V when compared to Group II (p < 0.001, for each). Although the combination group had the lowest histopathological scores, the differences were not significant. Translocation of bacteria to pancreas and mesenteric lymph nodes was significantly less than controls (p < 0.001, for each). OS parameters decreased significantly in all 3-AB treated groups (p < 0.02, for each).

Discussion: In this study, we showed that endotoxemia induced intestinal injury and bacterial translocation can be prevented in acute necrotizing pancreatitis by inhibiting the enzyme PARS. 3-AB treatment resulted in significant decrease both in oxidative stress and bacterial translocation. This suggests that a number of mechanisms may be involved while inhibition of PARS exerts beneficial effects in the course of acute pancreatitis.

HBO and 3-AB is effective not only in decreasing histopathological scores and OS, but also in preventing BT in acute experimental pancreatitis. Although seems slightly advantageous, combining these two modality is not favorable.

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An Exploratory Phase Diagnostic Study of Organ Dysfunction Score Performance for the Prediction of Severity in Acute Pancreatitis

J.M. Mason,1 S. Balachandra,2 B.I. Babu,2 A. Bagul,2 A.K. Siriwardena.2 1School of Medicine and Health, Durham University, Stockton-on-Tees, UK; 2Regional Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK.

Objective: Determining the severity of patients with acute pancreatitis early in admission is important both to guide clinical practice and to recruit patients into studies.

Methods: A consecutive series of 181 patients with a clinical diagnosis of acute pancreatitis were recruited prospectively. Organ dysfunction scores (LODS, MODS and SOFA), C-reactive protein and APACHE II scores were recorded. Patients who died or used critical care during admission were classed as 'severe' cases. The ability of tests to accurately select patients was assessed.

Results: The ability of all test measures to accurately select severe cases within the first 24 hours of admission was generally inadequate. At 24 hours, a LODS score ≥ 1 achieves a test sensitivity of 90% and positive predictive value of 38%. Thus only one in three patients selected for enhanced care would subsequently prove to be a severe case, although only 10% of severe cases would be missed. A SOFA score of 3 or more with a test sensitivity of 47% and positive predictive value 71% would miss half of severe cases but the majority of cases selected would be severe. The use of multiple tests is unlikely to be helpful given the degree of correlation between measures.

Conclusion: Current organ dysfunction scoring methods have similar performance for prediction of severity but there is no "stand-out" test. If these limitations are accepted, organ dysfunction scoring can be used to categorise severity in the forthcoming Atlanta revision.

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Improved Delayed Gastric Emptying With Straight Stomach Reconstruction and Twisted Anastomosis to Jejunum After Pylorus Preserving Pancreaticoduodenectomy (PPPD): 118 Consecutive Cases in a Single Institution

T. Masui, R. Doi, K. Kami, K. Ogawa, Y. Kawaguchi, K. Fujimoto, M. Koizumi, K. Nagai, S. Uemoto. Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University, Kyoto, Japan.

Background: Delayed gastric emptying (DGE) is a leading cause of complications after pylorus preserving pancreaticoduodenectomy (PPPD), ranging from 5 to 57 %. Here, we have introduced a straight stomach reconstruction after PPPD and found low rate of DGE with the definition by International Study Group of Pancreatic Surgery (ISGPS) in comparison with conventional PPPD.

Methods: From April 2004 to March 2008, 118 consecutive patients underwent PPPD and reconstructed with antecolic method in our hospital. Twelve PPPD cases were reconstructed with conventional Child procedure and the rest 102 cases were modified as follows; the duodeno-jejunostomy was performed with straight method and the jejunum was anastomosed with 30 degree anti-clockwise twist. The incidence of DGE was evaluated according to the grading system suggested by ISGPS.

Results: The 102 PPPD group with new reconstruction method (PPPDR) has lower incidence of DGE compared to the conventional 12 PPPD group (PPPD) (7% versus 25%). The overall morbidity rates of PPPDR group was not significantly different from that of PPPD group but shorter hospital stay was observed in PPPDR group.

Conclusions: The straight stomach reconstruction and twisted anastomosis could reduce delayed gastric emptying in PPPD reconstruction.

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Role of the KLF11-MMP Pathway in Stellate Cell Biology and Tumor Suppression

A. Mathison, A. Liebl, V. Shah, G. Lomberk, R. Urrutia. Mayo Clinic, Rochester, MN.

Stellate cells are emerging as key players in remodeling of the tumor microenvironment that influences progression of pancreatic cancer. TGFβ has been shown to be critical for supporting the function of stellate cells. In this study, we evaluated the function of KLF11, a TGFβ mediator protein with tumor suppressor function in pancreatic epithelial cells. Infection of stellate cells with KLF11 adenovirus in combination with array analysis and bioinformatics revealed that KLF11 upregulates expression of MMPs, without changing expression of inhibitor proteins, TIMP1 and TIMP2, while downregulating TIMP3, suggesting that KLF11 may favor remodeling of the pancreatic tumor microenvironment via activation of this key extracellular proteolytic pathway. Upon analyzing several of these promoters via ChIP, we found that KLF11 binds to these targets, suggesting it participates in direct regulation of these genes. Indeed, xenografts generated by co-injecting pancreatic epithelial cancer cells along with KLF11-infected stellate cells grew at a significantly slower rate than pancreatic epithelial cancer xenografts co-injected with control-infected stellate cells. Together, these results demonstrate, for the first time, that: 1. KLF11 regulates key pathways in stellate cells which participate in remodeling of the tumor microenviroment, and 2. KLF11 behaves as a tumor suppressor for pancreatic tumorigenesis, not only by acting on epithelial cells, but also by influencing stellate cell biology. This data advances our understanding of molecular pathways which are operational in stellate cells for modulating pancreatic tumorigenesis.

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Caerulein Induced Pancreatitis and Expression of Receptor for Advanced Glycation Endoproducts in Spontaneously Diabetic Torii Rat

Y. Matsuhashi,1 Y. Tando,1 E. Sato,1 A. Kon,1 S. Chikazawa.1 A. Matsumoto,1 T. Suda,1 T. Nakamura,2 T. Takeuchi.3 1Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; 2Department of Health Science, Hirosaki University School of Medicine, Hirosaki, Japan; 3Tokyo Women's Medical University, Tokyo, Japan.

Introduction: Chronic pancreatitis is characterised the pancreatic exocrine and endocrine deficiency. Recently advanced glycation endproducts (AGE) and receptor for AGE (RAGE) are reported as one of causes of diabetic complications, however the relation of AGE-RAGE and change of pancreatic lobules is unknown. We investigated whether AGE-RAGE developed the fibrotic change and exocrine deficiency or not.

Methods: Pancreas was removed from male Spontaneously Diabetic Torii (SDT) rat with repeated intraperitoneal caerulein injection under ether anesthesia. Sections were stained with HE or Masson-Trichrome. Serum glucose level, amylase activity and insulin concentration were assessed. Minced pancreatic lobules were incubated with AGE. Expression of RAGE-mRNA was estimated by RT-PCR.

Results: Fibrosis and hemosiderin deposition around the Langerhans islets were observed in control SDT rat, and no more histological changes were observed in caerulein treated SDT rat. RAGE-mRNA level was low in pancreas, and caerulein didn't affect the expression of RAGE. RAGE-mRNA level was not elevated after incubated with AGE.

Conclusion: Our results indicated that there were not strong relations the onset of diabetes and the caerulein induced pancreatitis, AGE-RAGE and fibrotic changes in pancreatic lobules.

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Significance of the Breath Test by Using Benzoyl-Tyrosyl-[l-13C]Alanine in Comparison With the BT-PABA Test for Evaluating the Pancreatic Exocrine Insufficiency

A. Matsumoto,1 Y. Tando,1 M. Yanagimachi,1 Y. Matsuhashi,1 S. Chikazawa,1 A. Kon.1 T. Suda,1 T. Nakamura,2 T. Takeuchi.3 1Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; 2Department of Health Science, Hirosaki University School of Medicine, Hirosaki, Japan; 3Tokyo Women's Medical University, Tokyo, Japan.

Aim: The breath test by using Benzoyl-L-Tyrosyl-[l-13C]Alanine (Bz-Tyr-Ala) is compared with the BT-PABA test for the diagnosis of exocrine pancreatic insufficiency. We defined the exocrine pancreatic insufficiency as the cases with more than 5 g of fecal fat excretion (steatorrhea) per day with meals including fat more than 40 g/day.

Subjects and Methods: We performed both the breath test and the BT-PABA test in 30 cases (7 cases with pancreatic diseases, and 23 controls). We used the Δ13CO2 peak value (‰) in the breath test and the urinary excretion rate of PABA (%) from 6-h urine collection in the BT-PABA test, respectively. In both tests, we defined the exocrine pancreatic insufficiency as "mean-1.5SD" of healthy controls.

Result: There are 100% sensitivity and 91.3% specificity in the breath test, while 100% sensitivity and 69.6% specificity in the BT-PABA test.

Conclusion: The breath test has higher specificity than the BT-PABA test for the evaluation of exocrine pancreatic insufficiency.

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Pre-Operative Diagnosis of Synchronous Pseudopapillary Neoplasm (SPNs) of the Pancreas

K. Matsumoto,1 K. Yamao,1 A. Sawaki,1 N. Mizuno,1 K. Hara,1 S. Hijioka,1 H. Imamura,1 Y. Kobayashi,1 Y. Shimizu,2 K. Hosoda,3 Y. Yatabe.3 1Department of Gastroenterology, Aichi Cancer Center Hospital; 2Department of Gastrointestinal Surgery, Aichi Cancer Center Hospital; 3Department of Pathology and Genetics, Aichi Cancer Center Hospital.

The case of a 37-year-old woman who had two, synchronous SPNs of the pancreas is reported. The patient underwent abdominal echography as part of screening for HCV-Ab positivity during gravid periodic check-up, and a pancreatic tail tumor was detected. She was referred to our hospital for further examination of the pancreatic tail tumor. There were two masses, one 30-mm and one 20-mm in the pancreatic body and tail, respectively, which were slightly enhanced on abdominal CT. On EUS, the surface was smooth, the margin was clear, an echoic lesion was seen in the hypoechoic mass, and there was no lateral shadow. MRI showed a low- and high-intensity mass of the body and a low- and low-intensity mass of the tail on T1- and T2-WI images, respectively. EUS-guided fine needle aspiration biopsy (EUS-FNA) suggested SPN because βcatenin was positive and E cadherin was negative on immunohistochemistry. With a diagnosis of SPNs based on the EUS-FNA findings, distal pancreatectomy was performed. Histopathological finding of the resected specimen showed SPNs arising synchronously. To the best of our knowledge, this is the first report of the pre-operative diagnosis of two synchronous SPNs of the pancreas.

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Duct Morphology and Etiology Influence Endotherapy Outcome in Indians With Pancreatic Stones: A Single Center Prospective Experience

A. Maydeo, S.P. Bhandari, M.R. Bapat, V. Dhir. Institute of Advanced Endoscopy, Mumbai, India.

Objective: To assess the response to pancreatic endotherapy with reference to duct morphology and etiology of pancreatic stones.

Patients and Methods: Five hundred patients diagnosed with pancreatic duct stones of varying etiology were prospectively enrolled into four different groups based on the duct morphology; between January 2001 and December 2007 and subjected to endotherapy. Their endotherapy results were assessed. Group I: Patients with stones in main duct or side branches in association with a uniform ductal dilation without strictures; Group II: Pancreatic stones (PS) in setting of pancreas divisum and a uniform ductal dilatation without strictures; Group III: Patients with ductal strictures and stones and Group IV: Patients having stones in association with an inflammatory head mass, pseudocyst (s) or stones confined to the pancreatic tail. Interventions included extracorporeal shock wave lithotripsy, pancreatic sphincterotomy, stone removal and pancreatic stenting.

Results: Ductal clearance could be achieve in 97% of 291 patients in Group I, 92.8% of 42 in Group II, 63.2% of 117 in group III and 42% of 50 in group IV patients. Patients in group I and II had idiopathic pancreatic stones predominantly as compared alcohol in group III and IV. There was no procedure related mortality.

Conclusions: Response to endotherapy was superior in patients with idiopathic pancreatic stones with uniform duct dilation as compared to patients with complex duct morphology and alcohol as etiology.

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Development of a Protein Based Assay to Detect Subclinical Johanson-Blizzard-Syndrome in Patients With Unexplained Exocrine Insufficiency

J. Mayerle,1 N.K. Karanam,1,2 S. Bauhuber,3 F.U. Weiss,1 L. Steils,2 U. Völker,2 M. Zenker,3 M.M. Lerch.1 1Department of Medicine A, Ernst-Moritz-Arndt-University Greifswald, 2Institute of Functional Genomics, Ernst-Moritz-Arndt-University 3Institute of Human Genetics, University of Erlangen-Nuremberg, Germany.

Introduction: Juvenile exocrine pancreatic insufficiency has various causes. One of them is Johanson-Blizzard-Syndrom (JBS, OMIM 243800). JBS is an autosomal recessive disorder with an incidence of 1:250.000 and characterized by a combination of congenital abnormalies that invariably include exocrine pancreatic insufficiency. JBS is caused by mutations in the UBR1 gene. The aim of this study was the development of a protein based diagnostic assay to detect subclinical cases of JBS.

Material and Methods: Lymphoblasts from 14 patients with different mutations in the UBR-1 gene and variable phenotype, as well as 11 controls were subjected to proteome analysis. Principal component analysis (PCA) of JBS patients and controls was combined with quantification of Ubr-1 expression by Western blot. Hierarchical clustering of patients and controls was employed for spots displaying lowest p-levels, derived from Golubs algorithms. 20 spots which discriminated between subclinical JBS and controls in a ROC analysis were identified by mass spectroscopy.

Results: On 2D Gels of lymphoblast extracts 1295 proteins were differentially expressed in patients and controls. PCA analysis based clearly discriminated JBS patients from controls. 4 patients differed from the rest and resembled controls. These patients had residual Ubr-1 expression and a milder phenotype. Hierarchical clustering of the three groups (controls, patients with residual Ubr-1 expression and patients without Ubr-1 expression) showed marked differences in the gene tree. Choosing a five spot protein panel (Interferon-induced GTP binding protein, HLA class II histocompatibility antigen, Annexin A6, FK506-binding protein 4, GRP78) permitted discrimination between controls and JBS patients with mild or severe phenotyes (predictive strength of 1, area under ROC curve).

Conclusion: JBS is might be a more common cause of exocrine pancreatic insufficiency in children. Its extrapancreatic manifestations are variable and presently the only diagnostic test - particularly in milder cases - consists in sequencing all 47 exons (161 kb) of the UBR1 gene. Using a proteomics approach we identified a panel of 5 lymphyoblast proteins with which even atypical and milder cases of JBS can be diagnosed with high accuracy.

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New Diagnostic and Severity Criteria of Acute Pancreatitis -Proposal of Pancreatitis Bundle-: JPN Guidelines 2010

T. Mayumi,1,3 T. Takada,2,3,5 M. Yoshida,2,3,5 K. Hirata,3 H. Amano,2,3,5 S. Arata,3 M. Hirota,4,7 Y. Kimura,3 M. Sekimoto,3 K. Takeda,3,4 K. Wada,2,3,5 K. Otomo,6 T. Shimosegawa,4,7 M. Tanaka.4 1Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Department of Surgery, Teikyo University School of Medicine, Japan; 3The Japanese Society for Abdominal Emergency Medicine, Sapporo, Japan; 4The Japan Pancreas Society, Fukuoka, Japan; 5The Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan; 6Japan Radiological Society, Tokyo, Japan; 7The Research Group for Intractable Diseases and Refractory Pancreatic Diseases, the Japanese Ministry of Health, Labour, and Welfare, Sendai, Japan.

We already published Japanese and English evidence-based JPN Guidelines for the management of acute pancreatitis in 2003 and in 2006. Since the Research Group for Intractable Diseases and Refractory Pancreatic Diseases proposed a modified diagnostic and severity criteria of acute pancreatitis in 2008, we soon searched new evidence, renewal JPN guidelines and proposed "Pancreatitis bundle" for the improvement of patients' outcomes and assessment of the guidelines. New severity assessment criteria consist of the prognosis score and the enhanced computed tomography (CT) grade. The former is simplified with reduced number of items that are also clean cut. Either 3 points and over in the prognosis score or CT Grade 2 and over is determined as severe pancreatitis. Other than above determined as mild pancreatitis. These guidelines propose "Pancreatitis bundle" that include 10 items recommended A or B in the text.

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The Growth Factor HB-EGF Synergizes With Activated Kras to Initiate Pancreatic Tumor Formation

A.L. Means. Depts. of Surgery and Cell and Developmental Biology, Vanderbilt University, Nashville, TN.

Due to typically late diagnoses, little is known about initiation of pancreatic ductal adenocarcinoma, the most common cancer of the pancreas. We are using mouse models to understand what regulates the early events in tumor formation. Mouse models have confirmed that activated Kras contributes to but is not sufficient for pancreatic tumorigenesis. Expression of the growth factor HB-EGF occurs in pancreatic cancer lesions, including in early stage lesions. Using mouse models, we found that overexpression of sHB-EGF (a constitutively secreted version of this growth factor) alone led to fibrosis and ductal and acinar hyperplasia/dysplasia beginning around 1 month of age. Activated Kras expression similarly did not result in any aberrant morphology until 1-2 months of age when fibrosis and ductal lesions began to be observed. However, the combination of sHB-EGF overexpression and activated Kras had synergistic effects, with PanIN-like lesions beginning 1-2 days after birth, and complete replacement of the normal pancreatic epithelium by ductal lesions within three weeks of age. Lesions exhibited papillary structure, loss of polarity, cribriform architecture and luminal budding. These data suggest that activated Kras in conjunction with HB-EGF signaling are sufficient for tumor formation in the pancreas.

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Zinc Alpha2-Glycoprotein Is a Novel Tumor Suppressor Which Decreases EMT in Pancreatic Cancer

C. Michalski,1 B. Kong,1 X. Hong,1 S. Streit,1 I. Esposito,2 H. Friess,1 J. Kleeff.1 1Dept. of Surgery and 2 Institute of Pathology, Technische Universität München, Munich, Germany.

Background: Epithelial to mesenchymal transdifferentiation (EMT) which is enhanced by TGFβ signaling in the late stage of pancreatic cancer (PC), leads to aggressive tumor progression.

Methods: Following identification of a loss of zinc alpha2-glycoprotein (ZAG) expression in PDAC using DNA microarray analysis, levels of ZAG were analysed in pancreatic tissues and cancer cell lines. To assess the reason for loss of ZAG, de-methylation or deacetylation-inhibition assays were performed. Following silencing of ZAG using siRNA oligonucleotides, cell growth and invasion were evaluated in the presence or absence of ZAG and/or TGFβ.

Results: ZAG was lost in PanIN 3 lesions and in PC cells, also reflected in vitro where only 2 out of 7 cancer cell lines were ZAG-positive. Treatment with trichostatin A reconstituted ZAG expression whereas de-methylation with 5-AZA had no such effect. Silencing of ZAG in Aspc-1 cells (TGFβ-responsive) induced a more invasive phenotype with increased vimentin-expression. In Panc-1 cells (no ZAG-expression) human recombinant ZAG suppressed vimentin-expression and blocked TGFβ-mediated cancer cell invasion as well as phosphorylation of ERK2. In Aspc-1 cells (Smad4 negative), ZAG silencing increased constitutive and TGFbeta-mediated ERK2-phosphorylation and induced p21-expression.

Summary: Loss of ZAG in PC due to histone de-acetylation suggests a role as a tumor suppressor. Through interference with TGFβ-mediated ERK signalling, ZAG blocks invasion and EMT of PC cells.

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Pancreatic Resection in Elderly Patients

Y. Minari,1 T. Nishi,1 T. Tanaka,1 Y. Matsugu.2 1Department of Digestive and General Surgery, Shimane University Faculty of Medicine. 2Department of Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.

Aim: In recent years, pancreatic resection has come to be indicated mainly in the elderly. However, risk increases with age, therefore, indication of the operation as well as pre- and post-operative management are important. The safety of pancreatectomy was investigated retrospectively in elderly patients over 70 years in our department.

Materials & Methods: From May 1996 and December 2007, 274 patients underwent pancreatic resection. The operative procedure was pancreaticoduodenectomy (PD) in xxx cases and distal pancreatectomy (DP) in xx cases, and combined resection of portal vein was performed xx cases. The subjects were divided into two groups by the aged 70 and above (aged group, n = 88, 75.0 + 3.5 yr) and the aged 69 and below (control, n = 186, 59.5 + 8.1 yr). Fifteen preoperative factors and 4 operative factors were compared between these two groups. For risk assessment using the POSSUM system, data on 12 parameters related to physiological score (PS) and 6 parameters related to operative severity score (OS) were derived from the database or individual patients.

Results: Postoperative complications were seen in 100 cases (%), and death during hospital stay occurred in 11 cases (%). In the term of 15 preoperative factors, the incidence of cardiovascular failure and urea level were significantly higher in the aged group than in the control. In the 4 operative factors, the operative time was significantly lower in the aged group than in the control. Of the POSSUM parameters analyzed, the physiological score of the aged group (18.5 + 2.9) was significantly higher than the control (15.4 + 3.0). There were no difference between the groups for post-operative complication (36/88, 64/186) and hospital death (4/88, 7/186).

Conclusion: Pancreatic resection can be performed safely even in elderly patients aged 70 and above.

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Effects of Exercise Training and Detraining on the Exocrine Pancreas in Zucker Fatty Rats

K. Minato,1 Y. Shiroya,1 T. Kondo.2 1School of Human Ecology, Wayo Women's University, Ichikawa, Japan; 2Research Center of Health, Physical Fitness, and Sports, Nagoya University, Nagoya, Japan.

Backgrounds: We have found that voluntary running training increases pancreatic weight, pancreatic protein content, and pancreatic enzyme activity in Zucker Fatty rats.

Aim: The purpose of the present study was to investigate whether the training-induced improvements in exocrine pancreas of Zucker Fatty rats are influenced by detraining.

Methods: Male Zucker Lean rats were used as control (LC). Male Zucker Fatty rats were divided into 3 groups: Obese (OB), Trained (TR), and Detrained (DTR) groups. The LC and the OB rats had free access to food, the TR and DTR rats had food intake restricted to 78% of the OB group level. The TR and DTR rats were exercised voluntarily on the wheel ergometer with a load of 30% on their body weight every day. Following 4 weeks of exercise training, DTR rats were kept inactive (i.e., detrained) for 2 weeks with free access to food. After 6 weeks, all rats were prepared for experiment. The pancreas were excised and weighed. Protein content and amylase activity in pancreatic tissue were measured. Pancreatic tissues were prepared for transmission electron microscopy.

Results: Pancreatic wet weights, protein contents, and enzyme activities were decreased in OB rats. Acinar cells from OB rats were atrophied and degenerating cells were also observed. Exercise training improved these parameters, while detraining reversed the effects of exercise training close to the obese rats levels.

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Intraductal Papillary Mucinous Neoplasm - Associated Invasive Carcinoma (IPMN-INV) Has Favorable Survival After Resection

M. Mino-Kenudson,1 A.L. Warshaw,2 C. Correa-Gallego,2 A. Muzikansky,3 V. Androutsopoulos,2 V. Deshpande,1 M.B. Pitman,1 S.P Thayer,2 G.Y. Lauwers,1 C. Fernández-del Castillo.2 Departments of 1Pathology, 2Surgery, and 3Biostatistics, Massachusetts General Hospital, Boston, MA.

Background: The aim of this study was to compare the survival after resection of IPMN-INV with that of conventional pancreatic ductal adenocarcinoma (PDAC) and analyze pathologic features that may account for the difference in survival.

Methods: The study cohort consisted of 68 consecutive IPMN-INV cases resected at a single institution. Pathologic parameters were examined in the IPMN-INV group and compared with those of 579 consecutively resected PDACs. Log rank and Cox regression analysis were applied to identify pathologic factors associated with survival.

Results: Median survival was 54 months after resection for IPMN-INV vs. 18 months for PDAC (P < 0.0001). IPMN-INV was less likely to be associated with advanced T stage (T3-T4, 62% vs. 82%), regional LN metastasis (35% vs. 66%), poor differentiation (18% vs. 40%), perineural (47% vs. 70%) and vascular (19% vs. 34%) invasion, and microscopic margin involvement (22% vs. 36%). On multivariate analysis, the association with IPMN (P = 0.0032) along with advanced T stage (P = 0.0074), LN metastasis (P < 0.0001), poor differentiation (P = 0.0005), vascular invasion (P = 0.0401), and margin involvement (P = 0.0011) were independently predictive of survival.

Conclusions: The favorable outcome of IPMN-INV compared to PDAC is due in part to its lower rate of adverse pathologic features, but may also be attributed to its less aggressive biology.

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Histological Diagnosis of Autoimmune Pancreatitis Using EUS-Guided Trucut Biopsy: A Comparison Study With EUS-FNA

N. Mizuno,1 W. Hosoda,2 V. Bhatia,3 K. Hara,1 A. Sawaki,1 S. Hijioka,1 H. Imamura,1 S.B.H. Ko,4 Y. Yatabe,2 H. Goto,4 K. Yamao.1 Departments of 1Gastroenterology and 2Pathology and molecular diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan; 3Department of Medical Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India; 4Department of Gastronenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Aim: The aim of this study was to evaluate the feasibility and safety of endoscopic ultrasonography (EUS)-guided trucut biopsy (TCB) for diagnosis of autoimmune pancreatitis (AIP).

Methods: Fourteen patients with suspected AIP based on imaging studies underwent both EUS-guided fine-needle aspiration (FNA) and EUS-TCB for diagnosis of AIP and exclusion of pancreatic cancer (PC). According to the revised Japanese clinical diagnostic criteria, AIP was diagnosed in 8 while the remaining 6 patients had pancreatitis of other etiologies. Pathologically, AIP was defined as lymphoplasmacytic sclerosing pancreatitis (LPSP), and sub-divided into two types: definite LPSP (d-LPSP) showing fulspectrum of LPSP and probable LPSP (p-LPSP) without obliterative phlebitis or abndant (>10 cells/hpf) IgG4-positive plasmacytes infiltration.

Results: PC was excluded in all patients. EUS-FNA resulted in 3 of 8 patients with AIP were reported as p-LPSP, one was reported as normal, and 4 were inconclusive. One of 6 with non-autoimmune pancreatitis was diagnosed as p-LPSP on EUS-FNA, one as idiopathic chronic pancreatits (ICP) and 4 were inconclusive. By using EUS-TCB, all AIP patients were diagnosed as LPSP (4 d-LPSP and 4 p-LPSP). Of the 6 patients with non-autoimmune pancreatitis, 3 were diagnosed as LPSP (1 d-LPSP and 2 p-LPSP) and 3 showed ICP on TCB. No complications were identified in any patient with either EUS-FNA or TCB.

Conclusion: EUS-TCB is a safe and accurate procedure for obtaining a histological diagnosis in patients with suspected AIP. EUS-TCB can serve as a rescue technique in cases of AIP lacking typical findings.

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Surgical Outcomes of Intraductal Mucinous Neoplasm of the Pancreas Based on Our Criteria for Resection

S. Mizuno, H. Kato, Y. Nobuoka, Y. Azumi, M. Kishiwada, T. Hamada, M. Usui, H. Sakurai, M. Tabata, S. Isaji. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University, Tsu, Japan.

Before the establishment of consensus guideline for the management of intraductal mucinous neoplasm (IPMN), we have treated the patients with IPMN based on our criteria for resection.

Fifty-four patients with resection of IPMN from January 1997 to April 2009 were divided into two groups: Group A with 12 patients who underwent resection after more than 12-month follow-up and Group B with 42 patients who underwent resection at the time of diagnosis. Our criteria for resection were as follows: the main-duct type, and branch-duct type with cystic size > 30 mm, main pancreatic duct diameter > 7 mm, intramural nodule > 5 mm, or cyst-related symptoms.

In Group A, most of them were followed as a small-size branch duct type with mean follow-up of 22.8 months. The type of IPMN according to the pathological findings was main duct type in 5 of Group A and in 15 of Group B and branch duct type in 7 of Group A and in 27 of Group B. In main duct type, the main duct diameter and incidence of carcinoma did not differ between Groups A and B: 11.2 mm and 60% vs 13.1 mm and 53.3%. In branch duct type, the cyst size and incidence of carcinoma did not differ between Groups A and B: 32.4 mm and 14.3% vs 33.2 mm and 25.9%. The patient survival did not differ between the two groups and no patients died of tumor recurrence.

Our criteria for resection are feasible, but we have to keep in mind that 40% of the follow-up patients was diagnosed as main duct type after resection.

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CD133+ Cells Are Resistant to Anoikis in Pancreatic Cancer

T. Moriyama, K. Ohuchida, C. Lin, N. Ikenaga, H. Sakai, K. Mizumoto, M. Tanaka. Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Background and Aims: Metastasis is one of major causes of poor prognosis in pancreatic cancer. Resistance to anoikis (apoptosis resulting from loss of cell-matrix interactions) may allow survival of cancer cells during systemic circulation, thereby promoting distant metastasis. On the other hand, cancer stem cells (CSC) have been suggested to be responsible for the failure of cancer treatment. In this study, we focused on CD133, one of CSC markers in pancreatic cancer, and investigated resistance to anoikis of pancreatic cancer.

Methods: We have isolated CD133+ and CD133- cells from parent pancreatic cancer cell lines using flow cytometry. The CD133+ and CD133- cells were cultured on the plates with super-low attachment surface, and evaluated cell survival and changes of CD133 expression.

Results and Discussion: CD133+ cells showed significantly increased cell survival compared to CD133 cells (P = 0.004). Surprisingly, almost all of the cells surviving in the CD133 cells expressed CD133+ as well as the cells in the CD133+ group. These results suggest that CD133+ cells are at least in part responsible for resistance to anoikis of pancreatic cancer, and CD133+ cells are easy to survive in circulating condition. We will conduct further experiments about the mechanisms of anoikis.

Conclusion: Resistance to anoikis seen in CD133+ cells may be a new possible target for the treatment of pancreatic cancer.

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CA 19-9 as a Predictor of CT Response for Patients With Locally Advanced Pancreatic Cancer (LAPC)

D.J. Moskovic,1 P. Carlson,1 H. Dakik,1 W. Qiao,2 M. Javle,2 D.R. Fogelman.2 1Baylor College of Medicine, Houston, TX; 2Department of GI Medical Oncology, M.D. Anderson Cancer Center, Houston, TX.

Introduction: Current methods to evaluate treatment response in LAPC are inadequate as CT imaging often cannot demonstrate tumor response during or after treatment. We evaluated CA 19-9 as a method of predicting CT response for LAPC patients.

Methods: We reviewed 150 LAPC patients treated with induction chemo +/− chemoradiation (CRT). Radiologic response (RR), clinical benefit (CB = RR + stable disease[SD]), baseline, final, and nadir CA 19-9 were assessed. Associations between RR, CB, and CA19-9 were evaluated using Fisher's exact test.

Results: 142 of 150 patients had complete records. 91 patients had induction chemo. Of these, 25 patients had a RR and 44 had SD. Baseline CA 19-9 was compared to nadir during induction and final CA 19-9 after induction. A decrease in CA 19-9 from baseline to nadir and to final correlated with CB (p = 0.03, p = 0.002) but not RR (p = 0.77, p = 0.38). CRT was given to 107 patients, 31 of whom had RR and 38 had SD. A CA 19-9 decrease from baseline to the end of CRT correlated with CB (p = 0.003) but not RR (p = 0.79). CA 19-9 decrease from baseline to nadir during CRT did not correlate with RR (p = 1.0) or CB (p = 0.1).

Conclusions: CA 19-9 can be used as a marker of response to chemo or CRT for LAPC patients. Patients experiencing declining CA 19-9 at each step in therapy are likely to experience clinical benefit. Conversely, a rising CA 19-9 suggests likelihood of progression. These data may guide clinical decision making when following these patients.

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Inhibition of Autophagy Triggers Apoptotic Cell Death in Pancreatic Cancer Cells

N. Mujumdar, T. MacKenzie, S. Vickers, A. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Autophagy is a dynamic process in which intracellular membrane structures sequester proteins and organelles to degrade and turnover these materials. Increasing evidence indicates the importance of autophagy in cancer and tumor development; - however, the very fundamental question-whether autophagy kills pancreatic cancer cells or protects them from unfavorable conditions is currently unknown. Our laboratory has previously shown that Triptolide, a diterpene triepoxide, decreases cell viability of human pancreatic cancer cells in vitro and inhibits tumor growth in vivo (Cancer Research 2007). Thus, the aim of this study was to check the effect of Triptolide on autophagy in pancreatic cancer cells.

Methods: S2-013 and S2-VP10 cells were treated with Triptolide and/or a pool of siRNA specific for autophagy genes (atg5 and beclin1) or an autophagy -specific inhibitor, 3-methyl adenine (3-MA) and assayed for cell viability (CCK8 assay), autophagy (LC3II Immunofluorescence, LC3II western blotting and acridine orange staining) and apoptosis (Cytochrome C release, Annexin V staining and Caspase-3 activation).

Results: Treatment of S2-013 and S2-VP10 cells with Triptolide resulted in a decline in cell viability after both 24 h and 48 h. The decrease in cell viability was independent of apoptosis as monitored by cytochrome c release, annexin V staining and caspase-3 activation. However there was an induction of autophagy in these cell lines as monitored by LC3II western blotting and Immunofluorescence. Triptolide also increased the number of acridine orange positive cells in these cell lines, which is a marker of autophagy. Inhibition of autophagy by atg5 or beclin-1-specific siRNA pool or by 3-MA still resulted in a decline in cell viability following Triptolide treatment. However, inhibition of autophagy (either by siRNA or 3-MA) resulted in an increase in annexin V positive cells as well as caspase-3 activation.

Conclusions: Thus, our study shows that Triptolide can kill pancreatic cancer cells by induction of autophagy. However, in the absence of autophagy, Triptolide can result in cell death via the apoptotic pathway. This suggests either of the two possibilities: induction of autophagy and apoptosis are two independent mechanisms for cell death, or autophagy inhibits apoptotic cell death in pancreatic cancer cells.

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Triptolide Induces Apoptotic and Autophagic Cell Death in Pancreatic Cancer Cells

N. Mujumdar, T. MacKenzie, S. Vickers, A. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Pancreatic cancer is the most aggressive of all human malignancies with an extremely low 5-year survival rate of <1% in the United States. Our laboratory has previously shown that Triptolide, a diterpene triepoxide, decreases the cell viability of human pancreatic cancer cells in vitro and inhibits tumor growth in vivo (Cancer Research 2007).

Aim: In the present study we have investigated whether-Triptolide-mediated decrease in cell viability of pancreatic cancer cells is via an apoptotic or non-apoptotic pathway.

Methods: MiaPaCa-2, S2-013 and S2-VP10 cells were treated with different concentrations of Triptolide (0-200 nM) and assayed for cell viability (CCK8 assay), apoptosis (AnnexinV staining, Cytochrome C release and Caspase-3 activation) and autophagy (LC3II immunofluorscence, LC3II western blotting and acridine orange staining).

Results: Triptolide treatment resulted in decreased cell viability of MiaPaCa-2, S2-013 and S2-VP10 after 24 and 48 h of treatment. However, only MiaPaCa-2 showed cytochrome C release, annexin V staining and caspase-3 activation after Triptolide treatment. Furthermore, silencing of caspase-3 with a pool of siRNA resulted in a rescue of Triptolide-mediated cell death only in MiaPaCa-2 but not the other two cell lines. In contrast to MiaPaCa-2, both S2-013 and S2-VP10 showed an upregulation of an autophagy specific marker, LC3II, as observed by western blotting and by immunoflourescence on treatment with Triptolide. S2-013 and S2-VP10 also showed an increase in acridine orange staining on Triptolide treatment which was not seen in MiaPaCa-2.

Conclusions: Thus, our study shows that Triptolide can kill pancreatic cancer cell by activating two different pathways: apoptosis in MiaPaCa-2 and induction of autophagy in S2-013 and S2-VP10.

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GAIP Interacting Protein C-Terminus (GIPC): A Novel Target for Pancreatic Adenocarcinoma Therapeutics

D. Mukhopadhyay,1 M.H. Muders,1 M.R. Spaller.2 1Department of Biochemistry and Molecular Biology, College of Medicine, Mayo Clinic, Rochester, MN; 2Department of Pharmacology and Toxicology, Dartmouth Medical School, Norris Cotton Cancer Center, Lebanon, NH.

Purpose: Various studies have demonstrated the importance of GAIP interacting protein, C-terminus (GIPC, also known as Synectin) as a central adaptor molecule in different signaling pathways and as an important mediator of receptor stability. GIPC is associated with different growth promoting receptors like IGF-1R and integrins. These interactions were mediated through its PDZ domain. Using tissue microarrays, we have shown that GIPC is overexpressed with pancreatic cancer progression. The goal of this study was to demonstrate the importance of GIPC in pancreatic cancer growth and to evaluate a possible therapeutic strategy by using a GIPC-PDZ domain inhibitor. Furthermore, the effect of targeting GIPC on the IGF-1 receptor as one of its associated receptors was tested. In vivo effects of GIPC/Synectin knockout were studied after lentiviral transduction of luciferase-expressing pancreatic cancer cells with shRNA against GIPC/Synectin. Knockdown of GIPC/Synectin led to a significant inhibition of pancreatic adenocarcinoma growth in an orthotopic mouse model. Additionally, a GIPC-PDZ-targeting peptide was designed. This peptide was tested for its influence on pancreatic cancer growth in vitro and in vivo. Importantly, the cell-permeable GIPC-PDZ inhibitor was able to block tumor growth significantly without showing toxicity in a mouse model. Furthermore, we have observed that targeting GIPC was accompanied by a significant reduction in IGF-1R protein levels in pancreatic cancer cells. Taken together, our findings demonstrate that targeting GIPC/Synectin and its PDZ domain inhibits pancreatic carcinoma growth and is a potential strategy for therapeutic intervention of pancreatic cancer.

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The MEK/ERK Pathway Positively Modulates the Notch Pathway in Human Pancreatic Cancer Cells

P. Mysliwiec, M.-J. Boucher. Gastroenterology Unit, Fac. Of Medicine, University of Sherbrooke, Canada.

Background: The Notch pathway is normally inactive in the adult pancreas. However, recent findings revealed that Notch signalling is reactivated during pancreatic carcinogenesis and synergizes with KRas in PanIN initiation and progression. However, the molecular links between these two pathways are still unknown.

Aim: To evaluate the impact of the Mek/Erk pathway, downstream of KRas, on the Notch signalling pathway.

Methods: HEK293T and MIA PaCa-2 cell lines were used. Mek/Erk activity was down-regulated by treatment with the specific inhibitor U0126. Transfection of a constitutive active form of Mek (MekCA) was used to increase Mek/Erk activity. Notch-dependent transcription was measured by luciferase assays using a specific (CSL) luciferase reporter gene.

Results: 1- Expression of the active form of Notch (NIC) as well as Notch-dependent transcription were detected in pancreatic cancer cells. 2- Inhibition of the Mek/Erk activity down-regulated Notch-dependent transcription while increased Mek/Erk activity had the opposite effect. 3- No modulation in NIC expression was observed following modulation of the Mek/Erk activity. 4- However, by in vitro kinase assays, we observed that NIC worked as a substrate for Erk. 5- More interestingly, in vivo phospholabeling experiment revealed that NIC was more phosphorylated in MekCA-transfected cells compared to Mek wild-type-transfected cells.

Conclusion: Taken together, our results provide evidences that the Mek/Erk signalling pathway promotes NIC phosphorylation which correlates with increased NIC-dependent transcription.

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Impact of Perioperative Factors on Survival Following Pancreatectomy for Invasive Ductal Carcinoma of the Pancreas

S. Nagai, T. Fujii, M. Kanda, A. Kanzaki, S. Yamada, H. Sugimoto, S. Nomoto, S. Takeda, A. Nakao. Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Aim: To evaluate prognostic factors following surgery for invasive ductal carcinoma of the pancreas.

Methods: The medical records of 242 patients with invasive ductal carcinoma were studied (median age, 63 years; male, 61%). Between April 1984 and June 2009, 168 (69.4%) underwent pancreaticododunectomy, 55 underwent (22.7%) distal pancreatectomy, and 19 (7.9%) underwent a total pancreatectomy. Based on UICC stage, these patients were classified into 2 groups (A, stage I/II; B, stage III/IV). Survival and prognostic factors were evaluated in each group.

Results: Seven patients were in stage I, 189 in stage II, 7 in stage III, and 39 in stage IV (group A, n = 196; group B, n = 46). The mean survival time was 2.7 ± 0.3 and 0.9 ± 0.1 years in groups A and B, respectively. After multivariate analysis, the poor prognostic factors in group A were age >70 years (hazard ratio, 1.99), blood loss >1000 ml (1.77), postoperative complication (1.69), without chemotherapy (2.03), poor differentiated adenocarcinoma (por) (4.63), and N+ (2.37). In group B, age >70 years (10.39), operative time >10 hr (1.96), por (4.38), tumor explosion (3.20), tumor size >2 cm (1.31), and N+ (13.21) remained significant.

Conclusions: Although biologic factors were important indicators, perioperative factors, including blood loss during surgery and postoperative complications, also influenced the survival rates regardless of the UICC stage. Careful surgical techniques and management may improve prognosis.

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Feasibility of Using an Internal Pancreatic Duct Stent for Pancreaticojejunal Anastomosis in Pancreaticoduodenectomy

Y. Nagano,1 M. Ueda,1 K. Nojiri,1 Y. Minami,1 K. Taniguchi,2 R. Matsuyama,2 I. Endo,2 C. Kunisaki.1 1Yokohama City University Medical Center, Gastroenterological Center, Yokohama, Japan. 2Department of Gastroenterological Surgery, Yokohama City University, Graduate School of Medicine, Yokohama, Japan.

Aim: The aim of this study was to evaluate the feasibility of using an internal pancreatic duct stent for pancreaticojejunal anastomosis in pancreaticoduodenectomy.

Patients and methods: Between 2000 and 2007 total 157 consecutive patients underwent duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy at the Yokohama City University. POPF (postoperative pancreatic fistula) and hospital stay were analyzed between internal pancreatic duct stent (internal group) and external pancreatic duct stent (external group).

Results: Internal stent was used in 82 patients, while external stent was employed in the remaining 75 patients. Incidence of pancreatic fistula was similar for the internal group (35.4%) and the external group (32%). However the incidence of grade B and C of all POPF in the internal group was significantly lower than that in external group (72.4% vs. 95.8%). The hospital stay for the internal group was 29.4 ± 14.4 (range 12-80) days, which was significantly shorter than that of the external group (42.8 ± 9.1, range 21-84 day). Thirty one patients (37.8%) in the internal group discharged within 21 days.

Conclusion: Pancreticojejunostomy with an internal stent may be useful method with an acceptable morbidity and shorter postoperative hospital stay.

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Src Kinase Inhibition Results in Increased Expression of E-Cadherin by Repressing the Transcription Factor Slug in Pancreatic Cancer Cells

N.S. Nagaraj, N.B. Merchant. Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Introduction: Src targets cadherin-mediated cell-cell adherens junctions. Down regulation of E-cadherin is thought to play an important role in tumor invasion and metastasis. The purpose of this study was to examine the effect of Src kinase inhibition on the transcriptional regulation of E-cadherin mediated cell-cell adhesion in pancreatic cancer.

Methods: E-cadherin and β-catenin expression was analyzed by Western blot, immunofluorescence and RT-PCR in multiple pancreas cancer cell lines after Src kinase inhibition with Dasatinib (DTB) and Src shRNA. Several E-cadherin transcriptional repressors were characterized by RT-PCR. Cell motility, anchorage independent growth, migration and invasion were assayed. Luciferase promoter activity for E-cadherin was measured.

Results: Src kinase inhibition resulted in enhanced E-cadherin and β-catenin expression at the cell membrane in a dose-dependent manner. This increase in E-cadherin protein and mRNA expression was associated with an increase in cell aggregation and a decrease in Slug expression while no changes were seen in expression of Snail, Twist, Zeb1, Sip1 and WT1. Repression of Slug also correlated with an increase in E-cadherin promoter activity. Furthermore, cell motility, anchorage independent growth, migration and invasion of pancreas cancer cells were also inhibited. Src shRNA also attenuated migration and invasion.

Conclusion: Src kinase inhibition induces cell adhesion in pancreatic cancer cells by upregulation of membranous E-cadherin and β-catenin through a Slug-dependent mechanism. These data suggest that Src may be a key regulator of epithelial to mesenchymal transition in pancreas cancer.

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Src Kinase Inhibition Attenuates Pancreatic Tumorigenesis Through Inhibition of Multiple Downstream Signaling Pathways

N. Nagaraj, M. Washington, F. Revetta, N. Merchant. Departments of Surgery and Pathology, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Src is linked to tumor development and metastases through activation of multiple downstream signaling pathways. The purpose of this study was to determine the effects of Src inhibition on downstream signaling and tumorigenesis in pancreas cancer.

Methods: Immunohistochemical staining for Src was performed on a pancreatic tissue microarray. Antitumor effects of Dasatinib (DTB), a Src kinase inhibitor, were measured in vitro and in vivo. Western blotting was used to monitor its effect on multiple signaling molecules.

Results: Src expression increases with the progression of pancreatic neoplasia in human pancreatic tissue. DTB inhibited activation of multiple signal transduction pathways implicated in cell survival (AKT), proliferation (ERK), angiogenesis (STAT3, MAPK), motility, migration and invasion (FAK, JNK, paxillin) at low nM concentrations. Furthermore, DTB inhibited tumor cell proliferation (IC50 of 2.8-51.3 nM), migration, invasion and anchorage independent growth as well as induced cell cycle arrest and apoptosis. Decrease in S-phase was consistent with the decrease in the expression of cyclin D1 and c-myc. In support of this, shRNA targeting Src inhibited migration and invasion of pancreatic cancer cells. DTB inhibited tumor growth in a mouse xenograft model.

Conclusion: Src kinase inhibition results in decreasing the activity of downstream signaling pathways which are implicated as having key roles in tumorigenic properties in pancreatic cancer cells. This suggests that targeting Src kinase with DTB is a rational therapeutic approach in pancreas cancer.

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The Clinical Research About the Balance Between Pro/Anti-Inflammatary Cytokines in Acute Severe Pancreatitis

C. Nai Qiang, M. Bin, F. Qiang, C. Yun Feng. Department of Surgery, Tianjin Nankai Hospital, Tianjin, China.

Aims: we elucidate the relationship between SAP immunobalance and infection organ dysfunction, mortality by observing the dynamic changes of pro/anti-inflammatory cytokines in acute severe pancreatitis patients.

Methods: 72 cases admitted to the hospital from 2007.7 to 2008.12 are divided into infectious and non-infectious groups, death and survival groups, MODS and non-MODS groups separately. In the different time points which are admission time, third, seventh, and fourtheenth day after admission, we observe the changes of relevant indicators such as TNF-a,IL-6,IL-10 and IL-4,et al. We also try to find out the relationship between SAP immunobalance and infection, organ dysfunction and mortality.

Results: Compared with admission time,the levels of TNF-a and IL-6 of SAP cases in third day increase obviously, and those of IL-10 and IL-4 in seventh day also increase obviously (P < 0.05). Compared with non-infectious group, the levels of IL-10 and IL-4 of infectious group in fourteenth day increase obviously, on the contrary those of TNF-a and IL-6 decrease obviously (P < 0.05). Compared with non-MODS group, the levels of TNF-a and IL-6 of MODS group in third day increase obviously. Compared with survival group, the levels of TNF-a and IL-6 of death group in admission time and third day increase obviously.

Conclusions: In the early stage of SAP the serum pro-inflammatory cytokines(TNF-a and IL-6) are activated excessively, which is related to MODS and mortality. And when secondary infections happen in the late period of SAP, we find there are excessive releases of anti-inflammatory cytokines(IL-10 and IL-4), imbalance between pro/anti-celluar cytokines and excessive anti-inflammation response.

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Inhibition of Peroxisome Proliferator-Activated Receptor Gamma Activity Suppresses Pancreatic Cancer Cell Motility

A. Nakajima, H. Takahashi, N. Kobayashi, K. Kubota. Division of Gastroenterology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, Japan.

Peroxisome proliferator-activated receptor gamma (PPARγ) is a ligand-activated transcription factor that has been implicated in the carcinogenesis and progression of various solid tumors, including pancreatic carcinomas. We aimed to clarify the role of this receptor in pancreatic cell motility in vitro and metastasis in vivo. Cell motility was examined by assaying transwell mig2ration and wound filling in Capan-1 and Panc-1 pancreatic cancer cells, with or without the PPARγ-specific inhibitor T0070907. A SCID xenograft metastasis model was used to examine the in vivo effect of PPARγ inhibition on pancreatic cancer metastasis. In both transwell-migration and wound-filling assays, inhibition of PPARγ activity suppressed pancreatic cell motility without affecting in vitro cell proliferation. Inhibition of PPARγ also suppressed liver metastasis in vivo in metastatic mice. In PPARγ-inhibited cells, p120 catenin (p120ctn) accumulation was induced predominantly in cell membranes, and Rho GTPases Rac1 and Cdc42 were inactive. Inhibition of PPARγ in pancreatic cancer cells decreases cell motility by altering p120ctn localization, and by suppressing the activity of Rho GTPases Rac1 and Cdc42. Based on these findings, PPARγ could function as a novel target for therapeutic control of cancer-cell invasion or metastasis.

Abbreviations: PPARγ - peroxisome proliferator-activated receptor gamma, PDAC - pancreatic ductal adenocaricinoma cells, p120ctn - p120 catenin

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Outcome of Spleen Preserving Distal Pancreatectomy

M. Nakamura,1 J. Ueda,2 M. Sada,2 S. Takahata,2 S. Shimizu,2 M. Tanaka.2 1Cancer Therapy and Research, 2Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan.

Aim: To evaluate the outcome of spleen-preserving distal pancreatectomy (SPDP) with special reference to dilatation of gastric veins.

Background: The standard procedure of distal pancreatectomy includes combined resection of spleen. However, limited distal pancreatectomy preserving spleen is also acceptable for benign or borderline tumors. Today, SPDP has become more popular in laparoscopic surgery. It is urgent to evaluate the clinical outcome of SPDP.

Methods: Eleven patients of SPDP performed in Kyushu University are analyzed by dynamic CT scan. Nine cases were performed under laparoscope, and two were by open method. Splenic vein and artery were preserved in 5 patients (AV-pre) and excised in 6 patients (AV-ex; Warshaw's procedure).

Results: Five AV-pre patients did not show any dilated gastric mural veins (GMV), while 4 out of 6 AV-ex patients showed dilated GMV in CT. Two of the 4 patients with dilated GMV underwent endoscopic examination of stomach. Unexpectedly, one patient with severely dilated GMV in CT showed no gastric varix, while the patient with mild GMV in CT showed gastric mild varix by the endoscope. No patients have experienced bleeding from GMV developed after SPDP.

Discussion: SPDP excising splenic vessels causes GMV dilatation. However, CT signs of dilated gastric veins are not correlated with endoscopic findings. The clinical meaning of GMV dilatation is still unknown.

Conclusion: SPDP causes GMV dilation. However, further analysis is necessary to evaluate the clinical significance.

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CpG DNA Activates Pancreatic Stellate Cell Via Toll-Like Receptor9

T. Nakamura, N. Fujimori, T. Oono, Igarashi, T. Ito, R. Takayanagi. Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan.

Background: Pancreatic stellate cells (PSCs) are known for collagen producing cell. Recently it is revealed that PSCs work as an immunocompetent cell. PSCs express toll-like receptors (TLRs) to recognize pathogens. The TLR9 recognizes CpG DNA, whose motif is rich in bacterial DNA. TLR9 function becomes clear in dendritic cells but until now it is not well known for its function on PSCs.

Aims: To clarify the possible role of CpG DNA as a trigger factor for overt pancreatic inflammation on PSCs.

Methods: PSCs were isolated from the Lewis rat. The expression of TLR9 mRNA was evaluated using reverse transcription-PCR. Localization of TLR9 and internalization of CpG DNA were analyzed using a confocal laser scanning microscope. PSCs were incubated with CpG DNA (0-20 ⊐M, 0-24 H) and then cell proliferation was assessed using a BrdU cell proliferation assay kit.

Results: We confirmed the expression of TLR9 at the mRNA and protein level. CpG DNA was internalized in the cytoplasm which was co-localized with TLR9. In response to CpG DNA administration, PSCs proliferated at dose- and time-dependent manners. Interestingly, PSCs proliferated earlier than PDGF-induced proliferation, achieving a peak 6 hours after administration, suggesting that PSC could respond readily for innate immunity.

Conclusion: It is suggested that PSCs express TLR9 and internalize CpG DNA, and that PSCs proliferate at dose- and time-dependent manners after internalization of CpG DNA. In conclusion, bacterial DNA might be involved in progression of pancreatic inflammation via TLR9 on PSC.

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Economic Impact of Fast-Track Surgery After Pancreaticoduodenectomy

T. Nakamura,1 Y. Inoue,1 Y. Ambo,1 T. Noji,1 A. Kamaei,1 Y. Hashimoto,1 N. Okada,1 Y. Nanno,1 O. Suzuki,1 F. Nakamura,1 A. Kishida,1 A. Kurita,2 M. Osanai,2 A. Katanuma,2 K. Takahashi,2 H. Maguchi,2 N. Kashimura.1 1Department of Surgery, Teine-Keijinkai Hospital, Sapporo, Japan; 2Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan.

Objective: The aim of our study focuses on economic impact of fast-track surgery after pancreaticoduodenectomy (PD).

Methods: All 283 consecutive patients undergoing PD at the Department of Surgery, Tenine- Keijinkai Hospital from 1995 through 2008 were reviewed retrospectively. Of these, 134 patients were treated by a fast-track protocol from 2004 to 2009 that included earlier postoperative feeding and mobilization. The patients were compared with 149 patients that received a traditional protocol from 1995 to 2004. Outcome endpoints were morbidity, length of stay and total cost of postoperative recovery.

Results: The rates of intra-abdominal complications including pancreatic fistula were similar in the two groups. Delayed gastric emptying was reduced in the fast-track group but not statistically significant (29.1 versus 42.1 per cent; P = 0.06). Length of stay was reduced with the fast-track protocol (median 24 versus 45 days; P < 0.001), with reduced postoperative cost ($8,716 versus $18,511; P < 0.001).

Conclusion: A fast-track surgery after PD has proved to reduce postoperative length of stay and their cost.

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Intestinal-Type IPMN Shows Better Prognosis Than Non-Intestinal-Type IPMN Due to Its Less-Aggressive Behavior

K. Nakata,1 K. Ohuchida,1 S. Aishima,2 Y. Sadakari,1 K. Morimatsu,1,2 A. Hayashi,1,2 E. Nagai,1 K. Mizumoto,1 M. Tanaka.1 Department of 1Surgery and Oncology; 2Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Backgrounds: Few reports have analyzed the prognosis of IPMN with respect to the degree of invasion and the disease subtypes (intestinal and non-intestinal).

Methods: 71 patients with intraductal papillary mucinous carcinoma (IPMC) were evaluated.

Results: 29 patients (40.8%) had carcinoma in situ (CIS), 10 (14.1%) minimal invasion (MI-IPMC) and 32 (45.1%) massive invasion, and there were no disease-specific deaths among the patients with CIS or MI-IPMC. However, we had two MI-IPMC patients with lymph node metastasis. Lymph node metastasis (P = 0.022), non-intestinal type (P = 0.002), massive invasion (P = 0.014), and tubular carcinoma (P = 0.011) were detected as significant factors to predict poor prognosis in invasive carcinoma derived from IPMN. Intestinal-type IPMC showed a significantly higher survival rate compared with non-intestinal type IPMC (P = 0.003), and MI-IPMC were more frequent in intestinal type IPMC compared with non-intestinal type IPMC (P = 0.019). Among the 32 patients with massively invasive IPMC, tubular invasion, lymph node metastasis, lymphatic, serosal and retroperitoneal invasion were observed more frequently in non-intestinal type IPMC than in intestinal type IPMC.

Conclusions: Intestinal type IPMC, more frequently associated with minimal invasion or colloid carcinoma, shows better prognosis compared with non-intestinal type IPMC.

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S100P Is a Novel Marker to Identify Invasive Lesions in Intraductal Papillary Mucinous Neoplasms

K. Nakata,1 K. Ohuchida,1 S. Aishima,2 Y. Sadakari,1 K. Morimatsu,1,2 A. Hayashi,1,2 E. Nagai,1 K. Mizumoto,1 M. Tanaka.1 Department of 1Surgery and Oncology; 2Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Backgrounds: Intraductal papillary mucinous neoplasms of the pancreas (IPMNs) are subclassified based on morphological features and different immunohistochemical profiles have been identified in association with the subtypes. We previously reported that S100P was an early developmental marker of pancreatic carcinogenesis, and that there was higher S100P expression in IPMNs than in normal pancreatic ductal epithelium. However, there have been no reports on novel diagnostic markers to distinguish IPMN from non-neoplastic lesions, and to detect invasive tumor cells.

Materials and Methods: Surgical specimens of IPMN obtained from 105 patients were investigated using immunohistochemistry.

Results: S100P expression was not detected in normal pancreatic ductal epithelium, but was detected in all IPMN cells (100%) with diffuse nuclear or nuclear/cytoplasmic staining. MUC5AC was also expressed in most of the IPMNs (102 of 105, 97%). S100P was clearly detected in minimally invasive areas of IPMNs. Furthermore, S100P was diffusely expressed in the invasive component of IPMNs (32 of 32, 100%), including perineural and lymphatic invasion. On the other hand, MUC5AC was expressed in only 23 cases of 32 invasive components (P < 0.01).

Conclusions: These data suggest that the S100P antibody may be a useful marker for detecting IPMNs, especially for evaluating the invasive component.

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Current Strategy for Cancer of the Distal Pancreas - Importance of MDCT and Anterior Approach

S. Narumi, Y. Toyoki, K. Ishido, D. Kudoh, H. Morohashi, K. Hakamada. Department of Digestive Surgery, Hirosaki University School of Medicine, Hirosaki, Japan.

Introduction: Prognosis of cancer of the distal pancreas remains poor. Surgery for patients with severe invasion around celiac trunk is not favorably indicated. Retrospective analysis was performed and we introduce strategy for advanced cancer of the distal pancreas.

Patients and Method: Among 200 patients with advanced pancreatic cancer, 40 patients with cancer of the distal pancreas were involved. Two patients with severe invasion to the celiac axis underwent combined resection of the celiac axis.

Preoperative diagnosis: Evaluation with MDCT is inevitable, especially focusing on degree of invasion to the celiac axis and SMA.

Anterior approach: Prior to dissection of the spleen and the tail of the pancreas, vascular control should be initiated. After dissection around the celiac axis, the splenic artery is cut if possible. Touching the tumor should be avoided with great effort.

Results: After introducing evaluation with MDCT and anterior approach since 2000, prognosis of the patients with advanced cancer of the tail of the pancreas is improving. Three- and 5-year survival improved to 45.3% and 34.0% from 27.2% and 13.6% respectively. Surgery with no residual tumor consist of 85.7%. After 2002, adjuvant chemotherapy with gemcitabine was introduced and 49.8% of 3-year survival has been achieved.

Conclusion: Preoperative assessment with MDCT and anterior approach for the cancer of the distal pancreas can improve prognosis. Chemotherapy involved gemcitabine seems effective.

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The Exocrine Pancreas and Fluid Secretion in PCK Rats

S. Naruse, S. Furuya, H. Ishiguro, L. Yi, A. Yamamoto, M. Nakakuki, T. Kondo, S. Nagao. Miyoshi Municipal Hospital, National Institute for Physiological Sciences, Department of Human Nutrition, Nagoya University Graduate School of Medicine, Education and Research Center of Animal Models for Human Diseases, Fujita Health University, Japan.

Background: The polycystic kidney (PCK) rat is an animal model for autosomal recessive polycystic kidney disease (ARPKD) caused by mutations in the polycystic kidney and hepatic disease (PKHD1) gene. The PKHD1 protein, fibrocystin, is localized to primary cilia in epithelial cells and appears to be related to their function. ARPKD is characterized by cystic dilatation of renal collecting ducts and intrahepatic bile ducts, but pathophysiology of the pancreas is less documented.

Methods: The pancreas in PCK rats was examined by microscopy and immunohistochemistry for AQP1. Interlobular ducts were isolated by microdissection and the fluid secretory rate was measured by videomicroscopy.

Results: The appearance of the pancreas in PCK rats was normal, but interlobular ducts were enlarged. The AQP1 immunoreactivities in epithelial cells of larger interlobular ducts and main duct in PCK rats were more abundant than those in controls. Basal secretion was not different among ducts isolated from PCK, heterozygote, and wild rats. Sequential application of 0.1 and 10 nM secretin increased fluid secretion in all genotypes. The fluid response of PCK ducts to 10 nM secretin (0.98 ± 0.03 nl min-1 mm-2) was significantly (p < 0.05) larger than that of hetero (0.68 ± 0.01) or wild (0.69 ± 0.01) ducts.

Conclusion: The interlobular ducts are dilated in PCK rats and their fluid response to secretin is enhanced.

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A Case of Giant Mucinous Cystadenocarcinoma of the Pancreas

H. Nitta, H. Itoh, T. Suwa. Department of Surgery, Fukaya Red Cross Hospital, Saitama, Japan.

A 26-year-old woman was admitted to our hospital because of abdominal distension, nausea and vomiting lasting for one week. A soft elastic mass of an infant head in size was present at upper abdomen. Computed tomography (CT) showed a giant multilocular cyst over 25 cm in diameter with enhanced nodule on cystic wall adhering to the pancreatic body and tail. Under a preoperative diagnosis of mucinous cystadenocarcinoma of the pancreas, we conducted operation. A giant tumor with a smooth capsule was revealed, and was partly adhering to gastric wall. We surgically resected the tumor with partial gastrectomy and distal pancreatectomy. Macroscopic findings of the resected specimen showed that the cystic tumor had thin septums with irregular nodule 3.5 cm in size toward the lumen. Although histopathological diagnosis was minimally invasive mucinous cystadenocarcinoma with ovarian-like stroma, it was assumed that the tumor contained highly malignant potential because of remarkable invasion to the lymphatic vessels and anaplastic component in the nodule. Though the patient is currently receiving chemotherapy with gemcitabine, no recurrence has been observed two years after the surgery. We report a relatively rare case of mucinous cystadenocarcinoma of the pancreas over 25 cm in size together with some discussion of the literature.

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Serous Cystic Tumor of the Pancreas Is a Favorable Tumor Occurring From Intercalated Duct

B. Nobukawa,1 M. Takase,1 Y. Fukumura,1 K. Suda,1 T. Yao.1 1Department of Human Pathology, Juntendo University, Tokyo, Japan.

Aims: Serous cystic tumors (SCTs) of the pancreas are rare and their histogenesis is unknown. We studied clinicopathologically SCTs and attempted to elucidate their histogenesis.

Methods: Seventeen surgically resected specimens and one obtained at autopsy from patients with SCTs were investigated using histological, histochemical, immunohistochemical and ultrastructural techniques.

Results: The 18 patients had 21 adenomas and one adenocarcinoma, including two cases with triple adenomas. No von Hippel-Lindau disease associated SCT was identified. A tumor-forming pancreatitis, an intraductal papillary-mucinous tumor, two early gastric carcinomas, early colon carcinoma, and a multiple myeloma were identified in one patient each. Three lesions connected to a pancreatic duct were identified: 2 to the intercalated duct and one to the branch duct. One patient had an adenocarcinoma showing vessel infiltration and marked perineural invasion and a metastatic liver tumor was identified. All the patients were alive and free of the disease. Immunohistochemically, the tumor cells resembled both the centroacinar cells and the intercalated ducts. Histochemically, all the SCTs contained periodic acid Schiff-positive glycogen granules in their cytoplasm. Electron microscopy revealed that tumor cells contained glycogen granules.

Conclusions: We concluded that SCTs of the pancreas may be arising from the intercalated ducts and occasionally they are multicentric and malignant, and other malignancies are sometimes complicated.

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Diagnosis and Indication for Resection of Pancreatic Serous Cystic Neoplasms

Y. Nobuoka, H. Kato, M. Azuni, M. Kishiwada, T. Hamada, S. Mizuno, M. Usui, H. Sakurai, M. Tabata, S. Isaji. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University, Tsu, Japan.

Pancreatic serous cystic neoplasms (SCN) are considered to have a benign biological and clinical course, with only few cases being malignant. The optimal timing of resection remains controversial. There have been no reports concerning the involvement of the main pancreatic duct (MPD).

From October 2005 to February, 7 patients were diagnosed as SCN by the imaging findings or by resection. The patients were divided into 2 groups: Group A with 5 patients who could be diagnosed as SCN and Group B with 2 patients who was diagnosed as the other cystic neoplasms.

In Group A, 1 patient who had a tumor of 2 cm without involvement of MPD did not receive resection, and 4 patients received resection: 1 with a tumor of 10 cm showing MPD stenosis developed symptoms and 3 with tumors of 3.5 to 7.5 cm demonstrated MPD stenosis. Operation was less invasive procedures such as medial pancreatectomy and laparoscopic distal pancreatectomy. In Group B, 1 patient with macrocytic type received distal pancreatectomy with splenectomy, and another patient underwent pylorus-preserving pancreaticoduodenectomy with a diagnosis of intraductal papillary mucinous carcinoma. In the pathological findings, the tumor was an extremely rare tumor in which the solid component existed together with the macrocystic type.

Unless the diagnosis of SCN is certain, all cystic tumors should be resected. Even if the correct diagnosis of serous cystadenoma is made, the case showing the involvement of MPD is indication for resection.

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Clinicopathological Response of Preoperative Chemoradiation for Pancreatic Cancer

T. Nomi, M. Sho, H. Kanehiro, S. Ko, T. Yamada, T. Akahori, I. Yamato, J. Doh, D. Hokuto, Y. Nakajima. Department of Surgery, Nara Medical University, Nara, Japan.

Introduction: Current treatment has significantly improved the prognosis of the patients with pancreatic cancer. However, it is still not satisfactory and further studies are clearly required. To improve patient survival and operative curability, we are currently trying to evaluate chemoradiation prior to surgery.

Methods: Treatment of concurrent full-dose gemcitabine (1 g/m2) and radiotherapy (50-54Gy) was applied to 7 patients (4 with potentially resectable tumors and 3 with initially nonresectable tumors). Patients were reevaluated with CT and MRI for resectability after chemoradition. After 3-4 weeks of chemoradiation, patients underwent curative-intent surgery: 3 pancreaticoduodenectomy (PD) and 4 distal pancreatectmy (DP). One hundred two patients who underwent resection without chemoradiation were used as controls.

Results: There was no significant difference in the operating time and blood loss. No mortality was observed. All patients had histological responses to CRT as evidenced by denatured cancer cells or tissue necrosis. Among them, three patients had only less than 50% viable tumor cells in the resected specimen. Remarkably, pathological lymph node metastasis was not found in all 7 patients with CRT, while 59.3% of patients in control group had lymph node metastasis.

Conclusions: Preoperative CRT had no significant influence on surgery and mortality. More importantly, some antitumor effects including the inhibition of lymph node metastasis was observed in all patients.

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The Effect of Administration of Hochuekkito, Japanese Herbal Medicine, After PHRSD or PPPD

S. Nomoto, M. Kanda, A. Nakao. Department of Surgery II, Nagoya University, Nagoya, Japan.

Background and Aim: Delayed gastric emptying (DGE) comprised one of the most troublesome complications of PpPD. In this study, we aimed to examine the clinical effects of Hochuekkito, one of the Kampo, on patients who were undergoing PHRSD or PpPD with pancreatogastrostomy.

Patients and Methods: Forty-two patients were undergoing PHRSD or PpPD with pancreatogastrostomy. Thirteen of 42 cases were administered to take 7.5 g of Hochuekkito three times a day (2.5 g/ time) after the 4th post-operative day (POD). Regarding the effects on nutritional status and systemic inflammation, we compared two groups: Group A was administered the Hochuekkito (13 cases) and Group B, was not given Hochuekkito (29 cases).

Results: The interval period to start oral intake after surgery was significantly decreased in Group A, 12.7 ± 5.7 days, as compared with Group B, 27.7 ± 14.7 days (p = 0.0011). There was a significant decrease in the amount of time required to remove CV catheter in the Group A 23.3 ± 8.9 days after operation compared with 37.8 ± 17.2 in Group B (p = 0.068). Body temperature values were not significantly different in both groups during POD 1 to 3, 584.3 ± 225.0 in group A and 484.2 ± 212.1 in group B. However, the value was significantly smaller in Group A 77.5 ± 59.9 between POD 4 to 14, as compared with Group B 186.4 ± 185.3 (p = 0.0464). In addition, the hemoglobin values significantly recovered three months after operation in group A, 2.13 ± 1.73 (g/dl), as compared with in group B, 0.58 ± 1.35, (p = 0.0035).

Conclusion: The administration of Hochuekkito helps to improve disorders after PHRSD or PpPD operation.

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Proliferation of CD163+ Spindle-Shaped Macrophages in Lymphoplasmacytic Sclerosing Pancreatitis

K. Notohara. Department of Pathology, Kurashiki Central Hospital, Kurashiki, Japan.

Background: Lymphoplasmacytic sclerosing pancreatitis (LPSP) is the histological prototype of autoimmune pancreatitis. Although lymphocytes and plasma cells are well-known inflammatory constituents seen in LPSP, little has been discussed so far on the role of macrophages.

Design: Resected pancreata from 15 patients with LPSP were gathered, and immunostains for CD163, a-smooth muscle actin (SMA) and IgG4 were carried out.

Results: There were numerous CD163+ macrophages within LPSP. Most of them were small and slender, and were different from those macrophages with abundant cytoplasm. Numerous CD163+ cells were identified within the inflamed lobules and in the periductal inflammatory cuffs. In fact, most of the spindle-shaped cells morphologically identified in these inflammatory foci were CD163+ and SMA-. The spindle-shaped macrophages were also identified and coexisted with SMA+ fibroblasts in the fibrosis. Notably the formers were a constituent of the storiform fibrosis. Lymphocytes and plasma cells, including those with IgG4 expression, were numerous in the areas with abundant CD163+ macrophages. The number of CD163+ macrophages in each case correlated with that of IgG4+ plasma cells and the degree of lymphoplasmacytic infiltrates.

Conclusion: CD163+ spindle-shaped macrophages are one of the major inflammatory components of LPSP, and are seen in the inflamed lobules, periductal inflammatory cuffs and fibrosis. They are a constituent of storiform fibrosis. These findings are unique to LPSP, and CD163 could be a useful marker for the histological diagnosis of LPSP.

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Biomechanical Characterization of Pancreatic Tumor Cells by Dielectrophoresis Force Generation in a Microfluidic System

M. Oeinck,1 K. Riehemann,2 H. Fuchs,2 J. Schnekenburger.1 1Department of Medicine B, University of Muenster, Muenster, Germany; 2Center for Nanotechnology, Department of Physics, University of Muenster, Muenster, Germany.

Background: Marker free characterization of tumor cells by physical cell properties has a broad potential in cell biology and in vitro diagnostics. Here we have used dielectrophoretic force generation in a microfluidic chamber for analysis of pancreatic tumor cell deformation in an electric field.

Methods: Highly differentiated PaTu8988S cells and dedifferentiated PaTu8988T pancreas tumor cells were suspended and injected in a cytocon microfluidic system. Single cells were caged within the field cage using 6 V at 700 kHz. Rapid alteration of electrode polarity for 2 min induced stretching forces to cells. Cell elongation and deformation was imaged by bright field microscopy and quantified by automated object analysis.

Results: Force application to pancreatic tumor cells induced cell deformation and frequently a rapid development of membrane blebs. Membrane blebbing was not associated with apoptotic events. Statistical analysis revealed significant differences in deformation parameters and an average blebbing of PaTu8988S cells of 25.44 % and 75.41 % in PaTu8988T cells.

Conclusions: Pancreatic tumor cells differ in membrane stability depending from their state of dedifferentiation. Cell membranes of an invasive mesenchymal tumor type are much weaker attached to the cytoskeleton indicating the ability for rapid rearrangement during cell migration.

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Serine Protease Inhibitor Kazal Type 1 Induces EGFR Activation and Cell Proliferation Through EGFR/MAPK Cascade

M. Ohmuraya,1 M. Hirota,2 K. Yamamura.1 1Institute of Resource Development and Analysis, Kumamoto University, Kumamoto, Japan; 2Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan.

Background & Aims: Serine protease inhibitor Kazal type 1 (SPINK1), which is expressed in normal human pancreatic acini and in a variety of solid tumors, increases the proliferation of a variety of cell lines. However, its receptor and signaling pathways are not known yet. The epidermal growth factor receptor (EGFR) is overexpressed in pancreatic cancer and in chronic pancreatitis. Thus, we hypothesize that SPINK1 is a ligand for EGFR, leading to the activation of its signaling pathway in pancreatic cancer.

Methods & Results: Using human pancreatic cancer tissue, we performed immunostaining by anti-SPINK1 antibody and anti-EGFR antibody. In human pancreatic cancer, SPINK1 and EGFR are co-expressed. And SPINK1 overexpressed in PanIN (Pancreatic intraepithelial neoplasia) lesion. We analyzed whether human SPINK1 protein can activate EGFR and its downstream target using 3T3 fibroblast and 4 pancreatic cancer cell lines (AsPC-1, MIA PaCa-2, PANC-1 and Capan-2). Our data demonstrated that EGFR and its downstream target were phosphorylated by SPINK1.

Conclusions: SPINK1 is overexpressed for the glandular cavity formation of pancreatic tubular adenocarcinoma and PanIN lesion. It suggests that SPINK1 involves in carcinomatous growth and development through EGFR/MAPK cascade.

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Laparoscopic Pancreatic Resection: Experience of Seven Patients With Pancreatic Tumor

T. Okada, N. Kuroda, M. Satake, K. Suzumura, M. Takahashi, K. Ohashi, Y. Yoshida, K. Oh, J. Yamanaka, Y. Iimuro, J. Fujimoto. Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.

Backgrounds: Laparoscopic pancreatic surgery (Lap- Ps) may appear to confer benefit over the equivalent open surgery in adequate cases. In the present study, we analyzed the clinical outcome of patients with pancreatic tumors who received Lap-Ps.

Methods: A retrospective clinical chart review was performed in seven patients with pancreatic tumors underwent Lap-Ps. Diagnosis was obtained by CT, MR, and US. Operative time, loss of blood, complications, and the length of the hospital staying (LOS) were analyzed.

Results: All seven patients were female with a mean age of 45. Cases include four solid-pseudopapillary tumor, two insulinoma with adrenal tumor, and one hamartoma. Only one case (hamartoma) was converted to open surgery, because the tumor seemed to invade the renal vein and potential malignancy was suspected. Lap-Ps was undergone in other six cases, four patients received distal pancreatectomy with spleen preservation and two received partial pancreatic resection. The mean operation time was 182 minutes and the mean blood loss was 26 ml. The postoperative pancreatic fistula was observed in two cases, but both were improved by conservative treatment. Food intake was started the 3rd postoperative day in all six cases, and the mean LOS was 14 days.

Conclusions: Lap-Ps with preserving the spleen is feasible for the patients with pancreatic benign tumors. It may provide less postoperative pain, a quicker recovery, and short LOS, and considered to be a widely accepted procedure.

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Role of 18F-Fluorodeoxyglucose Positron Emission Tomography in the Diagnosis of Early Pancreatic Cancer

K. Okano,1 H. Sutou,1 K. Kakinoki,1 K. Izuishi,1 Y. Nishiyama,2 Y. Suzuki.1 1Department of Gastroenterological Surgery, 1Department of Radiology, Faculty of Medicine, Kagawa University, Kagawa, Japan.

Background: Pancreatic cancer remains a highly lethal disease, early detection is essential to allow potentially curative resection. The aim of this study was to investigate the contribution of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) to the diagnosis of early pancreatic cancer.

Methods: This study involved 31 patients with proven invasive ductal cancer of pancreas. The patients were divided into three groups according to the maximum diameter of the tumor as follows; TS1 (maximum size ≤ 2.0 cm), TS2 (2.0 cm <, ≤ 4.0 cm) or TS3-4 (4.0 cm <). The standardized uptake value (SUV) for FDG was calculated in each patient and the relationships between the SUV and various clinicopathological factors including TS were analyzed.

Results: The tumors ranged from 1.3 to 11.0 cm in diameter. There were 5 patients in TS1, 15 patients in TS2 and 11 patients in TS3, 4. The sensitivity of FDG-PET, CT, MRI, the serum levels of CEA and CA19-9 were 100%, 40%, 0%, 0%, 40% in TS1, 93%, 93%, 89%, 20%, 73% in TS2 and 100%, 100%, 100%, 73%, 91% in TS3-4. All of the 5 patients in TS1 (from 13 mm to 20 mm) were diagnosed as pancreatic cancer by FDG-PET, preoperatively. The mean SUV did not show a significant difference in relation to TS (TS1: 5.8 + 4.5, TS2: 5.7 + 2.2, TS3-4: 8.2 + 3.9), respectively.

Conclusions: These results indicate that FDG-PET is the only useful modality for the detection of small early pancreatic cancers.

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Therapeutic Intervention Targeting a Hedgehog-Dependenet Barrier to Drug Delivery in Pancreatic Cancer

K.P. Olive,1 M.A. Jacobetz,*1 C.J. Davidson.*2 A. Gopinathan,*1,2 D. McIntyre,1 D. Honess,1 B. Madhu,1 M.A. Goldgraben,1 H. Ireland,1 S. Reichelt,1 W.J. Howat,1 P. Huang,3 S.E. Davies,4 R.H. Hruban,5 N. Whitebread,6 K. McGovern,6 J. Adams,6 C. Iacobuzio-Donahue,5 J. Griffiths,1 D.A. Tuveson.1 1Cancer Research UK, Cambridge Research Institute, The Li Ka Shing Centre, Robinson Way, Cambridge, CB2 ORE, UK; 2Abramson Family Cancer Research Institute, University of Pennsylvania, Philadelphia, PA 19104, USA; 3Oncology Franchise, Merck and Co, North Wales, PA 19454, USA; 4Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 2QQ, UK; 5Departments of Oncology and Pathology, The Sol Goldman Pancreatic Cancer Research Center, Sidney Cancer Center and Johns Hopkins University, Baltimore MD 21287, USA; 6Infinity Pharmaceuticals Inc, Cambridge, MA 01239, USA.

*These authors contributed equally to this work.

Ductal pancreatic tumors are unusually resistant to chemotherapy, exhibiting primary resistance to each of the numerous regimens tested to date. These tumors are also unusually desmoplastic and harbor a sparse and inefficient vasculature. The resulting lack of perfusion appears to play a role in the inefficient delivery of numerous chemotherapeutic agents to the parenchyma of pancreatic tumors. Recent evidence has implicated the sonic hedgehog pathway in promoting desmoplasia through a paracrine signaling mechanism active in pancreatic tumors of both humans and the Kras/p53/PdxCre (KPC) mouse model. We sought to evaluate the dependence of stromal desmoplasia on Hedgehog (Hh) pathway signaling and, by extension, assess the effects of Hh pathway inhibition on drug delivery and chemoresistance.

Using IPI-926, a semisynthetic inhibitor of the Smoothened protein, we found that stromal contribution was markedly diminished within 10 days of inhibition of the Hh pathway. Paradoxically, the depletion of stromal cells was coincident with an increase in microvessel density, despite previous data indicating a pro-angiogenic role for the Hh pathway. These non-cell autonomous changes resulted in an increase in the delivery of small molecules to KPC pancreatic tumors and an increase in apoptosis when administered in combination with gemcitabine. Ultimately, mice treated with both IPI-926 and gemcitabine had a significant extension of survival and a decrease in the incidence of liver metastases. We conclude that the Hh pathway plays an important role in the maintenance of pancreatic tumor stroma and that this contributes to the primary chemoresistance of pancreatic tumors. These data also support the clinical evaluation of agents that target the stroma in pancreatic cancer.

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Poly(A) cDNA Real-Time PCR in Pancreatic Ductal Juice in Patients Undergoing Pancreaticoduodenectomy

M. Oliveira-Cunha,1 A.J. Sheen,1 R.J. Byers,2 A.K. Siriwardena.1 1Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; 2Department of Histopathology, Manchester Royal Infirmary, Manchester, UK.

Background: Currently there is much emphasis on earlier diagnosis of pancreatic cancer. Pancreatic juice collected during ERCP may be a potentially useful biological fluid.

Aim: to explore the feasibility of cancer genome study by the isolation of RNA from ductal juice.

Methods: With informed consent, intra-operative sampling of pancreatic juice was undertaken in 42 patients undergoing pancreaticoduodenectomy for suspected tumour. The RNA isolated was then quantified by Nanodrop analysis and RNA integrity by Bioanalyzer. We performed Poly(A) PCR on RNA isolated using standard published protocols. Finally real-time PCR was performed. Samples were normalized for 2 reference genes (GAPDH and PSMB6). The genes of interest were: TFF2, CPB1, SPINK1, S100P and KLK3.

Results: The median volume of pancreatic juice obtained by intra-operative aspiration was 1110 μl (range from 50 to 5000 μl). The median RNA yield was 10.45 ηg/μl (range from 4 ρg/μl to 127 ηg/μl). RT-PCR was positive for pancreas specific genes (TFF2 and CPB1), cancer-related genes (S100P and SPINK1) and negative for PSA in all samples.

Conclusions: These results demonstrate that RNA analysis of pancreatic juice is feasible using the PolyA cDNA technique. Once PolyA PCR has been applied, the resulting PolyA cDNA can be expanded to produce an essentially permanent archive of representative cDNA suitable for screening with multiple gene-specific probes.

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EGFR Mutation in Pancreatic and Peri-Ampullary Cancer

M. Oliveira-Cunha,1 A.K. Siriwardena,1 William Newman.2 1Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; 2Department of Clinical Genetics, St Mary's Hospital, Manchester, UK.

Background: Pancreatic and peri-ampullary cancers exhibit a high incidence of activating KRAS mutations. The RAS protein is involved in EGFR signaling. Studies in lung cancer have demonstrated that EGFR mutations and K RAS mutations are mutually exclusive. Mutational statuses of KRAS and EGFR, and EGFR overexpression analysis in pancreatic cancer can predict sensitivity to EGFR inhibitor therapy. The aim of this study is to explore the presence of EGFR and KRAS mutations and the copy number of EGFR in pancreatic and peri-ampullary cancers.

Methods: One hundred and two patients undergoing pancreaticoduodenectomy or pancreatic biopsy for cancer were recruited. Samples of fresh frozen pancreatic tissue, pancreatic juice and formalin-fixed paraffin-embedded tissue were obtained. EGFR mutation was analyzed by DNA sequencing of exons 18-21 in the tyrosine kinase domain. KRAS mutation was analyzed by sequencing codons 12 and 13. Quantitative real-time polymerase chain reaction was performed to determine EGFR expression. The study was undertaken with institutional ethics committee approval.

Results: EGFR mutation was found in 1 (1%) of 102 cases. The mutation detected was an amino acid substitution in exon 18. SNPs in exon 20 were identified in 59 cases (57.8%). Increased copy numbers of EGFR were not found in any of the cases studied. Thirty patients (41%) of 74 in whom KRAS was studied harboured a point mutation in codon 12 of the KRAS gene.

Conclusions: The incidence of somatic mutations of EGFR in pancreatic and peri-ampullary cancer is low. There does not appear to be a reciprocal relationship between KRAS and EGFR in pancreatic cancer unlike that in lung cancer.

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Combination With hTERT-Promoter Dependent Conditionally Replicative Adenovirus Enhances the Gene Transduction of Replication-Defective Adenovirus in Pancreatic Cancer Cells

M. Onimaru,1 K. Ohuchida,1 E. Nagai,1 K. Mizumoto,1 M. Tanaka.1 Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Purpose: Adenovirus gene therapy shows promising results for cancer treatment but its transgene expression is sometimes low in clinical studies. Recently, some reports showed combination with conditionally replicative adenovirus (CRAd) enhanced the gene transduction of replication-defective adenovirus (RDAd), but there are no reports about interactions between hTERT-promoter dependent CRAd (hTERT-CRAd) and RDAd yet. Therefore, we investigated the effect of hTERT-CRAd, Ad5/3hTERTE1, on the transgene expression of RDAd, AdNK4, in pancreatic cancer.

Results: We compared biological effects of CRAd-combination group (AdNK4 + Ad5/3hTERTE1) and control-combination group (AdNK4 + Ad5/3hTERTLuc). In CRAd-combination group, NK4 expressions are increased in both culture media and within infected cells, resulting in enhancing inhibitory effect of invasion of infected pancreatic cancer cells. Transgene expression of NK4 was increased in the cells by adding cultured media from the CRAd-combination cells, and also increased in the cells transfected with an E1-expressing-plasmid. Furthermore, NK4 expression within subcutaneously implanted tumors was also increased in CRAd-combination group in vivo.

Conclusion: hTERT-CRAd enhances the transgene expressions of RDAd and this enhancement is induced by replication of RDAd by adenovirus E1 derived from co-infected hTERT-CRAd. This might be a promising strategy against advanced pancreatic cancer.

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Natural History of Branch Duct Intraductal Papillary Mucinous Neoplasms Greater Than 30 mm: A Review of 37 Cases

M. Osanai, H. Maguchi, S. Hashigo, T. Kin, A. Kurita, M. Ohtsubo, K. Yane, A. Katanuma, K. Takahashi. Center for Gastroenterology, Teine-Keijinkai Hospital.

Background & Aims: IPMN/MCN international consensus guidelines recommend surgical resection for branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) greater than 30 mm in diameter. However, individual patient circumstances may occasionally make such intervention prohibitively risky. The aim of this study was to clarify the natural history of BD-IPMNs greater than 30 mm.

Patients & Methods: 389 patients with BD-IPMNs were treated in our institute from 1997 to 2008. 37 patients with BD-IPMNs greater than 30 mm and with more than 12 months follow-up were identified and their cases reviewed. Evaluation points were 1) initial clinical data, 2) serial morphological changes, and 3) outcomes.

Results: 1) Mean observation period was 42 months (13 to 175 months) (M:F = 21:16; median age, 73 y). The initial size of the cystic lesion ranged from 30 to 50 mm in diameter (median 35 mm). 20 patients (54%) had no mural nodules, while 17 patients initially had mural nodules ranging from 2 to 30 mm in diameter (median, 6 mm). 2) In seven of the 37 patients (18.9%), there was obvious enlargement of the cystic lesion and/or dilation of the main pancreatic duct. The three patients with cystic enlargement underwent routine follow-up examination. Of the remaining four patients with new mural nodules or enlargement of existing mural nodules, three patients underwent surgical resection; pathological diagnosis was adenoma in two and carcinoma in situ in one case. 3) Four patients died of extrapancreatic malignancies, 2 patients died of liver failure, and 1 patient died of newly appeared complicated ductal carcinoma of the pancreas. Thus, no patients died of IPMN itself during the follow-up period.

Conclusion: Of 37 BD-IPMNs greater than 30 mm, morphological change was observed in only 18.9% during the follow-up period of 13 to 175 months. This suggests that close observation may be a reasonable approach to BD-IPMNs greater than 30 mm in size.

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Two Cases of Pancreatic Adenosquamous Carcinoma

A. Osawa,1 M. Watanabe,1 K. Asai,1 H. Matsukiyo,1 A. Osawa,1 T. Saito,1 K. Dotai,