Abstracts of Papers Submitted to the 48th Meeting of the American Pancreatic Association, November 8–11, 2017, San Diego, California

Heme Oxygenase-1 Inhibition Under Hypoxia Modulates Stemness and Immune Response in Pancreatic Cancer

M.Y. Abdalla,¹ I.M. Ahmad,² B.E. Britigan,³ S.K. Batra,⁴ S. Kumar.⁴Departments of ¹Pathology/Microbiology and ²Medical Imaging and Therapeutic Sciences, University of Nebraska Medical Center, Omaha, NE; ³Internal Medicine, Research Service, VA Medical Center, Nebraska-Western Iowa, Lincoln, NE and University of Nebraska Medical Center, Omaha, NE; ⁴Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE.

Background: Pancreatic ductal adenocarcinoma (PDAC) is the fourth most common cause of cancer-related death in the USA. PDAC is asymptomatic and often metastasize early leading to a meager 5-year survival rate of ~8 %. Hypoxia contributes to the metastasis and resistance to chemotherapeutics in PDAC. Hypoxia reprograms the gene expression profile and upregulates heme oxygenase-1 (HO-1), which provide survival advantage, and play a key role in the immune-modulations in PDAC. We showed that HO-1 is increased in ducts and stroma of PDAC clinical samples. The relationships between HO-1, hypoxia, and response to chemotherapy, however, is unclear. We hypothesize that inhibiting HO-1 under hypoxic conditions suppress the growth of pancreatic tumor, modulates immune response and sensitize PDAC cells to chemotherapy.

Methods: PDAC cells (CD18/HPAF and Capan-1) were tested for proliferation, oxidative stress, stemness markers and checkpoint regulator PDL-1 expression, under hypoxic (1% Oxygen) and normoxic conditions in the presence of HO-1 inhibitors (ZnPP and SnPP), Gemcitabine and HO-1 activator (CoPP) (5–50 mM).

Results: Hypoxia upregulates the expression of HO-1 in PDAC cells. Inhibiting HO-1 with ZnPP and SnPP sensitized PDAC cells for gemcitabine under hypoxia (1% Oxygen) and significantly reduced their survival, expression of stemness markers (CD133, CD44 and ALDH1/2) and immune suppressive marker, PDL-1 compared to normoxia. The in vivo, pancreatic tumor weight were significantly reduced (P < 0.05) when SnPP was combined with gemcitabine. Immunohistochemistry shows significant increase in cleaved caspase 3 staining in animals receiving combined treatment comparing to control or gemcitabine only. Mechanistically, inhibition of HO-1 increased ROS, apoptosis and oxidized GSH production (P < 0.05).

Conclusion: Altogether, we demonstrate that HO-1 inhibition enhance the efficacy of gemcitabine by reducing PDAC cell stemness and modulate immune responses, therefore provides a novel therapeutic approach for PDAC.

Comparison of the Prognostic Value of Preoperative Factors in Patients With Pancreatic Cancer

T. Abe, K. Nakata, Y. Mori, Y. Miyasaka, K. Ohuchida, T. Ohtsuka, M. Nakamura. Department of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University, Fukuoka, Japan.

Background: Recently, the preoperative nutritional and immunological factors of patients have been found to be associated with prognostic outcomes of malignant tumors. However, the clinical significance of these factors remains controversial in pancreatic ductal adenocarcinoma (PDAC).

The aim of this study was to evaluate the prognostic value of these factors in predicting survival of patients with PDAC.

Methods: A retrospective study of 329 patients who underwent macroscopically curative resection for PDAC and 95 patients with noncurative factors who did not undergo resection was conducted to investigate the prognostic impact of tumor derived factors and patients derived factors including modified Glasgow Prognostic Score, prognostic nutritional index (PNI), the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio and lymphocyte/monocyte ratio.

Results: In the multivariate analysis for patients with resectable PDAC, PNI was an independent factor for overall survival (OS) and disease-free survival (DFS). The median OS of patients with PNI ≤45 was significantly shorter than that of patients with PNI >45 (17.5 vs. 36.2 months, respectively; P < 0.001). The median DFS of patients with PNI ≤45 was significantly shorter than that of patients with PNI >45 (9 vs. 19 months, respectively; P < 0.001). In the multivariate analysis for patients with unresectable PDAC, only NLR was an independent prognosis factor. The median OS of patients with NLR >5 was significantly shorter than that of patients with NLR ≤5 (2.7 vs. 8.9 months, respectively; P < 0.001).

Conclusion: PNI in patients with resectable PDAC and NLR in patients with unresectable PDAC may be useful as a prognostic predictor.

SF-12 Measured Quality of Life After Total Pancreatectomy With Islet Auto-Transplantation (TPIAT) for Chronic Pancreatitis

D.B. Adams,¹ C. Chung,¹ K.A. Morgan,¹ S. Owczarski,¹ J.J. Borckardt,² H. Wang.¹Departments of ¹Surgery and ² Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC.

Introduction: Outcome assessment after operative management of chronic pancreatitis with total pancreatectomy with intra-portal islet- auto-transplantation is problematic. The 12-Item Short Form Survey (SF-12) has been validated as an effective metric in measuring patient QOL outcomes in patients with chronic diseases.

Aims: The purpose of this study was to evaluate the feasibility of long-term quality of life outcomes in chronic pancreatitis patients who underwent TPIAT measured by physical quality of life (PQOL) and mental health quality of life (MhQOL) with the SF-12.

Methods: Consecutive cases of TPIAT (n = 160) were reviewed at a single institution over a 7-year period (March 2009-March 2016). Thirty-day, 90-day, and long-term QOL outcomes were monitored through a prospectively maintained database with IRB approval. A retrospective review and analysis was conducted to assess the implementation effectiveness of SF-12 measured outcomes.

Results: One hundred and sixty patients were available for long-term follow-up. The median duration of follow-up was 4.8±0.2 years. Pre-op, 6-month, 1-year, 2-year, 3-year measured PQOL was: 27,32,33,33,34 percentiles. MhQOL was: 40,43,44,42,42 percentile. Percent of patients with good outcomes defined as a 3 point increase in QOL score from baseline or score > 35 at 1,2,3,4,5 years after follow-up was: PQOL 75,73,68,62,67 % and MhQOL 82,78,83,89,78 %.

Conclusion: QOL measurement with the SF-12 of patients who underwent TPIAT management of chronic pancreatitis was readily implemented into the practice of a multi-disciplinary TPIAT program and is effective in assessing long-term value of TPIAT.

Cathepsin C Affects Severity of Acute Pancreatitis by Regulating Activation of Neutrophil Enzymes

A. Aghdassi,¹ D. John,¹ J. Aschenbach,¹ M. Sendler,¹ F.U. Weiss,¹ J. Mayerle,² M.M. Lerch.¹¹Department of Medicine, University Medicine Greifswald, Greifswald, Germany; ²Department of Medicine II, University Hospital München-Grosshadern of the LMU, München, Germany.

Introduction: In acute pancreatitis both, a premature activation of digestive proteases (zymogens) and invasion of inflammatory cells occur. The cascade like activation of zymogens is initiated by activation of the lysosomal enzyme cathepsin B (CTSB), whereas neutrophil elastase (NE) is important for leukocyte migration by cleavage of cell-cell contact proteins.

Aim: We studied whether cathepsin C (CTSC), a lysosomal enzyme expressed in the pancreas as well as in inflammatory cells, can contribute to development of acute pancreatitis.

Methods: Acute experimental pancreatitis was induced in CTSC^−/− and NE^−/− mice and corresponding wildtype controls by repetitive cerulein injections. Severity was assessed by histology, protease activation and analysis of inflammatory cell invasion. Isolated CTSC^−/− acinar cells were investigated for protease activation after supramaximal cholecystokinin stimulation. CTSC^−/− neutrophil granulocytes were isolated for in-vitro assays.

Results: CTSC^−/− mice showed a milder course of acute pancreatitis whereas in isolated acinar cells zymogen activation was unaltered. Neutrophils deficient of CTSC showed less cleavage of the cell-cell contact protein E-cadherin and less activation of neutrophil elastase. Severity of pancreatitis was attenuated in NE^−/− mice as well.

Conclusion: Severity of acute pancreatitis is dependent on cathepsin C. However this effect seems to be driven mainly by neutrophil granulocytes via neutrophil elastase whereas acinar cells events play a minor role. Our findings support the relevance of immune cell proteases in acute pancreatitis.

Lower Mortality Rates After Pancreas Surgery in High-Volume Centers: A Nationwide Study in Finland 2012–2014

R. Ahola, J. Sand, J. Laukkarinen. Tampere University Hospital, Tampere, Finland.

Introduction: Centralization of pancreas surgery is slowly proceeding in Finland, a country with a sparse population of 5.5 million people and public health care system.

The aim of this study was to analyse the effect of hospital volume on PD associated mortality and complications in Finland in 2012–2014.

Methods: The Finnish National Register (HILMO) was searched for pancreatoduodenectomies (PD) and total pancreatectomies (TP) performed between 2012–2014. Demographics, histopathologics and complications were recorded from the patient archives. Complications were graded according to Clavien-Dindo and international study groups for fistulae (POPF), hemorrhage (POPH) and delayed gastric emptying (DGE). Hospitals were categorized in high (HVC; ≥20) and low (LVC <20) volume centers according to number of PDs performed per year.

Results: A total of 406 operated patients (median age 67 (range 22–85) years; 52% male) were included. Two HVCs (55%) and 11 LVCs (45%) performed the operations (92% PDs, 8% TPs). Demographics or ASA classes showed no difference between the volume groups. More vascular resections were performed in HVCs (16% vs 4.4%, P = 0.000). The 30- and 90 day mortality were significantly lower in HVCs (0.9 and 2.2% vs 9.9 and 12.2%, P = 0.000). No significant difference was found in Clavien-Dindo complication grades 0–4 or among PD-related, grade B-C complications between HVC and LVC (POPF 8.3 vs. 9.5%, POPH 3.4 vs. 5.4% and DGE 4.9 vs. 6.0%).

Conclusions: Complication rates did not differ between the volume groups, but mortality was significantly lower in HVC still in 2012–2014. This may be explained by “failure to rescue” in LVCs. These Results favour proceeding further with centralisation of pancreas surgery.

Treatment of Pancreatic Cancer Through Targeting Cancer Cell Metabolism by Mitochondrial Uncouplers

A. Alasadi, S. Jin. Department of Pharmacology, Rutgers-RWJMS, Piscataway, NJ.

Background: Pancreatic Ductal Adenocarcinoma (PDA) is characterized by rapid progression, metastatic recurrence and highly resistance to therapeutic treatment. PDA cells exhibit aerobic glycolysis, or the Warburg effect, which reduces pyruvate flux into mitochondria and shunts glucose metabolites into pathways for synthesis of the building blocks (e.g. ribose) and reducing agents (e.g. NADPH) supporting cell proliferation. In addition, PDA cells are highly addicted to glutamine. Mitochondrial metabolism of glutamine provides metabolic intermediates for biosynthesis. Mitochondrial uncoupling is a process that facilitates protons influx across the mitochondrial inner membrane without generating ATP, stimulating a “futile” cycle that consumes pyruvate and glutamine. We propose that mitochondrial uncoupling is effective in treating PDA by antagonizing the anabolic effect of the Warburg effect and reducing glutamine.

Methods: Here we studied mitochondrial uncouplers niclosamide ethanolamine (NEN) and its analogue (MB1-47) in terms of metabolic effects and anti-cancer activities, in both cultured PDA cells and mouse models.

Results: NEN and MB1-47 cause growth inhibition of human and murine PDA cells, arrest cell cycle at G0-G1 phase, and reduce clonogenicity. These Results are concomitant with metabolic alterations characterized by increased TCA flux and reduction in PPP flux and glutamine level. When PDA cells are injected into liver of mice, NEN or MB1-47 reduce tumor growth and tumor occurrence. In addition, MB1-47 diminishes hepatic metastasis when PDA cells are transplanted intrasplenically into NSG mice.

Conclusion: Our data highlight a unique approach for treating PDA, and provide novel experimental drug leads for future investigation.

Axios Stent Shortens the Resolution Time in Peripancreatic Fluid Collections Drainage After Cystgastrostomy

Y. Al-Azzawi, M. Fasullo, J. Kheder, W. Wassef. Division of Gastroenterology, UMass Memorial Health Care, Worcester, MA.

Background/Aim: Pigtail stents are often being used in treating peripancreatic fluid collection like; Pseudocyst(PS) and/or wall-off necrosis (WON). The new large metal axial stents (Axios) carries a lower risk of migration and leak when compare to the pigtail ones. Our aim in this study is to compare the duration needed for the cyst to resolve and stent to be removed after stent placement and successful drainage. Also, we studied the percentage of necrosectomy need following the stent placement.

Results: 54 patients, 12 patients had Axios stents and 42 had pigtail stent, were included in our cohort. The mean age of the cohort was 52 ± 18 y. Males represented 67% of the cohort. The main causes of pancreatitis were gallstone pancreatitis followed by alcohol with percentages of 40% and 28% respectively. WON represented 52% of the indications for the stent placement. The mean duration of the cyst to resolve was 57 and 102 days in the Axios stent and the pigtail stent respectively. The duration from the stent placement to the stent removal was 48 and 81 days in the Axios and pigtail groups respectively. Resolution of the cyst was shorter in the Axios stent group when compared to the pigtail group with P value of 0.02. The duration from stent placement to removal was also shorter in the Axios stent when compared to the pigtail stents (P value of 0.01). 26 patients in the pigtail group needed necrosectomy while 5 patients in the Axios group. The duration from the stent placement to the discharge was shorter in the Axios stent with a mean of 2.7 days while 2.8 days in the pigtail group.

Conclusion: Axios stents has a shorter resolution time and stent removal time than the traditional pigtail when used in treating WON and pseudocyst. In contrast, no differences were found between Axios and pigtail stents in terms of the need for necrosectomy.

Cancer Risk in Patients Meeting AGA 2015 Management Criteria for Pancreatic Cystic Lesions

M. Al-Haddad,¹ S. Jackson,² N. Toney,² C. Narick,³ S. Finkelstein,³ N.G. Haddad.⁴¹Department of Medicine, Indiana University, Indianapolis, IN; ²Clinical Development, Interpace Diagnostics, Pittsburgh, PA; ³Interpace Diagnostics, Pittsburgh, PA; ⁴Division of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC.

Aim: We examined the utility of the AGA 2015 management criteria in assessing risk of malignancy in pancreatic cystic lesions followed for up to 8 years. We also examined the incremental utility of ancillary molecular analysis in helping to assess risk of cancer in patients meeting such criteria.

Methods: This is analysis of data from a national pancreatic cyst registry cohort. AGA positive (AP) criteria included: severe cytological atypia and/or presence of at least two positive imaging features. Patients lacking such criteria were considered AGA negative (AN). Integrated molecular pathology (IMP) “Benign” and “SI” were considered low risk; “SHR” and “Aggressive” high risk. Kaplan Meier and hazard ratio (HR) analysis was used to assess risk of cancer. Bayes theorem was used to calculate risk of cancer at various malignancy prevalence.

Results: AP criteria (22/491) elevated cancer risk (15.0 HR, P < 0.001). AN criteria (469/491) did not lower cancer risk (0.7 HR, P = 0.074). For AP criteria cancer risk was 38-76% at a malignancy prevalence of 1-5%; for AN criteria it was 1-4%. Reclassification by IMP did not significantly change cancer risk of AP patients. By contrast, reclassification of AN patients as high risk by IMP increased cancer risk (7.4 HR, P < 0.001). Reclassification of AN patients as low risk by IMP decreased cancer risk (0.3 HR, P < 0.001). For high risk IMP, cancer risk was 8-31% at a malignancy prevalence anticipated for AN criteria; for low risk IMP it was 0-1%.

Discussion: Although infrequent, AP criteria increases cancer risk, even when cancer prevalence is low. AN criteria itself does not help stratify cancer risk. Molecular analysis can help to identify patients meeting AN criteria at higher risk of cancer and distinguish them from those at low risk.

Perioperative Hydrocortisone Treatment Reduces Postoperative Pancreatic Fistula After Distal Pancreatectomy in a Randomized Controlled Trial

A. Antila, A. Siiki, J. Sand, J. Laukkarinen. ¹Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

Background: Postoperative pancreatic fistula (POPF) is the major complication after distal pancreatectomy (DP). In our recent randomized trial we showed that perioperative hydrocortisone (HC) treatment reduces Clavien-Dindo 3–5 complications after pancreaticoduodenectomy. (Laaninen et al, Annals of Surgery 2016). In this study we Aimed to find out whether perioperative hydrocortisone treatment prevents the risk for POPF after DP.

Methods: 40 patients planned for DP at Tampere University Hospital were randomized to receive perioperative treatment with intravenous HC 100 mg or placebo. The first dose was given at the induction of anaesthesia. 31 patients underwent DP and continued in the study. All had a high-risk, soft pancreas (>40% acini in the pancreatic transsection line as analysed perioperatively). They continued to receive HC/placebo every 8 hours for two days postoperatively. All complications were graded, the primary endpoint being POPF.

Results: Median age was 68 (39–82) years and 35% were men. The groups were similar for age, sex and ASA class distribution. 90-day mortality was zero. With HC treatment the rate of clinically significant POPF (5.9% vs 28.6%, P = 0.016) were significantly reduced compared to placebo. The rate of overall Clavien-Dindo III-V complications was 5.9 and 21.4% in the in the HC and placebo group, respectively (ns; P = 0.058).s

Conclusion: Perioperative HC treatment decreases the rate of clinically relevant POPF after distal pancreatectomy.

Total Psoas Density on Preoperative Axial CT Scan as a Predictor of Postoperative Pancreatic Fistula (POPF) Development After Pancreatic Resection Surgery

G. Armstrong,¹ L. Phelan,¹ Y. Khaled,¹ T.D. Maclaine,² C. Macutkiewicz,¹ R. Adair,¹ A. Aldouri,¹ A. Smith.¹¹Pancreatic Surgery, St James's University Hospital, Leeds, United Kingdom; ²LIBACS, University of Leeds, Leeds, United Kingdom.

Aim: To examine preoperative psoas muscle radiological characteristics as a predictor of postoperative pancreatic fistula (POPF) development and length of hospital stay.

Background: POPF complicates the recovery of around 15 to 20% of all pancreatic resections and is a cause of significant patient mortality and morbidity. The “sarcopenic obesity” phenotype with large volumes of adipose tissue and low anti-gravity muscle strength is a now common. These patients are at high risk of POPF but identifying them preoperatively is difficult. Total Psoas Density (TPD) measured on CT could be an accurate predictor POPF risk.

Methods: Retrospective analysis of psoas muscle characteristics on preoperative axial CT at the L3 lumbar vertebrae level in 125 patients who underwent major pancreatic resection at a single institution between 2013 and 2015 inclusive and correlation with postoperative outcomes.

Results: Logistic regression demonstrated low pre-operative TPD was a predictor of POPF; Odds ratio 0.67 (95% CI, 0.45-0.98) P value 0.04. For every 10 unit increase in TPD there was a 33% decrease in the odds of POPF. TPD was also strongly correlated with length of hospital; Incidence Rate Ratio (IRR) of 0.89 (95% CI, 0.83-0.96) P value 0.003. When adjusted for age, gender and Clavien-Dindo graded complications, there was an 8% decrease in the number of days hospital stay for every 10 unit increase in TPD. Total psoas area, gender, age and Cardiopulmonary Exercise (CPX) testing scores were not predictive of POPF development or all source complications rates.

Discussion: TPD is easy to measure on axial imaging and is a strong predictor of POPF and length of stay. CPX testing and patient demographic factors alone failed to predict surgical outcomes. TPD is a more precise measure of sarcopenic obesity and therefore of POPF risk than TPA.

Conclusion: TPD should be considered part of the pre-operative patient assessment. Future research should include defining the risk stratification benefit of TPD assessment, its relationship to Body Mass Index (BMI) scores.

Plasma SuPAR Levels in Chronic Pancreatitis and Pancreatic Cancer

A. Aronen,¹ J. Aittoniemi,² R. Huttunen,³ A. Nikkola,¹ I. Rinta-Kiikka,⁴ J. Nikkola,¹ O. Limnell,⁵ I. Nordback,¹ J. Sand,¹ J. Laukkarinen.¹¹Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; ²Fimlab Laboratories, Tampere, Finland; Departments of ³Internal Medicine and ⁴Radiology, Tampere University Hospital, Tampere, Finland; ⁵Faculty of Medicine and Life Sciences, Tampere, Finland.

Objectives: SuPAR (soluble urokinase plasminogen activator receptor) is a marker associated with human body systemic inflammation and certain malignant diseases. A previous study stated that urinary suPAR/creatinine ratio is elevated both in chronic pancreatitis (CP), and pancreatic cancer (PC) (Sorio 2011). Our Aim was to study the levels of P-SuPAR in CP in a long-term prospective follow-up setting and to compare the Results to P-suPAR levels of PC patients to investigate whether P-suPAR could be used to distinguish CP from PC.

Methods: 83 patients (median age 47.5, range 25–71 years, 90% male) diagnosed with first acute alcohol-induced pancreatitis (AAP) were prospectively followed for 7.0 (0.3-9.8; median and range) years. Recurrent acute pancreatitis (RAP) episodes, development of CP and other covariates were registered during the follow-up. P-suPAR values were measured on first admission, after discharge, and at 5, 7, and 9 years. Results were compared with P-suPAR values of patients with a histologically verified PC.

Results: 39% of patients had at least one RAP episode and 14% developed CP during follow-up. P-suPAR levels at any time point did neither predict the RAP episodes, nor development of CP. However, mean P-suPAR levels of PC patients (4.9 [range, 3.3-7.8]) ng/mL, n = 6) were elevated compared to P-suPAR levels seen with CP patients (3.3 [range, 1.6-4.9]) ng/mL, n = 12) which stayed low during follow-up after recovery from first AAP.

Conclusion: Unlike PC patients, patients with first AAP have low P-suPAR levels on recovery and during long-term follow-up even though they develop CP. This preliminary data suggests that it could be possible to distinguish CP from PC using P-suPAR as a diagnostic tool.

Clinical Characteristics and Risk Factors of Pancreatic Cancer Patients in Our Hospital

A. Asakura, K. Nishiguchi, M. Taniguchi, N. Takahiko, M. Mori, Y. Kawasaki, T. Tokuda, H. Saiki, M. Sawamura, Y. Tokuda, Y. Onishi, T. Kawai, S. Hiyama, M. Hamano, M. Chiba, K. Yamamoto, N. Tatsumi, T. Ito. Gastroenterology, JCHO Osaka Hospital, Osaka, Japan.

Aims: Pancreatic cancer is still high mortal disease. Recently several effective chemotherapeutic regimens have been available. Early detection of pancreatic cancer is important for appropriate treatments, but many cases with pancreatic cancer have been diagnosed in advanced stages. In this study, we tried to clarify clinical characteristics and risk factors of this cancer in our hospital.

Methods: We enrolled 26 patients with advanced pancreatic cancer who were diagnosed in our hospital from January 2015 to December 2016.

Results: The enrolled patients consisted of 14 males and 12 females. Age of these patients was ranging from 37 years old to 89 years old (Median 68). As for principal symptoms, 6 patients complained of stomachache, 3 patients back pain, 4 patients jaundice. Four patients were detected by chance while they visited other departments in our hospital. As for the lesions of pancreatic cancer, 13 patients had pancreatic cancer in the head of pancreas, 9 patients the pancreatic body, 4 patients the tail of the pancreas. Five males and 3 females had diabetes. Three males had the other cancers in gastrointestinal tracts. Two females had lung cancer, 1 female gastrointestinal cancer, and 1 female breast cancer. For histological diagnosis, EUS-FNA was done for 16 patients, duodenal biopsy for 4 patients, ERCP for 1 patient. Following diagnostic procedures, we selected nab-paclitaxel plus gemcitabine for 7 patients, FOLFIRINOX for 1, gemcitabine plus S-1 for 2, solely S-1 for 2, and surgical resection for just 1 patient. Insertion of steel self-expanded metallic stents were applied to 4 patients in 6 cases with obstructive jaundice.

Conclusion: Patients with other cancers, especially gastrointestinal cancers, or diabetes were supposed to be involved in a high-risk group of pancreatic cancer. More data should be accumulated for precise selection of effective chemotherapies with interventional approaches based on histopathological diagnoses using EUS-FNA etc.

A System Biology Approach via Connectivity Mapping (CMAP) to Identify New Therapeutic Targets Against Lethal Pancreatic Cancer

P. Atri,¹ D. Ghersi,² S. Kaur,¹ M. Ponnusamy,¹ S.K. Batra.¹¹Department of Biochemistry and Molecular Biology, UNMC, Omaha, NE; ²School of Interdisciplinary Informatics, College of Information Science and Technology, University of Nebraska Omaha, Omaha, NE.

Background: Pancreatic cancer (PC) is a highly lethal disease due to high chemotherapy resistance to current drug regimens. Therefore, identifying novel therapeutic targets will improve the survival of PC patients. By utilizing a drug repurposing stategy, the present study Aims to explore FDA approved therapies for targeting highly lethal PC.

Methods: GEO data for PC cases (N = 106) and normals (N = 68) was extracted and processed using the Affy package from R Bioconductor. Robust Multi-Array Average (RMA) analysis was performed to normalize the data, followed by differential expression analysis using the Limma package to identify differentially expressed genes across PC patients among individual datasets. Drugs specific to PC differential gene sets across various datasets were identified using Connectivity Map (CMAP), a tool freely available from the Broad institute. Next, a score based ranking analysis was used to identify highly specific drugs common across various data sets.

Results: Connections among PC differentially expressed gene signature & FDA approved drugs (>2000) were identified using CMAP. Drugs common across several datasets were ranked according to negative ranking (opposing effect) identified in the CMAP. Our analysis identified nine PC specific therapeutic targeting drugs-HDAC inhibitors (ISOX, trichostatin-A, vorinostat,panobinostat, dacinostat, apicidin), ERK inhibitor (FR180204) and Glucocorticoid receptor inhibitors (hydrocortisone and clobestasol) Interestingly, among these vorinostat(HDAC inhibitor) has shown great potential in clinical trials in combination with radiation therapy. Our in silico analyses identified two new potential drugs -ISOX and FR180204, targeting HDACs and ERKs respectively. Further, efficacy studies of these drugs are on-going in PC in vitro models (cell lines & organoids).We next Aim to validate these drugs with in vivo PC progression mouse models.

Conclusion: We have identified highly potent and novel therapeutics for targeting highly lethal PC using connectivity mapping.

SEL1233 Maintains Mitochondrial Integrity, Inhibits Necrotic Cell Death, and Ameliorates Experimental Acute Pancreatitis

M. Awais,¹ X. Zhang,¹ D. Latawiec,¹ D.N. Criddle,¹ J. Sanvoisin,² C. Austin,² M. Peel,³ R. Sutton.⁴¹Institute of Translational Medicine, Liverpool University, Liverpool, United Kingdom; ²Selcia Ltd, Ongar, United Kingdom; ³Cypralis Ltd, Cambridge, United Kingdom; ⁴Institute of Translational Medicine, Liverpool University and Royal Liverpool University Hospital, Liverpool, United Kingdom.

Background & Aim: Persistent opening of the mitochondrial permeability transition pore (MPTP) is central to acute pancreatitis (AP). Cyclophilin D (CypD) is a peptidyl prolyl cis-trans isomerase (PPIase) that promotes opening of the MPTP. There are no suitable CypD inhibitors for human AP treatment. We investigated the effects of the CypD inhibitor SEL1233 on MPTP opening and necrosis in human and murine pancreatic acinar cells (PACs) and evaluated efficacy in murine AP.

Methods: Inhibition of CypD by SEL1233 was determined by PPIase assay. Calcium retention capacity assay using isolated mitochondria was performed to evaluate different concentrations of SEL1233 for MPTP inhibition. Necrosis of freshly isolated PACs was evaluated under a confocal microscope with propidium iodide in the presence of TLCS for human and murine PACs or POAEE for murine PACs. TLCS-AP was induced by retrograde injection of the pancreatic duct with 3 mM TLCS. 20 mg/kg SEL1233 was given IP and animals were sacrificed 24 h after AP induction. AP was assessed by standard biomarkers and blinded histopathology.

Results: SEL1233 suppressed human CypD enzymatic activity with Ki 4.2 nM and inhibited MPTP opening in a concentration dependent manner. SEL1233 at 1.0 μM significantly reduced necrotic cell death of PACs in cellular models of AP (P < 0.01 SEL1233+TLCS vs TLCS, P < 0.05 SEL1233+POAEE vs POAEE). SEL1233 significantly reduced serum amylase, pancreatic myeloperoxidase, IL-6 and histopathological scores in TLCS-AP.

Conclusion: SEL1233 maintains mitochondrial integrity by inhibiting the MPTP, reduces necrosis and ameliorates the severity of TLCS-AP. SEL1233 is a promising candidate drug for human AP.

Effects of Berberine on Acute Necrotizing Pancreatitis

G.S. Bae,^1,2 S.B. Choi,^1,2 D.G. Kim,³ J.Y. Shin,² M.J. Kim,¹ D.U. Kim,¹ S.J. Park.^1,21Department of Herbology, School of Oriental Medicine, ²Habang Body-fluid Research Center, and ³Center for Metabolic Function Regulation, Wonkwang University, Iksan, South Korea.

Background: We set out to examine whether berberine (BBR) might affect the severity of pancreatitis and pancreatitis-associated lung injury in choline-deficient ethionine supplemented (CDE) diet-induced severe acute pancreatitis (SAP).

Methods: SAP was induced by feeding a CDE diet for 3 days. BBR was administered intraperitoneally during CDE diet. Mice were sacrificed on days 1, 2, and 3 after the onset of CDE diet. The severity of pancreatitis was assessed by evaluating changes to the pancreas and lung and survival rate. Blood, pancreas and lung were harvested for further examination. Furthermore, the regulating mechanisms of BBR were evaluated on pancreas.

Results: Administration of BBR significantly inhibited histological damage to the pancreas and lung, and decreased serum level of amylase and lipase, myeloperoxidase (MPO) activity, cytokine production, and the mortality rate. Furthermore, administration of BBR inhibited activation of nuclear factor kappa B (NF-κB), c-Jun N-terminal kinases (JNK), and p38 in the pancreas during CDE diet.

Conclusion: These findings suggest that BBR attenuates the severity of pancreatitis by inhibiting activation of NF-κB, JNK, and p38, and that BBR could be used as a beneficial agent to regulate AP.

The Effect of Chemical Sensory Denervation on Experimental Acute Pancreatitis

E.R. Bálint,¹ Z. Balla,² L. Kiss,² A. Molnar,² V. Venglovecz,³ J. Maleth,¹ P. Hegyi,⁴ Z. Helyes,⁵ Z. Rakonczay.²¹First Department of Medicine, Departments of ²Pathophysiology and ³Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary; ⁴Institute for Translational Medicine & 1st Department of Medicine, University of Pécs, Pécs, Hungary; ⁵Department of Pharmacology and Pharmacotherapy, University of Pécs, Pécs, Hungary.

Introduction: Pain is a predominant symptom of acute pancreatitis (AP). Pain sensation is mediated by primary sensory neurons most of which express the cation channel nociceptor transient receptor potential vanilloid 1 (TRPV1). TRPV1 participates in neurogenic inflammation and thus has major roles in the pathogenesis of inflammatory disorders.

Aim: To investigate if denervation of TRPV1 neurons affects the severity of experimental AP.

Methods: The primary sensory neurons of male Sprague–Dawley rats were denervated by i.p. administration of the TRPV1 agonist resiniferatoxin (RTX) four weeks before the induction of AP. AP was induced by intraductal injection of 3% 1 ml/kg Na-taurocholate, or i.p. injection of 3 g/kg L-ornithine or 4x20 μg/kg cerulein. Rats treated with RTX and/or Na-taurocholate/L-ornithine/cerulein were compared to their respective saline-treated controls. To determine AP severity, laboratory and histological parameters were measured.

Results: Compared to controls, desensitization caused increased serum amylase and pancreatic myeloperoxidase activities, pancreatic water content and heat-shock-protein 72 expression in L-ornithine-induced AP, whereas the extent of necrosis increased in desensitized animals injected with Na-taurocholate. Desensitization ameliorated inflammation in cerulein-induced AP compared to the group without RTX pretreatment. Desensitization in itself did not significantly influence any of the measured parameters compared to the control group.

Conclusion: Chemical sensory denervation had distinct effects on the severity of different AP models. It exacerbated necrotizing AP, but alleviated edematous AP.

Randomized Trial Comparing the 22G Franseen Biopsy and 22G Aspiration Needles for EUS-guided Sampling of Solid Pancreatic Mass Lesions

J.Y. Bang, S. Hebert-Magee, U. Navaneethan, M. Hasan, R. Hawes, S. Varadarajulu. Center for Interventional Endoscopy, Florida Hospital, Orlando, FL.

Background: Given the poor outcomes of traditional chemotherapy, there is increased focus on molecular profiling for personalized pancreatic cancer treatment. Pancreatic tissue with architecture containing both tumor cells and desmoplastic stroma is pivotal for molecular analysis. Recently, three-plane symmetric needle with Franseen geometry, which is postulated to facilitate histological tissue procurement, has been developed for EUS-guided fine needle biopsy (FNB).

Aim: Compare tissue acquisition between 22G Franseen biopsy and 22G FNA needles in patients undergoing EUS-guided sampling of pancreatic masses.

Methods: Patients with solid pancreatic masses were randomized to undergo EUS-guided sampling using 22G Franseen and 22G FNA needles. Two dedicated passes were first performed using both needles in individual patients for cell block. Subsequent passes were performed for rapid onsite evaluation (ROSE) using both needles alternately until diagnosis was rendered. Main outcome measure: Compare total tissue volume and presence of desmoplastic stroma in pancreatic cancer. Secondary outcome measure: Compare rates of diagnostic cell block. Specialized software (Nikon DS-Fi2) was used for histological assessment in order to measure tissue area and isolate malignant cells from desmoplastic stroma.

Results: Of the 46 patients, final diagnosis was pancreatic cancer in 38, neuroendocrine tumor in 2, sarcoma in 1 and benign disease in 5. Median total tissue volume, 6.1 mm2 (IQR, 2.2–9.9) vs. 0.28 mm2 (IQR, 0.045–0.93), P < 0.001, and presence of desmoplastic stroma in tumor, 84.6 vs. 33.3% (P < 0.001) were significantly higher in the FNB cohort. Diagnostic yield at cell block was significantly higher for FNB cohort, 97.8 vs. 82.6% (P = 0.03). There was no difference in diagnostic adequacy at ROSE between FNB and FNA cohorts, 100 vs. 95.7% (P = 0.50).

Conclusion: The Franseen biopsy needle yields significantly more tissue with superior histology than the FNA needle. This development is likely to advance the role of EUS in facilitating molecular-based anti-cancer therapy.

Walled-off Necrosis (WON): Outcomes of an Algorithmic Approach to Necrosectomy

J.Y. Bang, M. Hasan, U. Navaneethan, R. Hawes, S. Varadarajulu. Center for Interventional Endoscopy, Florida Hospital, Orlando, FL.

Background: Endoscopic necrosectomy (EN) in walled-off necrosis (WON) is a labor intensive, high-risk, non-standardized technique that is associated with significant morbidity and mortality.

Aim: Compare clinical outcomes of WON patients treated by conventional EN versus algorithmic approach.

Methods: 45 consecutive patients with WON who had suboptimal treatment response to EUS-guided transluminal drainage, underwent necrosectomy. In initial period (2004–2013), EN was performed using a diagnostic/double-channel gastroscope in a conventional manner using polypectomy snares, biopsy forceps and retrieval nets. In later period (2014–2017), cap-fitted, single-channel, therapeutic gastroscope was used for performing EN in three sequential steps: debridement, necrosis extraction and irrigation. Debridement and extraction were performed using dedicated accessories based on size of necrotic activity and degree of adherence of necrotic debris. Debris were removed using 15-25mm round/15-30mm oval snares, and large 14.9mm rat tooth forceps were used when debris were not amenable for snaring. Intra-procedural lavage of the necrotic cavity was performed using saline mixed with gentamicin; hydrogen peroxide was reserved for end of procedure to avoid frothing that obscures visibility. Primary outcome measure: Compare treatment success and number of reinterventions performed.

Results: In 45 patients, n = 23 in conventional technique and n = 22 in algorithmic groups. Treatment success was significantly higher for algorithmic approach, 100 vs. 69.6%, P = 0.009. Of 7 patients with treatment failure in conventional technique cohort, 6 had open necrosectomy, 1 died of multiorgan failure. Median number of reinterventions was significantly lower for algorithmic approach, 1 (IQR, 1–1) vs. 2 (IQR, 1–2), P = 0.003. In multivariable logistic regression analysis, algorithmic approach was only variable associated with treatment success (OR, 60.4; P = 0.02).

Conclusion: Structured, algorithmic approach to endoscopic necrosectomy results in successful treatment outcomes.

Cocaine Induced Acute Pancreatitis: A Systematic Review

J.A. Barkin,¹ C.R. Simons-Linares,² Z. Nemeth,¹ J.S. Barkin.¹¹Division of Gastroenterology, University of Miami, Leonard M. Miller School of Medicine, Miami, FL; ²Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL.

Introduction: Cocaine is a common, dangerous, illicit drug responsible for multiple medical problems. It was first postulated to cause Acute Pancreatitis (AP) in 1990 by Bernad et al. AP etiology remains unknown in approximately 20% of patients. The aim of this systematic review is to investigate cocaine as a potential AP etiology.

Methods: A systematic search using PubMed/Medline, Embase, Scopus & Cochrane was performed through 6/1/17 with a reference librarian. Search terms were “Cocaine” & “Acute Pancreatitis” with all permutations. AP was defined by meeting 2 of 3 Revised Atlanta Classification criteria. Cocaine induced AP was defined by preceding use of cocaine, & exclusion of common AP causes when reported (significant alcohol use, biliary, hypertriglyceridemia, medications, hereditary). 2 authors reviewed each study for eligibility.

Results: The search yielded 171 results. 8 case reports met inclusion criteria. 7/8 (87.5%) were men, average age 26.4 yrs (range, 19–53 yrs), with 7/8 under age 30. AP development occurred within 48hrs of cocaine intake in 7/8 patients. 3 had history of, but no current alcohol use prior to AP onset. There were no further AP episodes after cocaine cessation in all 5 patients for whom data was available.

Discussion: Cocaine should be considered as a potential cause of toxin induced AP. Its mechanism remains unknown, but is likely due to a combination of its physiologic effects including vasoconstriction, micro-arterial thrombosis, & ischemia. Cocaine induced AP occurs primarily in young patients below age 30. Toxicology screens should be considered as standard of care in all patients under age 30 with AP. Inclusion of cocaine as an etiology of AP may reclassify idiopathic AP cases. Further studies are needed to investigate this association.

Risk of Progression of Pancreatic Cysts in Solid Organ Transplant Recipients: A Systematic Review and Meta-Analysis

J.A. Barkin,¹ E. Donath,² J. Goyal,¹ Z. Nemeth,¹ E.O. Souto,¹ P. Martin,¹ J.S. Barkin.¹¹Division of Gastroenterology, University of Miami, Leonard M. Miller School of Medicine, Miami, FL; ²Department of Internal Medicine, University of Miami, Leonard M. Miller School of Medicine, Atlantis, FL.

Introduction: Pancreatic cysts (PC) are common in liver transplant candidates. Immunosuppressive medications in solid organ transplant recipients (SOTRs) increase risk of developing malignancy. Risk of PC progression in SOTRs is unknown.

Aims: To establish incidence of PC progression in SOTRs & To establish relative risk (RR) of progression in SOTRs vs. controls.

Methods: A systematic search was performed using PubMed, Embase & Cochrane databases to 4/21/2017 with a reference librarian. Search terms were "pancreatic cyst" or "intraductal papillary mucinous neoplasm" (IPMN) & "solid organ transplant" with all permutations. Studies of adult SOTRs with PC or IPMNs followed to assess PC progression were included. The outcome measure was a composite of development of worrisome features by Fukuoka Criteria, high-risk features, consensus indication for resection or malignancy. Incidence & RR were calculated using a meta-analysis with fixed & random effects models.

Results: There were 120 total search results, all reviewed by 2 authors. 9 studies of 446 patients with PC in SOTRs met inclusion criteria. 4/9 had controls (98 SOTRs vs. 488 controls with PC). Overall incidence of PC progression to outcome in 9 SOTR studies was 4%(fixed)-7%(random effects models) (30/446 SOTRs), vs. 13.5% (66/488) in controls in 4 studies, with RR 1.23 (95% CI, 0.65-2.31; P = ns) in SOTRs vs. controls. There were 2 cases of pancreatic cancer (0.45%) in SOTRs & 1 in controls, with no attributable deaths.

Discussion: This is the first systematic review & meta-analysis examining risk of PC progression in SOTRs. The risk of PC progression in SOTRs remains low with no significantly increased RR compared to controls. Presence of PC should not be considered a contraindication to solid organ transplantation.

Frequency of Appropriate Use of Pancreatic Enzyme Replacement Therapy (PERT) and Symptomatic Response in Pancreatic Cancer Patients

J.A. Barkin,¹ A. Westermann,² W. Hoos,² C. Moravek,² L. Matrisian,² H. Wang,³ L. Shemanski,³ J.S. Barkin,¹ L. Rahib.²¹Division of Gastroenterology, University of Miami, Leonard M. Miller School of Medicine, Miami, FL; ²Pancreatic Cancer Action Network, Manhattan Beach, CA; ³Cancer Research And Biostatistics, Seattle, WA.

Introduction: Pancreatic cancer (PC) & its therapies can cause pancreatic exocrine insufficiency requiring pancreatic enzyme replacement therapy (PERT). Appropriate PERT use is during meals & snacks. The aim was to determine the frequency of appropriate use of PERT and its impact on symptom alleviation in PC.

Methods: Users enrolled in the Pancreatic Cancer Action Network’s Patient Registry (an online platform, launched 1/2016) were prompted to answer 25 questions about their experience with PERT. In May 2016, 5 supplementary questions were added to capture additional symptoms and side effects.

Results: 136 users completed the questionnaire by 3/2017 (33 prior to addition of the 5 questions). The median age at registry enrollment was 63 (range, 23–86). 62 (46%) were female, while 14 did not report gender. 70% had adenocarcinoma, 9% neuroendocrine, & 21% other/unknown. 85 (63%) had surgery, 59 (43%) radiation therapy, & 112 (82%) chemotherapy. 115/136 (84%) reported speaking to a healthcare professional about PERT and 104/115 (90%) were prescribed PERT. 68/104 (65%) reported that PERT was prescribed with all meals and snacks, of which 44/68 (65%) reported compliance. There were 63 responses about PERT timing, of which 40 (63%) took PERT with meals, 19 (30%) prior to meals, and 4 (6%) after meals. Patients taking PERT with meals had higher alleviation of symptoms with significant decrease in “Feeling of indigestion” & “Increased or foul smelling flatus” compared to those taking PERT prior to or after meals (P = 0.005 & P = 0.04). There was a trend of less “Frequent stools,” “Loose stools” & “Visible food particles in stool” if taking PERT with meals, along with more weight gain & less weight loss.

Discussion: Of 76% of PC patients prescribed PERT, 65% were prescribed PERT appropriately with all meals and snacks. Overall compliance with PERT administration guidelines was low (38%; 44/104). Improvement in symptoms significantly correlated with appropriate PERT use. Increased in PC patient & provider education on appropriate PERT use & administration is warranted.

The CA 19-9 and sTRA Antigens Define Independent PDAC Cell Subpopulations in Tumors, Lymph Nodes, Metastases, and Model Systems

D. Barnett,¹ Y. Liu,¹ K. Partyka,¹ L. Wisniewski,¹ G. Hostetter,¹ A.D. Singhi,² R.E. Brand,³ R.R. Drake,⁴ B.B. Haab.¹¹Center for Cancer and Cell Biology, Van Andel Research Institute, Grand Rapids, MI; ²Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA; ³Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁴Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC.

Molecular markers to detect and classify subpopulations of cancer cells could be invaluable for selecting treatments and guiding drug development. We previously found that a glycan related to the CA 19-9 antigen, referred to as sTRA, is a strong serological biomarker of pancreatic adenocarcinoma and is elevated in the plasma of about half of the patients with low CA 19-9. We hypothesized that the cancer cells producing CA 19-9 are a different subtype than those producing sTRA. Using multimarker immunofluorescence on tissue microarrays, we found that sTRA was significantly elevated (P < 0.001) in tumor tissue relative to adjacent pancreatic tissue in 6 separate TMAs covering 76 patients. Cells with dual staining of both markers tended to be in well-to-moderately differentiated glands with nuclear polarization, but exclusive sTRA staining was present in small clusters of cells with poor differentiation and large vacuoles, or in small and ill-defined glands. The dual-labeled cells and the exclusive-sTRA cells were associated with long and short, respectively, time-to-progression or survival in two additional TMAs covering 45 and 41 patients. A significant correlation existed between the levels in the primary tumors and the levels in matched lymph-node or liver metastases of each of the subpopulations. In 14 patient-derived xenograft tumors, the sTRA and CA 19-9 expression recapitulated the variation across primary specimens. Cell lines grown in 3D culture also had the same morphologies and variation of glycan expression as in xenografts. Therefore, the CA 19-9 and sTRA antigens define independent PDAC cell subpopulations in a variety of settings. Together they could have value for classifying subtypes of pancreatic cancer cells.

Healthcare Resource Utilization and Outcomes in Patients Undergoing Total Pancreatectomy With Islet Autotransplantation in the United States

M.D. Bellin,¹ L. Luis,² M. Abu- El-Haija,³ D. Adams,⁴ G.J. Beilman,⁵ S. Chinnakotla,⁶ T. Dunn,⁵ M.L. Freeman,⁷ T. Gardner,⁸ V. Kirchner,⁹ K. Morgan,¹⁰ J.D. Nathan,¹¹ B. Naziruddin,¹² T. Pruett,⁵ S.J. Schwarzenberg,¹³ V.K. Singh,¹⁴ K. Smith,⁸ J. Steel,¹⁵ M. Wijkstrom,¹⁵ P. Witkowski,¹⁶ D.L. Conwell.¹⁷¹Pediatrics, University of Minnesota, Minneapolis, MN; ²The Ohio State University Wexner Medical Center, Columbus, OH; ³Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; ⁴Medical University of South Carolina, Charleston, SC; ⁵Department of Surgery, University of Minnesota, Minneapolis, MN; ⁶University of Minnesota, Minneapolis, MN; ⁷Gastroenterology, University of Minnesota, Minneapolis, MN; ⁸Dartmouth-Hitchcock Medical Center, Lebanon, NH; ⁹Surgery, University of Minnesota, Minneapolis, MN; ¹⁰Medical University of South Carolina, Charleston, SC; ¹¹Pancreas Care Center, Liver, Kidney and Intestinal Transplant Programs, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; ¹²Baylor School of Medicine, Houston, TX; ¹³Pediatrics, University of Minnesota, Minneapolis, MN; ¹⁴Gastroenterology/Internal Medicne, Johns Hopkins Hospitals, Baltimore, MD; ¹⁵University of Pittsburgh Medical Center, Pittsburgh, PA; ¹⁶University of Chicago, Chicago, IL; ¹⁷The Ohio State University Wexner Medical Center, Columbus, OH.

Background: Chronic pancreatitis (CP) patients with refractory pain and recurrent attacks of acute pancreatitis are often considered for surgical (resection versus drainage) procedures, including total pancreatectomy with islet autotransplantation. Given the escalating cost of healthcare and the increasing interest in TPIAT, there is a need to better assess healthcare resource utilization and patient outcomes associated with surgical interventions for CP. Objective: To report inpatient demographics, hospital characteristics, comorbidities and surgical outcome in patients undergoing TPIAT for acute or chronic pancreatitis.

Methods: Utilizing the Nationwide Inpatient Sample, a retrospective analysis of inpatient admission of adults (≥18) who had a TPIAT between 2002 to 2013 for a diagnosis of Acute/Chronic Pancreatitis (AP 577.0, CP 577.1) was performed. Surgical procedure trend, demographics, hospital characteristics, comorbidities and surgical outcome over the study period were analyzed. Patients who were pregnant or had a pancreatic neoplasm were excluded.

Results: There were a total of 830 TPIAT performed between 2002 and 2013. The majority had CP (99%) > AP (12%) associated with the hospitalization discharge coding. The overall trend in TPIAT increased significantly during this time period (P < 0.001). TPIAT patients had a mean age of 41 y and were predominantly females (69%) from a high-very high income bracket (89%). The Elixhauser co-morbidities were equally distributed (53% <3 and 46% *>*3). As expected, all (100 %) surgical procedures were performed in large, tertiary academic medical centers. Geographically, TPIAT was more common in the Midwest (58%) >South (26%) > West (10%) > Northeast (5%). The mean LOS for TPIAT was 15 days, at a mean cost of 62 K dollars, and in-hospital mortality was 0%.

Conclusion: The number and percentage of TPIAT surgeries have increased over the past 10 years. There is a gender and geographic disparity for TPIAT surgery. Further investigation of the short- and long-term healthcare burden and related resource utilization is warranted.

Investigating the Urinary and Serum Proteome in Total Pancreatectomy With Islet Auto-transplantation (TPIAT)

M.D. Bellin,¹ D.L. Conwell,² T. Bennike,³ S. Ahmed,³ Z. Cruz-Monserrate,⁴ H. Steen.³¹Department of Pediatrics, University of Minnesota, Minneapolis, MN; ²The Ohio State University Wexner Medical Center, Colombus, OH; ³Department of Pathology, Boston Children's Hospital, Boston, MA and Harvard Medical School, Boston, MA; ⁴Internal Medicine/Division of Gastroenterology, Hepatology and Nutrition, The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: The major challenge of managing chronic pancreatitis (CP) is the lack of accurate radiologic and endoscopic modalities for early detection. Biopsy for “gold standard” histology is high risk and exocrine insufficiency is a late event occurring when >90% of the gland has been scarred. TPIAT affords a unique opportunity to study biological mechanisms as it provides the opportunity to study the effect of the presence/absence of the pancreas in humans. We hypothesize that the diseased pancreas modulates the urine and serum proteome, which can potentially be used for diagnostic purposes.

Aim: Determine the urinary and serum proteome changes resulting from TPIAT.

Methods: Urine and serum convenience samples were collected pre and post TPIAT from 22 and 48 patients, respectively. The urine and plasma samples were prepared for proteome analysis using our in-house developed urine and serum proteomics pipeline.

Results & Discussion: Urine: A total of 2484 proteins were identified in urine. 8% of these proteins showed significant up-/downregulation. The proteins downregulated after TPIAT were enriched in nucleotide binding proteins. Striking was also the downregulation of all components of the desmosome plaque. Among the proteins upregulated after TPIAT were lysosomal proteins as well as immunoglobulins. Serum: A total of 487 proteins were identified in serum. 7% of these proteins showed significant up-/downregulation. The upregulation of the immunoglobulins in urine was recapitulated in serum. Amongst the downregulated proteins was an enrichment of apolipoproteins particularly striking.

Conclusion: Using our high throughput body fluid proteomics pipeline identified numerous TPIAT-induced changes to the urine and serum proteome. Detailed proteome analysis is ongoing to determine the impact of total pancreatectomy and TPIAT-associated confounders.

Increased Rate of Advanced Stage Pancreatic Cancer at Diagnosis in Patients of Afro-Caribbean Descent

R. Beyer, K. Ragunathan, H. He, C. Demarco, S. Mori, A. Khorasanchi, S. Vignesh. Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY.

Introduction: Pancreatic cancer is the fourth most common cause of cancer death in the US, despite being the twelfth most commonly diagnosed cancer. This high mortality is largely due to the cancer being found at an advanced stage at diagnosis. African Americans are known to have a slightly higher incidence of and mortality from pancreatic cancer. However, it is unclear if the epidemiology is the same in patients of Afro-Caribbean descent. We aimed to compare the patient population at our safety net hospital, which are a majority African Americans and Afro-Caribbeans, to the data in the SEER database.

Methods: A retrospective chart review was performed on all patients diagnosed with pancreatic malignancy at Kings County Hospital, Brooklyn, New York from 2009 to 2013. Inclusion criteria was patients aged >18, and new diagnosis of pancreatic cancer. Patients were excluded if they were previously or currently undergoing treatment for pancreatic cancer at the time of presentation to our hospital. For data analysis, patients were excluded if they did not have enough data to determine stage of disease. Advanced stage was defined as AJCC stage 3 or 4.

Results: Our study identified 118 patients for analysis, 59 of whom were African American, and 59 Afro-Caribbean. 28 African Americans (47.5%) presented with advanced stage cancer, in comparison to 41 Afro-Caribbeans (69.5%). This compares to 54.2% of African Americans in the SEER database. 22 African-Americans presented with stage IV disease (37.3%), and 33 Afro-Caribbeans (55.9%).

Discussion: At our safety net hospital, African Americans presented with advanced stage pancreatic cancer at a rate similar to that found in the SEER database. However, patients of Afro-Caribbean descent presented with advanced stage pancreatic cancer at a higher rate. To our knowledge, this is the first study specifically looking at this underserved population. Further studies evaluating risk factors and prognostic factors in underserved populations are needed.

MUC4 Interaction With EGFR and Its Potential Implications in Pancreatic Cancer

R. Bhatia,¹ S. Joshi,¹ A. Aithal,¹ W. Junker,¹ A. Cannon,¹ B. Hall,² C.M. Thompson,¹ S. Kumar,¹ S.K. Batra,¹ M. Jain.¹Departments of ¹Biochemistry and Molecular Biology and ²Surgery, University of Nebraska Medical Center, Omaha, NE.

Background: EGFR1 signalling is critical for oncogenic K-ras-mediated initiation and progression of pancreatic ductal adenocarcinoma (PDAC). MUC4 is the most differentially expressed membrane bound mucins in PDAC, which functionally contributes to disease pathobiology by virtue of its interactions with EGFR family members (through its EGF domains). While the interaction of MUC4 with EGFR2 (HER2) has been well studied, its interaction with the key EGFR family member EGFR1 remains poorly characterized. Herein we characterized the interaction of MUC4 with EGFR1 and studied its implication on EGFR1 stability.

Methods: Effect of MUC4 on EGFR stability and internalization was studied by confocal live cell imaging and biochemical analysis. Co-immunoprecipitation (Co-IP) using anti-EGFR and anti-MUC4 antibodies was performed in Colo357 and Capan1 PDAC cells. Further we generated MUC4 domain deletion constructs containing functional domains and overexpressed them in MUC4 non-expressing AsPC1 cells.

Results: Confocal analysis indicated the co-localization of MUC4 with EGFR1 on PDAC cell surface and silencing of MUC4 resulted in increased internalization of EGFR1 following ligand activation. These findings were further corroborated by plasma membrane fractionation studies. Anti-MUC4 antibody effectively pulled down EGFR1 and phospho (Y1068) EGFR1 in a ligand-dependent manner from the lysates of Colo357 and Capan1 cells. Co-IP analysis from the lysates of cell overexpressing MUC4 domain deletion constructs demonstrated that MUC4-β domain was sufficient to effectively pull down EGFR1.

Conclusion: Our studies indicate that MUC4 physically interacts with EGFR1 in a ligand-dependent manner and prevents its internalization thereby enhancing its stability and potentiating downstream signalling.

Pancreatic Gene Expression During Recovery After Pancreatitis Reveals Unique Transcriptome Profiles

K. Boggs,¹ T. Wang,¹ A.I. Orabi,¹ T.A. Javed,¹ T. Sun,² J.F. Eisses,¹ F. Esni,³ W. Chen,¹ S.Z. Husain.¹Departments of ¹Pediatrics, ²Biostatistics, and ³Surgery, University of Pittsburgh, Pittsburgh, PA.

It is well known that pancreatic recovery after a single episode of injury such as an isolated bout of pancreatitis occurs rapidly. However, what changes are inflicted in such conditions to the molecular landscape of the pancreas is unclear. In the cerulein hyperstimulation mouse model of pancreatitis the pancreas has the remarkable ability to regenerate and recover per histological resolution of the pancreas within one week after injury. Whether histological resolution constitutes pancreatic recovery at a molecular level is not known. In this study, we sought to characterize the transcriptome by RNA-sequencing of the recovering pancreas up to two weeks’ post-injury. We were intrigued to find that one week after injury there were 319 differentially expressed genes (DEGs) compared to baseline (non-injured) pancreas and that after two weeks’ post-injury there remained 53 DEGs. Intriguingly 12.5% (40) of the DEGs persisted from week one to week two, and another 13 DEGs newly emerged in the second week. Overall, the DEGs were enriched for pathways associated with pancreatic digestion and absorption, the inflammatory response, cellular growth and differentiation, tissue remodeling, and islet cell maintenance. We found several trypsinogen genes to be persistently up-regulated DEGs one and two weeks after injury suggesting the pancreas is still working to replenish its zymogen pool. Many of the DEGs that newly emerge two weeks after injury are associated with ribosomal biogenesis and the translational machinery. We also found DEGs between male and female mice during recovery, many of which can be explained by sex linkage. To our knowledge, this is the first characterization by deep sequencing of the transcriptome during pancreatic recovery, and it reveals on a molecular basis that there is an ongoing recovery of the pancreas even after apparent histological resolution. The findings also raise the possibility of a novel emerging transcriptome upon pancreatic recovery.

Inhibition of DNA-PK Interferes With Pancreatic Cancer Cell Growth and Correlates With Inhibition of Autophagy

M.F. Bossanyi, M. Groleau, M.J. Boucher. Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada.

Introduction: It has been suggested that pancreatic ductal adenocarcinoma (PDAC) display high levels of genomic instability most likely contributing to cancer progression and/or resistance to therapy. Moreover, DNA repair mechanisms are particularly active in PDAC. Notably, an enzyme involved in the non-homologous end-joining pathway of DNA repair, DNA-PK, appears overexpressed in PDAC tissues as compared to the adjacent normal tissues. Given the poorly explored contribution of DNA-PK in pancreatic cancer biology, the aim of this study was to investigate the impact of DNA-PK inhibition in PDAC cells.

Methods: Experiments were performed on the pancreatic cancer cell lines MIA PaCa-2 and PANC-1. DNA-PK inhibition was achieved by using the specific inhibitor NU7441.

Results: 1) NU7441 treatment abrogated clonogenic growth of PDAC cells in a dose-dependent manner. 2) Anchorage-independent growth was also significantly reduced following DNA-PK inhibition. 3) Treatment with NU7441 led to a dose-dependent and time-dependent induction of apoptosis as visualized by PARP cleavage and caspase-7 activation. 4) Concomitantly, we observed increased expression of LC3-II and p62 upon NU7441 treatment suggestive of a potential interplay between DNA-PK inhibition and autophagy. 5) Using bafilomycin A1, our results indicated that NU7441 leads to a blockade in the autophagic flux.

Conclusion: Altogether, our results suggest that DNA-PK activity sustains PDAC cell growth. For the first time, our results demonstrate that DNA-PK inhibition imposes a blockade in autophagy, a catabolic process with a reported role in PDAC cell growth. Therefore, our results points toward a novel potential role for the DNA repair protein DNA-PK in the regulation of autophagy in PDAC cells.

Middle Segment Pancreatectomy: Its Complications and Safety

B. Cai, Z. Lu, J. Wu, W. Gao, J. Chen, F. Guo, J. Wei, C. Dai, K. Jiang, Y. Miao. ¹Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Middle segmental pancreatectomy (MSP) is designed for lesions in the neck and body of the pancreas. The peri-operative courses and outcomes of the procedure are conflicting.

Aims: To clarify whether MSP is safe and effective for lesions located in the mid-portion of the pancreas.

Methods: A total of 115 consecutive patients underwent MSP from March, 2006 to April, 2015, in the Pancreas Center at the First Affiliated Hospital of Nanjing Medical University. Demographic variables, surgical indications, peri-operative data and pathological findings were retrospectively obtained from medical records and analyzed. Long-term endo- and exocrine function and post-operative status outcomes were followed up.

Results: The median age of the patients was 52 years old (male: female = 39:76). The top 3 indications for surgery were SCN (33, 28.7%), pNETs (23, 20%) and IPMN (16, 13.9%). The mean operative time was 214.9 ± 91.7 minutes and the mean intraoperative estimated blood loss was 233.4 ± 275.5 mL. The mean post-operative hospital stay was 21.5 ± 10.2 days. The overall morbidity rate was 49.5%, with pancreatic fistula (43.5%) being the most common post-operative complication including 45 clinically related cases. A follow-up revealed that 14.8% experienced long-term complications (new-onset diabetes: 1.7%, pre-existing diabetes worsened: 4.3%, Regarding exocrine pancreatic function: 11.3%).

Conclusion: MSP provides excellent long-term pancreatic function at the expense of a significant post-operative morbidity rate. MSP is best indicated for benign or low-grade lesions in well-selected patients who are able to sustain potential serious complications and could benefit from improved long-term results.

Characterization of Collagen Producing Cells in Acute Pancreatitis Via Lineage Tracing

Y. Cao, B. Cheng, J. Li, J. Bailey, M. Younes, T.C. Ko. UTHSC-Houston, Houston, TX.

Introduction: Collagen (Col) producing cells are key mediators in organ fibrosis including chronic pancreatitis, with an unclear role in acute pancreatitis (AP). To explore their role in AP, we employed an inducible Col1a2-creERT mouse that can mark Col1 producing cells in tissue stroma, and performed lineage tracing of Col1 producing cells in normal and cerulein-induced AP pancreas.

Methods: Col1a2-cre;tdTom mice were in-house bred by crossing Col1a2-creERT mice with tdTomato reporter mice for this study. Mice (3–6 wks) were injected with tamoxifen (TAM, 1mg, 5days, ip) for induction of Cre recombination thus illuminating Col1 producing cells with red fluorescence (tdTom+). Pancreata were harvested at 48h after TAM injection. In a separate set, mice received TAM as above, and then received cerulein (50 μg/kg, 9x hourly, ip) for AP induction 48h later. PBS was injected as control. Pancreata were harvested at 1, 24, and 48h after cerulein injection. Immunofluorescence was performed using FITC (green) conjugated antibodies of PNA (an acinar marker), CD31 (an endothelial marker), or desmin (a pancreatic stellate cell (PSC) marker).

Results: Upon TAM injection in Col1a2-cre;tdTom mice, 10% of total pancreatic cells were labeled as tdTom+ that surrounded acini, ducts, and blood vessels. tdTom+ cells did not co-localize with PNA or CD31, while 50% of tdTom+ cells co-localized with desmin. Compared to PBS, cerulein induced a time-dependent increase of tdTom+ cells by 1, 2, 6% and tdTom intensity/cell by 1, 2, 3-fold respective to AP1, 24, 48 h.

Conclusion: PSCs constitute a main cellular source of Col1 producing cells. Col1 producing cells proliferate and are activated in cerulein-induced AP. How these cells impact AP induction and resolution warrants further investigation.

A TGF-ß-lin28b-miRNA Circuit Regulates EMT and Stemness in Pancreatic Cancer

L. Castellano, S. Ottaviani, A.E. Frampton. Department of Cancer and Surgery, Imperial College London, London, United Kingdom.

TGF-ß has a dual role in cancer it can stop proliferation or alternatively can induce epithelial-to-mesenchymal transition (EMT) and stemness promoting the progression of pancreatic ductal adenocarcinoma as well as other cancers. Surprisingly, the role of microRNAs (miRNAs) in the response of EMT and stemness of PDAC has not been previously described. We show that TGF-ß transcriptionally induces miR-100 and miR-125b via SMAD2/3. Although miR-100, miR-125b and let-7a derive from the same transcript MIR100HG, let-7a is unchanged, as TGF-ß also induces LIN28B which inhibits its maturation. MiR-100 and miR-125b each stimulate EMT and stemness, but only miR-125b promotes metastasis. To identify the target regulated by these two miRNAs, globally, we developed a novel high-throughput miRNA target discovery method through integration of AGO2-RIP-seq with RNA-seq in PDAC cell lines. We called this method RIP-USE and it discovers that genes targeted by miR-125b and miR-100 significantly overlap and mainly inhibit p53 and apoptosis pathways. Together, we uncover that TGF-ß induces an lncRNA, whose encoded miRNAs, miR-100, let-7a and miR-125b, play opposing roles in controlling PDAC tumorigenesis. Together, these miRNAs may represent useful therapeutic targets for PDACs.

Metformin Ameliorates Pancreatic Lesion Formation in Obese EL-KRAS and KC Mice

K. Castellanos,¹ A. Rodriguez,² G. Fantuzzi,¹ P.J. Grippo.³Department of ¹Kinesiology & Nutrition, ²Dentistry, and ³Medicine, University of Illinois, Chicago, IL.

Risk factors of pancreatic cancer (PC) development include diabetes and obesity, though it is unclear if diabetes is a cause or consequence of PC. A prolonged state of obesity can lead to diabetes and both may synergistically increase risk of PC incidence. The antidiabetic drug, Metformin (Met), has exhibited antitumor activity and may improve PC outcomes. The present study assessed the effectiveness of Met to inhibit the frequency and size of pancreatic neoplasms in EL-KRAS B6 (EK) and KC B6 mice. Wild type and EK mice were placed on: Chow, Chow+ Met, High Fat Diet (HFD), HFD + Met after weaning for 5 months. Glucose tolerance and body weight were not affected by the addition of Met, though EK mice developed ~40% less cystic papillary neoplasms (CPNs) on Met when compared to controls. Significantly fewer cysts were detected in pancreas of HFD+ Met group (11/mouse) than in the HFD alone (20/mouse). EK HFD+ Met had significantly lower pancreas and liver to body weight ratios compared to EK HFD mice, as well as significantly lower occurrence of fibrosis and acinar-ductal metaplasia (ADM). KC and control mice were administered two diets: HFD and HFD + Met over 5 months. Similar to Met-treated EK mice, KC mice on Met had significantly reduced PanIN frequency and size with higher percent normal pancreatic parenchyma. Yet, fibrosis and ADM only experienced a modest decrease in KC mice on the HFD+MET compared to HFD alone. Though not altering weight or glucose metabolism, Met significantly inhibited the etiology of pancreatic neoplasia in both EK and KC mice, suggesting that Met may slow or abrogate human PC development. Indeed, these findings may indirectly explain the association between PC and diabetes and supports that MET improves survival in obese diabetics with PC.

Dclk1 a Novel Therapeutic Target for the Reprogramming of PDAC TME

P. Chandrakesan,¹ N. Ali,¹ R. May,¹ N. Weygant,¹ D. Qu,¹ J. Yao,² S. Sureban,¹ M. Bronze,¹ C. Houchen.¹¹Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK; ²Oncology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.

Introduction: PDAC is characterized by a highly desmoplastic tumor microenvironment (TME) with increased infiltration of immunosuppressive cells, which creates an enormous challenge to therapeutic regimens. Several attempts to target only the desmoplasia of PDAC TME have been less than successful. Therefore, novel therapeutic strategies that can potentially target the immune suppressive TME in PDAC are required. We previously reported that doublecortin-like kinase 1 (Dclk1), regulates EMT and promote inflammation-associated tumorigenesis in PDAC models. We recently reported that Dclk1 inhibition reduced the expression of S100A9, which is critical for the production of myeloid-derived suppressor cells (MDSCs). In this study, we wanted to investigate the role of Dclk1 in the evasion of anti-tumor immunity in the PDAC TME.

Methods: KPCY mouse treated with our proprietary anti-Dclk1 mAb (CBT15) were analyzed for the cellular components (immunosuppressive cells) and non-cellular components (expression of Dclk1, EMT factors, cytokines and chemokines in the TME of PDAC by IHC, FACS, ELISA and RT-PCR.

Results: We found that the frequency of Dclk1+ cells, MDSCs, Tregs, fibroblasts and M2 macrophages, and immune checkpoints proteins (PD1, PD-L1 and CTLA-4) and S100A9 are higher in PDAC TME than in the pancreas of 5-week-old KPCY mice without PDAC. Inhibition of Dclk1 reduced the infiltration of immune suppressive cells, S100A9 protein, and immune checkpoints proteins in the PDAC TME and thus enhanced the frequency of cytotoxic T cells.

Conclusion: The present study provides a strong mechanistic link between Dclk1, the TME, and tumor-associated immunity, and provides a strong rational for the development of novel anti-Dclk1 agents that can enhance the host anti-tumor immunity.

Metformin Attenuates Progression of Pancreatic Ductal Adenocarcinoma Promoted by Diet-induced Obesity in the Conditional KrasG12D Mouse Model

H.H. Chang,¹ A. Moro,¹ C.E. Chou,¹ A.I. Schmidt,¹ J. Sinnett-Smith,² O.J. Hines,¹ G. Eibl,¹ E. Rozengurt.²Departments of ¹Surgery and ²Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease with virtually no efficacious treatments. Chronic conditions such as obesity and type-2 diabetes are known risk factors, thus making PDAC amenable for preventive strategies. Metformin, a widely used anti-diabetic drug shown to improve metabolic dysfunction, has been linked epidemiologically with reduced incidence, recurrence and mortality of cancer in diabetic patients. However, the efficacy and mechanisms of metformin in obesity-promoted PDAC are much less known. The aim of this study was to characterize the chemo-preventive effects of metformin on PDAC development using the KrasG12D model subjected to a high-fat, high calorie diet (HFCD). LSL-KrasG12D/+;p48-Cre (KC) mice were allocated to control diet (CD), HFCD, or HFCD with 5mg/ml metformin in the drinking water for 3 or 9 months. KC mice fed the HFCD had significant weight gain and hepatic steatosis, which were prevented by metformin. At 3 months metformin prevented HFCD-induced depletion of intact acini, formation of PanIN-3 lesions and stimulation of ERK and mTORC1 in pancreatic lysates. Analysis of the 9-month cohort demonstrated that mice fed the HFCD displayed more advanced PanIN-3 lesions and less intact acini in the pancreas, and marked increases in insulin and leptin. All these changes were greatly attenuated by metformin. Importantly, the HFCD-increased incidence of PDAC was completely abrogated by metformin (P < 0.01).

In conclusion, administration of metformin improved the metabolic profile and eliminated the promoting effects of diet-induced obesity on PDAC development in KC mice. Given that metformin is FDA-approved, our findings will have a strong translational impact for the development of novel chemo-preventive strategies for PDAC.

Morphine Treatment Increases the Severity of Acute Pancreatitis Via μ-Opioid Receptor

H. Cheema, U. Barlass, J. George, G. Gonzalez, V. Dudeja, R. Dawra, S. Roy, A.K. Saluja. Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL.

Background: Opioids such as morphine are widely used for the management of pain associated with acute pancreatitis. We have previously shown that morphine treatment leads to worsening of pancreatic and systemic injury in cerulein model of acute pancreatitis. In the current study, we evaluated if inhibition of opioid receptors can prevent morphine lead worsening of local and systemic injury in cerulein model of acute pancreatitis.

Methods: The cerulein model of acute pancreatitis was induced by 12 hourly intra-peritoneal injections of cerulein at a dose of 50 μg/kg/h to 6-8-week-old male wild type mice. After induction of cerulein AP mice were either given placebo, morphine alone or morphine and naltrexone (40 mg/kg). Naltrexone, an opioid receptor antagonist with highest affinity for μ-opioid-receptor, was administered IP at 12, 24 and 36 hours after induction of cerulein pancreatitis. Mice were sacrificed at 48 hours. The effect on local and systemic injury was evaluated using pancreatic and lung myeloperoxidase activity and histology. MPO data was expressed as MPO (U/μg protein). Necrosis was quantified and expressed as percent of total parenchyma. We further confirmed our finding by using μ-opioid-receptor knock out mice.

Results: Inhibition of Opioid receptors with naltrexone prevented morphine led worsening of pancreatic necrosis, as seen in histology and reduction of percent necrosis (18.4+1.4 vs 9.5+1.2). Naltrexone administration also led to significant reduction in local and systemic injury as measured by pancreatic MPO U/μg (5.0+1.2 vs 2.2+0.5) and lung MPO U/μg (15.2+4.9 vs 8.4+0.4) activity as compared to morphine treatment alone.

Conclusion: Morphine treatment led worsening in severity of acute pancreatitis in modulated only via opioid receptors.

Morphine Worsens the Severity of Acute Pancreatitis in Ethanol-Palmitoleic Acid Model of Acute Pancreatitis

H. Cheema, J. George, G. Gonzalez, V. Dudeja, R. Dawra, S. Roy, A.K. Saluja. Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL.

Background: Morphine is widely used for the management of pain associated with acute pancreatitis (AP). Interestingly, morphine is also known to affect the immune system and modulate inflammatory pathways in non-pancreatic diseases. We have previously shown that morphine increases severity in both cerulein and L-arginine models of AP. Alcohol abuse is commonly associated with pancreatitis. In the current study, we have evaluated the impact of morphine treatment on the severity of AP in a clinically relevant model of alcohol induced AP.

Methods: Ethanol-POA model of AP was induced in 6-8-week-old male WT mice by injecting 1.32 g/kg pure ethanol IP followed 1 hour later by 2 mg/kg POA (1:500 in DMSO). Subcutaneous pellet of either placebo or morphine (25 mg) was implanted at 12 hours and mice were sacrificed at 48 hours after initiation of AP. Local and systemic injury was evaluated using pancreatic and lung myeloperoxidase (MPO) activity and histology. MPO data was expressed as MPO (U/μg protein). Necrosis was quantified and expressed as percent of total parenchyma.

Results: Morphine treatment of mice with Ethanol-POA induced AP led to a statistically significant increase in pancreatic MPO U/μg (3.8±0.9 vs 1.2±0.7). Blinded quantification of pancreatic histology demonstrated that morphine treatment led to significant increase in percent necrosis (23.1±1.0 vs 9.1±1.1) in mice with AP. Morphine treatment of mice with AP led to a non-significant trend towards increase in Lung MPO when compared to mice with AP but without morphine treatment.

Conclusion: Morphine treatment worsens the severity in Ethanol-POA model of AP. Considering our results, the safety of morphine for analgesia during AP should be re-evaluated in future human studies.

A Metastatic Pancreatic Ductal Adenocarcinoma Animal Model With Clinical Relevance in Syrian Golden Hamster Induced by N-Nitrosobis(2-Oxopropyl) Amine

Y. Chen, H. Feng. School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, China.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) features as rapid metastasis and chemo-resistance with dismal prognosis. Most bench findings failed in clinical trial, partially attributing to lack of good animal models. Most xenografted animal models and genetic engineering mouse models fail to develop metastatic tumor, which is not the same as human PDAC. It is therefore important to develop preclinical animal models with good clinical relevance. Here, we explored the clinical relevance of N-nitrosobis(2-oxopropyl) amine (BOP) induced PDAC in Syrian Golden Hamster. This animal model is well mimicking human PDAC initiation and metastasis histologically and clinically.

Methods: Syrian Golden Hamsters were subcutaneously injected with BOP at the dosage of 10mg/kg once a week for 4 weeks. The hamsters were sacrificed for further analysis at certain time points after BOP injection. We established a nude mice model by orthotopically injecting an aggressive PDAC cell line SW1990 into the pancreas.

Results: At week 16, pre-malignant lesion, PanIN, could be found in 9 out of 10 (90%) hamsters, while at week 20 all hamsters developed PADC (100%). 24 weeks after BOP injection, all hamsters fully developed PDAC and had liver metastasis (100%), and 8 out of 20 (40%) developed lung metastasis. 6 out of 20 (30%) hamsters developed jaundice, which is an absent symptom in any other animal models of PDAC. In the xenografted nude mice model, 2 out of 10 (20%) had liver metastasis, while none of them had lung metastasis. Histological analysis revealed that hamster PADC and metastatic tumor had similar structures with that of human PDAC and liver metastasis. Heterogeneity of the tumor was also observed and well differentiated and poor differentiated cancer cells co-existed within a tumor. However, primary and metastatic tumors in the xenograft model, failed to represent human disease histologically, with absence of tumor microenvironment and interactions between cancer cells and stromal cells.

Conclusion: BOP induced hamster PDAC model better mimicked human PDAC with good clinical relevance.

Isolated Roux Loop Pancreaticojejunostomy Versus Single Loop Pancreaticojejunostomy After Pancreaticoduodenectomy: A Retrorospective Cohort Study

A. Chhaidar, M. Ben Mabrouk, A. Ben Ali. Department of General Surgery, Sahloul Hospital, Sousse, Tunisia.

Objectives: The aim of this study was to compare the postoperative outcome and the occurrence rate of postoperative pancreatic fistula (PF) between isolated Roux loop pancreaticojejunostomy (IRPJ) and single loop pancreaticojejunostomy (SLPJ) after pancreaticoduodenectomy (PD).

Methods: Data of patients who underwent IRPJ were compared with those of a pair-matched equal number of patients undergoing SLPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality and exocrine and endocrine pancreatic functions.

Results: Seventy patients treated by PD were included in the study. The two groups were comparable in both pre- and intra-operative parameters. The median total operative time was significantly longer in the SLPJ group (329 min versus 386 min; P = 0,001). Postoperative pancreatic fistula developed in 8 of 35 patients in the SLPJ group and 3 of 35 patients in the IRPJ group (P = 0.101). Four SLPJ patients and one IRPJ patient had POPF of type B or C (P = 0.773). Re-laparotomy was significantly more frequent in the SLPJ group (25.7% versus 8.5%; P = 0.04). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in 2 of 35 RYR patients and 4 of 35 SLPJ patients (P = 0.414).

Conclusion: The use of IRPJ does not seem to decrease the occurrence rate of postoperative PF in patients undergoing PD. But It was associated with a decrease in the incidence of re-laparotomy. This technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.

The IL1RN Genetic Polymorphism is Associated With Acute Pancreatitis in a Korean Ethnic Group

J.S. Choi. Division of Gastroenterology, Catholic Kwandong University International St. Mary’s Hospital, Incheon, South Korea.

Background/Aim: Several epidemiological studies have validated the association of interleukin gene polymorphisms with acute pancreatitis (AP) in different populations. However, there have been few studies in Asian ethnic groups. We aimed to investigate the relationships between inflammatory cytokine polymorphisms and AP as pilot research in a Korean population.

Methods: Patients who had been diagnosed with AP were prospectively enrolled. DNA was extracted from whole blood, and DNA sequencing was subsequently performed. Single-nucleotide polymorphisms (SNPs) of the IL1B, IL1RN, and TNFA genes of patients with AP were compared to those of normal controls.

Results: Between January 2011 and January 2013, a total of 65 subjects were enrolled (40 patients with AP vs. 25 healthy controls). One intronic SNP (IL1RN −1129T>C, rs4251961) was significantly associated with the risk of AP (odds ratio, 0.304; 95% confidence interval, 0.095-0.967; P = 0.043). However, in our study, AP was not found to be associated with polymorphisms in the promoter regions of inflammatory cytokine genes, including IL1B (−118C>T, c47+242C>T, +3954C/T, and −598T>C) and TNFA (−1211T>C, −1043C>A, −1037C>T, −488G>A, and −418G>A).

Conclusion: IL1RN −1129T>C (rs4251961) genotypes might be associated with AP in a Korean population.

Crosstalk Between Inflammation and Coagulation in Pancreatitis-Induced Respiratory Dysfunction

S. Chooklin, B. Pidhirnyy, S. Chuklin. Regional Clinical Hospital, Lviv, Ukraine.

Introduction: Acute lung injury is a serious early complication in patients with acute pancreatitis (AP) significantly increases mortality rates. Although the pathogenesis of acute lung injury in necrotizing pancreatitis is not completely clear, the activation of inflammatory cytokines and coagulation are keys in the initiation of this process.

Methods: We examined 155 patients with acute necrotizing pancreatitis. According to the international classification in 98 patients we diagnosed the moderate severe AP, and in 57 patients the severe AP. Disorders of lung function were in 60 patients. We determined the blood gases, indicators of hemostasis and inflammation.

Results: Analysis of the relationship of inflammation and hemostasis in patients with acute pancreatitis and respiratory dysfunction is accompanied by decreased of activated partial thromboplastin time (F = 17.046; P = 0.00011), increased of thrombin time (F = 37.935; P < 0.00001), fibrinogen concentration (F = 7.8707; P = 0.00665), D-dimers level (F = 24.272; P = 0.00001), and level of soluble fibrin-monomer complexes (F = 46.641; P < 0.00001), lack of activity of antithrombin III (F = 40.992; P < 0.00001), increased synthesis of C-reactive protein (F = 19.804; P = 0.00004), excessive production of proinflammatory cytokines IL-2 (F = 43.680; P < 0.00001), IL-6 (F = 27.703; P < 0.00001), and TNF-α (F = 50.186; P < 0.00001). The soluble fibrin-monomer complexes has sensitivity for predicting respiratory dysfunction in patients with severe acute pancreatitis is 86.2% and specificity is 83.8%, positive predictive value is 80.65%, and negative predictive value is 88.57%.

Conclusion: The mechanism of the acute lung injury following acute necrotizing pancreatitis is complicated. The inflammatory cascades and hypercoagulative state are initiated this pathological process.

Nfic is a Novel Nr5a2 Interactor and Regulator of the Pancreatic Acinar Program

I. Cobo,¹ J. Melià,² F. García,³ J.C. Park,⁴ J. Muñoz,³ F.X. Real.¹¹Cancer Cell Biology Program, Spanish National Cancer Research Center, Madrid, Spain; ²Humanitas Research Center, Rozzano, Italy; ³Proteomic Unit, Spanish National Cancer Research Center, Madrid, Spain; ⁴Department Oral Histology-Developmental Biology, School of Dentistry, Seoul National University, Seoul, Korea.

The transcriptional program of acinar cells is responsible for the maintenance of the exocrine phenotype, crucial for pancreatic homeostasis. The PTF1 complex is the master regulator of acinar identity. Complete acinar differentiation requires fine tuning by other proteins, including Nr5a2, implicated in pancreatitis and pancreatic cancer. We performed immunoprecipitation (IP) of Nr5a2 from total pancreas lysates followed by mass-spectrometry analysis and identified, among others, Nfic as a putative Nr5a2 interactor. The co-occurrence of both proteins in the same complex was confirmed by IP and western blotting. Nfic is a member of the CTF/NF-1 family of transcription factors, with ubiquitous distribution. Nfic knockdown in 266 cells resulted in decreased expression of digestive enzyme transcripts. In vivo, Nfic is expressed at E15.5 both in acinar and non-acinar cells. However, after E18.5, expression becomes restricted to acinar cells. Bioinformatics analyses revealed putative Nfic binding sites located at very short distances from Nr5a2 binding motifs in genomic regions bound by Nr5a2. IP of pancreatic chromatin followed by PCR showed that Nfic binds the promoters of Ptf1a, Amylase, Elastase, Cpa, and Ctrb1. Nfic−/− pancreata showed mild edema and leukocyte infiltration, and reduced levels of digestive enzyme mRNAs and protein. Acinar cells of Nfic−/− mice show a decreased expression of phospho-S6K1 and its substrate, phospho-S6, and increased expression of phospho-ERK. In addition, Nfic is down-regulated in ADM, PanINs, and pancreatic tumors in mice. Thus, Nfic belongs to a novel class of regulators of the acinar program that may play a role in pancreatic disease.

The Ohio State University Pancreas Disorders Network U-BioCHIP Platform: An Update

D.L. Conwell,¹ J. Muntel,² S. Ahmed,² Z. Cruz-Monserrate,¹ P.A. Hart,¹ P.A. Banks,³ L. Lee,³ H. Steen.²¹The Ohio State University Wexner Medical Center, Columbus, OH; ²Department of Pathology, Boston Children's Hospital, Harvard Medical School, Boston, MA; ³Center for Pancreatic Disease, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, MA.

Background: The major challenge of managing chronic pancreatitis (CP) is the lack of diagnostic modalities for the detection of early CP prior to irreversible organ damages: routine pancreas biopsy carries risk, exocrine insufficiency only develops clinically when >90% of the gland has been scarred, and current advanced imaging is expensive, and often ambiguous for early disease. We hypothesize that the diseased pancreas modulates the urine proteome that can be used to complement current diagnostic modalities.

Aim: Identify CP specific changes to the urinary proteome.

Methods: Urine samples were collected from 10 healthy controls, 16 and 31 patients with equivocal/mild and moderate/severe CP on MRI/MRCP (Cambridge criteria), respectively. The urine samples were analyzed using our in-house developed urine proteomics pipeline. Some of the subjects underwent endoscopic pancreas function test.

Results & Discussion: About 1500 urinary proteins were identified. Data analysis identified three different CATHEPSINS as being significantly upregulated in the urine of CP patients, which is noteworthy given the described association of cathepsins and CP. Many other biomarker candidates were identified and are currently being evaluated. Furthermore, we also identified pancreatic and inflammatory proteins correlating with the peak HCO₃- level in pancreatic fluid (PF).

Conclusion: Using our high throughput proteomics pipeline identified numerous proteins whose urinary abundance levels are modulated by CP and that correlate with peak HCO₃- levels in PF. These findings highlight the potential of urinary proteins for diagnostic and functional testing in pancreatic diseases.

ROR1 Targeting Drugs Induced Significant Apoptosis of Pancreatic Cancer Cells

A.H. Daneshmanesh,¹ M. Hojjat-Farsangi,¹ A. Moshfegh,¹ J. Schultz,² J. Vågberg,² S. Byström,² E. Olsson,² T. Olin,² A. Österborg,³ H. Mellstedt.¹¹Department of Oncology-Pathology, Cancer Center Karolinska, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden; ²Kancera AB, Karolinska Institute Science Park, Stockholm, Sweden; ³Department of Hematology, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden.

Introduction: Pancreatic carcinoma has still a dismal prognosis despite introduction of novel cytostatics and targeted therapeutics. There is a great clinical need for new drugs with other mechanisms of action. Pancreatic carcinoma cells express the onco-fetal receptor tyrosine kinase (RTK) ROR1 with a restricted expression on normal post-partem cells. ROR1 has been shown to be of importance in several malignancies for proliferation, survival, metastasis and epithelial-mesenchymal transition (EMT).

Methods: A small chemical compound KAN0439834 (530 Da) targeting the tyrosine kinase (TK) domain of ROR1 and a monoclonal antibody against the CRD region of the external domain of ROR1 were developed. Eight human pancreatic carcinoma cell lines expressing phosphorylated ROR1 were included in the study.

Results: Both compounds induced apoptosis of the cell lines. KAN0439834 was more effective than the anti-ROR1 mAb. There was a great variation in sensitivity between cell lines. The cytotoxic effects could be enhanced by combining KAN0439834 or anti-ROR1 mAb with gemcitabine but combining the two ROR1 targeting drugs the results varied. KAN0439834 and anti-ROR1 mAb dephosphorylated ROR1 and KAN0439834 was the most effective, able to completely dephosphorylate ROR1. Both compounds also dephosphorylated the co-receptor LRP6 and SRC as well as molecules of the non-canonical Wnt pathway PI3K/AKT/mTOR and the transcription factor CREB.

Conclusion: This is a report on preclinical evaluation of the first generation of an orally available ROR1 tyrosine kinase inhibitor (TKI) inducing a significant apoptosis of pancreatic tumor cells. Further preclinical and clinical development will establish the role of this novel targeted therapeutic in pancreatic cancer.

Intra- and Inter- Observer Agreement on CT Scan Features of Chronic Pancreatitis (CP)

A.K. Dasyam,¹ T. Tirkes,² Z.K. Shah,³ G. Tang,⁴ K. Vipperla,⁵ P.J. Greer,⁶ M. Topazian,⁷ E.L. Fogel,⁸ D.L. Conwell,⁹ D. Yadav,¹ N. Takahashi.¹¹¹Dept of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Dept of Radiology, Indiana University, Indianapolis, IN; ³ Dept of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH; ⁴Dept of Biostatistics, University of Pittsburgh, Pittsburgh, PA; ⁵University of Pittsburgh Medical Center, Pittsburgh, PA; ⁶Gastroenterology, University of Pittsburgh, Pittsburgh, PA; ⁷Div of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; ⁸Div of Gastroenterology and Hepatology, Indiana University School Medicine, Indianapolis, IN; ⁹Div. of Gastroenterology, Ohio State University Wexner Medical Center, Columbus, OH; ¹⁰Div of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; ¹¹Department of Radiology, Mayo Clinic, Rochester, MN.

Objectives: Cambridge classification (CC), initially proposed for ERCP, was later adapted for CT scan, and is recommended for use by recent APA guidelines (Pancreas 2015). However, no study has assessed the validity of CC or other morphological features of CP. We evaluated intra- and inter-observer variability in assessment of CT features of CP.

Methods: Anonymized contrast-enhanced CT scans of 32 CP patients enrolled in the NAPS2 from UPMC were reviewed on 2 separate occasions by 3 blinded non-UPMC radiologists. UPMC radiologist’s reads were considered as reference. Kappa statistic (k) assessed the intra- and inter-observer agreement– poor (<0.4), moderate (0.4-0.6), good (0.6-0.8), excellent (>0.8).

Results: Intra-observer agreement for CC in non-UPMC radiologists was moderate-good (k 0.54-0.79; % concordance [conc] 72–84). Agreement was good-excellent (k 0.74-0.81; % conc 72–81) for calcifications, moderate-good (k 0.54-0.72; % conc 59–72) for atrophy, excellent (k 0.81-0.9, %conc 81) for pancreatic duct (PD) caliber, but only moderate-good (k 0.49-0.66; % conc 66–78) for PD contour. Interobserver agreement for CC for first set of reads was poor-good (k 0.35-0.74; %conc 63–78). Agreement was moderate-good (k 0.66-0.79; %conc 63–81) for calcifications, good (k 0.64-0.71; %conc 63–72) for atrophy, excellent (k 0.81-0.95, %conc 69–94) for pancreatic duct (PD) caliber, but poor-good (k 0.17-0.72; % conc 47–75) for PD contour. Agreement for first and second reads were generally similar.

Conclusion: In this first validation study, we found acceptable agreement within and among radiologists for CT features of CP. An improved classification system would be desirable (a focus for CPDPC) – which will allow improved classification of patients for clinical and research purposes.

Downregulation of GRP78 Mediates Chemo-Sensitivity and Cell Death in PDAC

P. Dauer,¹ V.K. Gupta,² N.S. Sharma,² K.K. Kesh,² S. Banerjee,² A.K. Saluja.²¹Department of Pharmacology, University of Minnesota, Minneapolis, MN; ²Division of Surgical Oncology, University of Miami, Miami, FL.

Background: Endoplasmic reticulum (ER) stress and the unfolded protein response (UPR) have been shown to correlate with advanced stage, shorter survival, and chemoresistance in multiple cancers, including pancreatic cancer. The UPR is a homeostatic mechanism that allows cells to ameliorate stress-inducing conditions, which can result in cell survival. The activation and inactivation of UPR is regulated by glucose regulatory protein (GRP78). Our studies and others have shown that GRP78 is overexpressed in pancreatic cancer.

Aim: The purpose of this study is to elucidate the mechanism of UPR mediated chemoresistance in pancreatic cancer, which contributes to the poor survival statistics that have remained relatively unchanged for the past 30 years.

Results: One route of chemoresistance employed by cancer cells is through the upregulation of ABC transporters, which can efflux xenobiotics. Our studies show that mRNA expression of ABC transporters is significantly upregulated in KPC tumors versus KPC pancreata without tumors. Additionally, NRF2 (downstream of UPR activation), which transcriptionally regulates some ABC transporters, was also overexpressed compared to 1 month and 3 month KPC mice (P < 0.0001, P = 0.0065 respectively). Our studies show that by causing chronic ER stress through silencing GRP78 in gemcitabine treated MIA PaCa-2 cells, the % ABC transporter-efflux activity decreases from 25.1 to 0.5. Further, silencing GRP78 in gemcitabine treated MIA PaCa-2 cells decreases NRF2 activity from 1.7 to 1.2 relative luciferase units. This combination of gemcitabine and silencing decreased viability of MIA PaCa-2 cells to 0.49 compared to non-silenced cells, whereas gemcitabine alone decreased viability to 0.7 in 48 hours.

Conclusion: Based on our studies, the UPR could provide multiple selective targets for future therapeutics, which increase the chemo-sensitivity in pancreatic cancer.

Treatment of Locally Advanced Pancreatic Cancer Patients at Academic Centers is Associated With Improved Overall Survival: A National Cancer Database Analysis

J. David,¹ A. Torossian,¹ A.E. Hendifar,² N.N. Nissen,³ R. Tuli.¹Departments of ¹Radiation Oncology and ²Medicine, ³Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA.

Introduction: Pancreatectomies for pancreatic cancer at higher volume academic centers (AC) are associated with improved clinical outcomes relative to those performed at non-academic centers (NAC). However, the potential benefits of chemotherapy (CT) and radiation (RT) for locally advanced pancreatic cancer (LAPC) received at an AC have not been studied. Herein, we investigate the benefit of CT and RT treatment at an AC compared to NAC in LAPC patients.

Methods: The National Cancer Database (NCDB) was utilized to identify LAPC patients treated AC and NAC. ACs included NCDB designated academic/research programs, including National Cancer Institute comprehensive cancer centers. All other facilities were designated as NACs. All patients were treated with (CT) or chemoradiation (CRT). Univariate (UVA) and multivariate (MVA) Cox regression were performed to identify the impact of treatment at AC versus NAC on overall survival (OS).

Results: From 2004–2014, a total of 10123 patients with LAPC were identified. The median age was 66 years (range, 22–90) with median follow up of 11 months (range, 0.26–139 months); 49.8% were male and 50.2% female. All patients had clinical stage 3/T4 disease irrespective of nodal metastases. Of these, 4754 (47.8%) patients were treated at an AC and 5285 (52.2%) were treated at a NAC. On UVA, age, race, median income, education level, comorbidities, nodal disease and academic status were associated with improved OS. On MVA, treatment at ACs was associated with improved OS when compared to NAC (HR, 0.92; 95% CI, 0.88–0.96).

Conclusion: The treatment of LAPC patients with CT or CRT at an AC led to significantly improved OS rates. In the absence of prospective data, these results support the referral of LAPC patients, when feasible, to AC.

Exocrine Pancreatic Metabolic Demand is Increased in Necrotizing Pancreatitis (NP) but Not Mild Pancreatitis: Both of Which are Mechanistically Targeted by Hypothermia

C. De Oliveira, B. Khatua, B. El-Kurdi, K. Patel, V. Singh. Mayo Clinic, Scottsdale, AZ.

Background: The lack of effective predictors for NP prevents identification of patients needing more than supportive care during AP. Additionally, the approach of targeting specific steps initiated by an AP etiology narrows our therapeutic options. We thus measured metabolic demand in mild AP, NP and studied whether pancreatic hypothermia reduced this demand and improved outcomes.

Methods: Near infra-red 2-deoxyglucose (NIR2-DG; IV) was given to Wistar rats and NP (intraductal glyceryl trilinoleate; GTL, 50ul/100gm) or mild AP (IP cerulein 50 mcg/kg) were induced. Target temperatures (reducing in vitro acinar LDH leakage, PI uptake, active caspase-3, Ik-B degradation, Cai, ym) were achieved 1 hour after AP induction via transgastric cooling. NIR2-DG uptake was measured in vivo (IVIS spectrum) and ex vivo via whole organ imaging and by NIR imaging microscopy. Pancreatic necrosis, TUNELs, MPOs and markers of systemic severity were measured. A P < 0.05 was significant.

Results: In vitro cerulein (10-7M) and GTL induced injury were reduced by 80% at 34C and 25C respectively. In vivo unlike cerulein, GTL increased pancreatic 2-DG uptake after 1 hour of AP. This was noted in acinar cells and not islets. GTL caused 70% necrosis, while cerulein increased pancreatic MPO (2.65±0.2% vs. 0.2±0.1%), TUNELs (1.6%±0.1% vs. 0.3%±0.1%) vs. controls. Cooling reduced GTL induced 2-DG uptake (4.4±0.8 vs. 1.9±0.3 fold), pancreatic necrosis by 20%, systemic injury (shock, Sr. BUN, dsDNA, histone complexed DNA fragments) and improved survival (10% to 88% at 6 hours), along with reducing MPO, TUNELs in mild AP.

Conclusion: Imaging of pancreatic metabolic demand can predict NP. Therapeutic pancreatic cooling reduces this demand, necrosis and improves AP outcomes irrespective of etiology.

Hospital Admission for Acute Pancreatitis in a Chinese Population, 2011–2014: Big Data Analytics of Incidence and Hospital Expenses

L. Deng,¹ Q. Tan,¹ T. Jin,¹ K. Jiang,¹ J. Guo,¹ X. Yang,¹ W. Huang,¹ L. Sun,² Q. Xia.¹¹Department of Integrated Traditional Chinese and Western Medicine and ²West China Biomedical Big Data Center, West China Hospital of Sichuan University, Sichuan, China.

Background: Acute pancreatitis (AP) is one of the most common diseases of the gastrointestinal tract. We performed database study to robust estimate the incidence of hospital admission for AP and hospital expenses in a megalopolis of southwestern China.

Methods: We searched the biomedical database of West China, which comprises anonymized hospital statistical records data from 2011 to 2014. We selected all admissions for AP as the principal diagnosis recorded in the database. We used admissions for AP as the numerator and the total resident population in the area covered by the data as the denominator to calculate the incidence of hospital admission. The costs of the average costs per years, per admission and per day were investigated.

Results: A total of 31,894 people admitted to hospital with a principal diagnosis of AP were retrieved, of which 16,934 (53.1%) were men. The mean age of the patients was 52.1 (SE, 15.2) years overall. The incidences of hospitalization for AP were 56-63/per 100 000 population from 2011–2014. Incidence rates for both men and women increased substantially during the study period. Average expenses per hospitalization and annual average expenses per patient exceeded the rising of Customer Price Index (CPI). Excluding the factor of CPI growth, the average cost per admission in 2014 escalated up to 1.13-folds of 2011, and the average cost per day was 1.22-folds. Hospital expenses due to AP occupies about 50% of Per-Capita Disposable Income (PCDI) for urban residents.

Conclusion: The incidence of hospitalization and hospital expenses for AP remarkably increased and caused a serious health economic burden.

Pancreatic Pseudocysts and Parenchymal Necrosis in Patients With Autoimmune Pancreatitis: A Systematic Review

J.A. Donet, J.A. Barkin, T. Keihanian, Z. Nemeth, J.S. Barkin. University of Miami, Leonard M. Miller School of Medicine, Miami, FL.

Introduction: Autoimmune Pancreatitis (AIP) is a cause of acute pancreatitis (AP). Potential AP complications (pancreatic pseudocysts (PC) & parenchymal necrosis) & their natural history & management are unknown in AIP.

Aim: To examine prevalence of AP complications of PC & pancreatic necrosis in AIP, & their characteristics, management & outcomes.

Methods: A systematic search using PubMed, Embase, Scopus & Cochrane was performed to 10/1/2016 with a reference librarian. Search terms were “Autoimmune pancreatitis,” “pancreatic pseudocyst,” “acute fluid collection,” & “pancreatic necrosis” with all permutations. AIP was defined by international guidelines. The search yielded 271 results reviewed by 2 authors. 14 case reports & 1 series of 3 patients were included.

Results: 12/17 (70.6%) patients were men, mean age 54.82±10.97 yrs (range 26–75 yrs). 8/17 had PC noted concurrently with AIP diagnosis. 9/17 had PC appear months to years after initial diagnosis. 10/17 had solitary PC on imaging, whereas 7 had multiple PC. PC location was variable. PC size: 4 small (<3cm) & 13 large (>3cm; 9cm max). 6/17 (35%) had normal pancreatic duct (PD) imaging, but 9/17 (53%) had PD narrowing/stenosis. 14/17 received steroids (4/4 small & 10/13 large PC). All 4 small PC responded completely to steroids, but only 4/10 (40%) large PC responded to steroids. 9/13 large PC went on to undergo endoscopic or surgical interventions. None of the 17 cases had pancreatic necrosis.

Discussion: Development of PC in AIP is rare with only 17 cases reported. PC in AIP can be single or multiple with variable size & location. Small PC responded well to steroids, with poor steroid response in large PC requiring intervention. AIP has not been reported to be associated with development of pancreatic necrosis.

Enhanced Recovery in Acute Pancreatitis (RAPTor): A Randomized Controlled Trial

E. Dong,¹ J.I. Chang,² D. Verma,² M. Batech,³ C. Villarin,³ K.K. Kwok,² W. Chen,³ B.U. Wu.²¹Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; ²Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; ³Kaiser Permanente Research and Evaluation, Pasadena, CA.

Introduction: Acute pancreatitis (AP) is a leading cause of hospitalization in the US. Despite frequency of disease, there have been relatively few attempts to optimize approach to routine care of patients with AP. We hypothesized that enchanced approaches to recovery may lead to earlier restoration of gut function in patients hospitalized with AP.

Methods: We performed a single-blind randomized-controlled trial of patients admitted from the emergency department between July 2016-April 2017. Patients with evidence of organ failure or the systemic inflammatory response syndrome at the time of enrollment were excluded. All patients enrolled within 24-hours of hospitalization and received standard fluid resuscitation. Participants were randomly assigned to receive either enhanced recovery consisting of patient-directed oral intake, early ambulation, and non-opioid analgesia versus standard treatment with opioid analgesia and physician-directed diet as well as nursing parameters. Primary study endpoint was time-to-oral refeeding. Secondary endpoints included differences in pancreatitis activity scores (PASS), length-of-stay, 30-day re-hospitalization. All analyses were conducted on an intent-to-treat basis.

Results: A total of 46 participants were enrolled. Etiologies were as follows: 61% gallstone, 15% alcohol, 13% hypertriglyceridemia, 11% other. Median age of the cohort was 53.1 years, 54.3% were female. There was a significant reduction in time to successful oral re-feeding in the enhanced recovery versus standard care group, median 13.8 vs. 124.8 hours, P < 0.001. Pancreatitis activity scores were lower at 48–72 hours among patients assigned to enhanced recovery, mean 43.5 vs. 72.1, P < 0.001. There were no significant differences in length-of-stay or frequency of 30-day readmission.

Conclusion: In this pilot randomized-controlled trial, enhanced recovery approaches were safe and effective in promoting earlier restoration of gut function in patients hospitalized for AP (NCT02813876).

Defining DDR Defectiveness and Replication Stress in Pancreatic Cancer

S.B. Dreyer,^1,2 E.M. Lampraki,¹ V. Paulus-Hock,¹ R. Upstill-Goddard,¹ G. Caligiuri,¹ P. Bailey,¹ D.K. Chang,^1,2 A.V. Biankin.^1,2,31Wolfson Wohl Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom; ²Glasgow Royal Infirmary, West of Scotland Pancreatic Unit, Glasgow, United Kingdom; ³South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.

Background: Integrated genomic analyses revealed 24% of pancreatic cancer (PC) harbor defects in DNA damage response (DDR) and a subgroup demonstrate upregulation in replication stress pathways. DDR defective tumors may preferentially respond to DNA damaging agents, and clinical responses to cell cycle inhibitors are seen in undefined subgroups, representing novel therapeutic strategies for PC. The aim of this study is to define and refine therapeutic segments for agents targeting DDR and replication stress in PC.

Methods: From 40 patient-derived cell lines (PDCL) and 64 patient-derived xenografts (PDX), generated and characterized as part of the International Cancer Genome Initiative (ICGC), we identified models with DDR defectiveness and increased replication stress. Cytotoxic viability assays were performed using agents targeting the DDR pathway and cell cycle, including Cisplatin, and inhibitors of PARP, ATR, WEE1, CHK1, CDK4/6 and PLK4. Subcutaneous PDX models were generated to test therapeutic regimens in vivo.

Results: DDR defective PDCLs were highly sensitive to Cisplatin and PARP inhibitors. Transcriptional signatures of replication stress predicted differential responses to cell cycle inhibitors of ATR, WEE1, CHK1, CDK4/6 and PLK4. ATR inhibition sensitized DDR competent models to Cisplatin, demonstrating ‘fabricated’ synthetic lethality. A BRCA1 mutant PDX model responded exceptionally to Cisplatin and PARP inhibitor monotherapy.

Conclusion: This proof of concept data demonstrates DDR deficiency and upregulated replication stress to be attractive targets in PC, using DNA damaging agents and novel small molecule inhibitors. Robust molecular assays with clinical utility to define DDR defectiveness and increased replication stress is urgently needed.

Feasibility and Clinical Utility of EUS Guided Biopsy of Pancreatic Cancer for Next-Generation Genomic Sequencing

S.B. Dreyer,^1,2 L. Evers,¹ N.B. Jamieson,² S. Martin,¹ F. Duthie,¹ S. Cooke,¹ P. Bailey,¹ C.J. McKay,^1,2 D.K. Chang,^1,2 A.V. Biankin.^1,21Wolfson Wohl Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom, ²Glasgow Royal Infirmary, West of Scotland Pancreatic Unit, Glasgow, United Kingdom.

Background: Next-generation sequencing technology has made genomic profiling guided therapy a reality for many cancer types. The aim of this study is to investigate the feasibility of genomic profiling using standard clinical endoscopic ultrasound (EUS) core biopsy samples of Pancreatic Cancer (PC) to allow personalised cancer care.

Methods: 51 patients underwent additional research biopsy at the time of diagnostic EUS biopsy. En-face frozen section was performed to enable targeted macro-dissection prior to DNA extraction, quantification and targeted gene sequencing (Agilent Comprehensive Cancer Gene Panel). Matching formalin-fixed (FFPE) diagnostic EUS biopsies and fresh frozen surgical resection specimens also underwent genomic profiling for comparison. Whole genome (WGS) and RNA sequencing was performed in selected patients.

Results: Targeted panel sequencing (n = 61) revealed known PC genes (KRAS, GNAS, TP53, CDKN2A, SMAD4) in 36 patients with histological evidence of PC. Potentially actionable somatic mutations (BRCA1, BRCA2, ATM, BRAF, JAK3) were found in 6 (17%) patients. WGS (n = 5) of EUS samples confirmed mutations identified on panel sequencing and revealed relevant mutational signatures and structural variation patterns that can act as putative biomarkers of therapeutic responsiveness. RNA sequencing (n = 54) segregated patients into key clinically relevant molecular PC subtypes based on transcriptome and reveals novel molecular insights into advanced, unresectable PC (n = 38).

Conclusion: We demonstrate here novel multi-omic analysis of pancreatic cancer using standard clinical EUS guided fine needle biopsies. Multi-omic analysis of EUS biopsies offers potential clinical utility to guide personalized therapy of PC in both the neoadjuvant and advanced settings.

A Flavonoid From Coreopsis Tinctoria Reduces Pancreatic Acinar Cell Necrosis and Severity of Experimental Acute Pancreatitis Models

D. Du,¹ R. Zhang,² N. Shi,³ T. Jin,³ D.N. Criddle,⁴ R. Sutton,⁵ W. Huang,³ Q. Xia.³¹West China-Washington Mitochondria and Metabolism Center, West China Hospital, Sichuan University, Chengdu, China; ²Laboratory of Ethnopharmacology, West China Hospital, Sichuan University, Chengdu, China; ³Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Center, West China Hospital, Sichuan University, Chengdu, China; ⁴Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; ⁵Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.

Background & Aim: The total flavonoid extract (TFE) from traditional Chinese medicine has been shown to reduce severity of experimental acute pancreatitis (EAP). We aimed to evaluate the effects of some flavonoids in TFEs from Coreopsis tinctoria in EAP.

Methods: The TFE was purified from the ethanol extract of Coreopsis tinctoria and six flavonoids (1–6) were isolated from the TFE. Necrotic cell death pathway activation induced by sodium taurocholate (NaTC, 5 mM) was assessed by propidium iodide (PI, 0.25 μM) in freshly isolated pancreatic acinar cells, pre-treated with various concentrations of extracts (0.25, 0.5 and 1 mM). Reactive oxygen species (DCFH-DA, 1 μM) and ATP levels were also measured. EAP was induced by 1) retrograde pancreatic duct infusion 0.1 ml/100 g NaTC in rats (sacrified at 24 h); 2) two intraperitoneal (i.p.) injections of palmitoleic acid (200 mg/kg) and ethnol (1.75 g/kg) administered 1 h apart in mice (sacrificed at 24 h); 3) seven hourly i.p. injections of 50 μg/kg cerulein in mice (sacrified at 12 h). Flavonoid 1 was adminstered at 0, 4 and 8 h after disease induction with equivalent concentrations in rats (8.6, 17.3, and 34.6 mg/kg) and mice (12.5, 25, and 50 mg/kg). Severity of EAP was assessed by biochemical, imunological markers and hisptopathology.

Results: The TFE and all the flavonoids reduced the NaTC-induced PI uptake in acinar cells with the best effect achieved by flavonoid 1 at 0.5 mM. Flavonoid 1 at this concentration also signficantly reduced reactive oxygen species generation and loss of ATP production induced by NaTC. In the EAP models, Flavonoid 1 reduced most the parameters for local pancreatic and systemic injuries with a consistent effect in reducing necrotic and overall histopathology scores.

Conclusion: A flavonoid from Coreopsis tinctoria reduces pancreatic acinar cell necrotic cell death pathway activation and severity of 3 EAP models. Further studies are needed to delineate the protective mechanisms of flavonoids for EAP.

The Economic Burden of Illness Associated With Exocrine Pancreatic Insufficiency (EPI)

E. Durden,¹ I.H. Winer,¹ J. Vora,² K. Cappell,¹ N. Khandelwal.²¹Truven Health Analytics, an IBM Company, Cambridge, MA; ²HEOR, AbbVie, Mettawa, IL.

Objective: To describe the incremental direct healthcare costs and indirect costs due to work loss incurred by patients with EPI compared to demographically similar patients without EPI.

Methods: Patients with evidence of pancreatic enzyme replacement therapy (PERT) from 1/1/2009 to 12/31/2014, and ≥12 months of pre- and post-index continuous enrollment in the MarketScan® databases were directly matched to patients without evidence of PERT. Data on indirect costs due to absence, short-term disability (STD), and long-term disability (LTD) were available for subsets of the overall population. Direct healthcare costs and indirect costs were compared between the matched EPI and non-EPI cohorts.

Results: After matching, the direct cost analysis cohorts consisted of 7,366 EPI cases matched to 22,089 controls. Total healthcare costs were higher among EPI cases than the controls in both the baseline (All-cause: $62,335 vs. $54,973; EPI-specific: $11,091 vs. $139) and follow-up (All-cause: $67,460 vs. $32,486; EPI-specific: $22,460 vs. $130) (all P < 0.001). While there were no significant differences in indirect costs due to absence, EPI cases had higher mean indirect costs associated with STD than the controls in both the baseline ($1,093 vs. $617; P = 0.002) and follow-up ($3,452 vs. $1,370; P < 0.001). EPI cases incurred higher mean indirect costs due to LTD during follow-up than the controls ($867 vs. $459; P = 0.042).

Conclusion: EPI patients incurred substantially higher direct healthcare costs than a cohort of matched non-EPI controls. No difference was observed in the indirect costs incurred due to workplace absence between the EPI cases and controls. However, EPI cases incurred higher indirect costs due to STD and LTD during the 12-month follow-up than the non-EPI controls.

A Novel Role for ARNT2 in Exocrine Pancreas Regeneration

L. Elferink,¹ I. Gaziova,¹ A. Joshi,² K. Pereira De Castro,² C. Elferink.²¹Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX; ²Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX.

Introduction: Injured acinar tissue is restored via acinar-ductal metaplasia (ADM), a reversible yet poorly understood mechanism in which surviving acinar cells regenerate and repopulate the exocrine pancreas. This study hypothesizes that the basic helix-loop-helix PAS (bHLH-PAS) protein transcription factor aryl hydrocarbon receptor nuclear translocator 2 (ARNT2) is a regulator of acinar repair.

Methods: Recurrent injury was induced in mice using six, hourly spaced i.p. injections of saline or cerulein (50ug/kg/injection) on alternate days for three days. Pancreata were analyzed; a) histologically by immunohistochemistry or confocal analysis; b) by chromatin immunoprecipitation (ChIP); c) global transcriptomic analysis using deep sequencing; and d) by RNA analysis using qRT-PCR.

Results: Our data demonstrate that; a) ARNT2 protein expression is increased dramatically in acinar cells of chronic pancreatitis patients but not patient-matched normal pancreatic samples; b) ARNT2 is recruited to the cMyc promoter in injured pancreata concomitant with increased cMyc expression, a known bHLH transcription factor involved in adult acinar cell maturation and maintenance; and c) increased ARNT2 protein staining in structures reminiscent of acinar-ductal metaplasia (ADM), following recurrent cerulein-induced acinar injury—an established mouse model for pancreatic damage.

Conclusion: Increased acinar ARNT2 expression is consistent with an intrinsic transcriptional response important for tissue repair. The characterization of ARNT2 driven transcriptional activity following injury will provide a mechanistic understanding of signaling networks important for acinar homeostasis and regeneration, a process which when disrupted promotes carcinogenesis.

A Histopathologic Comparison of Fibrosis Among Patients With and Without Pancreatitis

M. Faghih,¹ M. Noe,² R. Moran,² N. Yahyapourjalaly,² O. Brewer Gutierrez,² T. Boortalary,² J.R. Azadi,² M. Fetrat,² A. Zaheer,³ D.K. Andersen,¹ M. Makary,² A.M. O'Broin-Lennon,² V.K. Singh.²¹Johns Hopkins, Baltimore, MD; ²Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD; ³Gastroenterology, Johns Hopkins Hospital, Baltimore, MD.

Introduction: Histopathology is commonly used as the gold standard for diagnosing chronic pancreatitis (CP). However, there has never been a study comparing fibrosis among patients with CP, recurrent acute pancreatitis (RAP) and those without pancreatitis to determine the progression of disease.

Methods: Patients undergoing surgery between 2006–2017 were classified into 3 groups: CP, CT scan showing calcifications (n = 52); RAP, ≥ 2 episodes of acute pancreatitis without underlying calcifications (n = 19) who underwent total pancreatectomy with islet transplantation; and controls (n = 26) with serous cystadenomas (SCA) who underwent distal pancreatectomy with only the pancreatic tissue downstream of the SCA evaluated. Demographic and clinical data affecting pancreatic fibrosis was collected. Histology was evaluated for fibrosis score (FS) as per Ammann criteria. Marked FS was defined as FS≥6. A one-way ANOVA was utilized to compare FS among the 3 groups with pairwise comparisons evaluated using the Tukey post-hoc test.

Results: There were no significant differences between the 3 groups in regards to age, sex, BMI and diabetes. Alcohol (P = 0.001) and smoking (P = 0.01) were significantly higher in CP compared to the RAP group. Median FS was 9 (range, 6.3-12); 3 (range, 2–6) and 0.2 (range, 0.14-0.5) in CP, RAP and control patients of whom 84.1%, 5% and 0% had marked FS, respectively. There was a statistically significant difference between the 3 groups as determined by one-way ANOVA [F (2,90) = 96.58, P < 0.0001]. The mean FS was significantly higher in the CP (8.2±0.6) compared to RAP (4.6±0.6) and control groups (3.5±0.7) [both P < 0.001]. The mean FS in RAP was significantly higher than the control group (P < 0.0001).Median duration of symptoms in RAP patients was 5 (range 2–10) years with no significant trend observed between the duration of symptoms and FS (B = 0.4; 95% CI, -0.1 to -0.2; P = 0.6).

Conclusion: RAP is associated with significantly higher fibrosis than patients without pancreatitis but significantly less than CP. This suggests that RAP lies on a disease continuum with CP.

Increased Incidence of Pancreatic Ductal Adenocarcinoma in Chronic Pancreatitis Patients With Pancreatic Intraepithelial Neoplasia 2

M. Faghih,¹ M. Noe,² R. Moran,² T. Boortalary,² N. Yahyapourjalaly,² O. Brewer Gutierrez,² J.R. Azadi,² M. Fetrat,² N. Parsa,² A. Zaheer,² D.K. Andersen,¹ M. Makary,³ A.M. O'Broin-Lennon,² V.K. Singh.³¹Johns Hopkins, Baltimore, MD; ²Gastroenterology, Johns Hopkins Hospital, Baltimore, MD; ³Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD.

Introduction: Pancreatic intraepithelial neoplasia (PanIN) lesions are a common precursor of pancreatic ductal adenocarcinoma (PDAC). This study aims to assess the frequency and severity of PanIN lesions and risk of PDAC in chronic pancreatitis (CP) patients.

Methods: The histology of all patients undergoing Whipple (n = 37), Frey (n = 33) or total pancreatectomy (n = 5) for CP between 2006–2017 were assessed for PanIN lesions, fibrosis score (FS) per Ammann criteria and the percentage of intralobular and interlobular fat.

Results: There were 75 CP patients; 55.4% male; mean age of 52.5 ± 12 years; alcohol in 10%, tobacco in 18% and both in 33.7%. PanIN lesions were found in 66% of cases [PanIN-1A=11 (14%), PanIN-1B=18 (24%), PanIN-2=21(28%) and PanIN-3=0]. A total of 7 (9.2%) patients died over a median follow-up of 4.4 [2.6–7.9] years after surgery. There were 3 (3.9%) patients who died of PDAC which was seen only in those with PanIN-2 lesions [3/21 (14%) vs. 0/54 (0%), risk difference 14%, P = 0.0013]. There was significantly higher median interlobular fat (2.1 [IQR, 0–5] vs. 0 [IQR, 0–5]; P = 0.004) in patients with PanIN-2 lesions, but no differences in FS, when compared to patients with no PanIN or PanIN-IA/IB lesions.

Conclusion: There were 14 excess cases of PDAC per 100 CP patients with PanIN-2 compared to those with no PanIN or PanIN-1A/1B lesions over a median of 4.4 years after surgery.

Increased Opioid Analgesic Requirement Correlates With Morphologic Severity of Acute Pancreatitis

M. Faghih,¹ J.R. Azadi,² N. Parsa,¹ F. Garcia Gonzalez,¹ A. Zaheer,² V.K. Singh.¹¹Division of Gastroenterology and Hepatology and ²Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD.

Objective: To determine whether opioid analgesics requirements correlate with the morphologic and clinical severity of acute pancreatitis (AP) in hospitalized patients.

Materials and Methods: The records of all adult patients with a diagnosis of AP from 2006–2016 were reviewed. The revised Atlanta classification (RAC) was used to define AP. The morphologic severity of AP was graded according to the modified CTSI (MCTSI). Exclusion criteria included outside hospital transfers, readmission for AP within 2 weeks of discharge, underlying chronic pancreatitis (CP) as defined by the presence of calcification(s) and/or a dilated main pancreatic duct (≥5 mm) on past or current imaging, psychiatric comorbidities, intubation with mechanical ventilation, chronic opioid use, illicit drug use and no contrast enhanced CT scan in first 72 hours of admission. Persistent SIRS (PSIRS), persistent organ failure (POF), ICU admission were used as measures of clinical severity. Comorbidity was quantified using the Charlson index (CCI). All opioids administered in the first 7 days of hospitalization were recorded and converted to oral morphine equivalents (OME). The total OME per day of treatment for abdominal pain was used for the analysis. Age, gender, etiology, and CCI were adjusted for in the multivariable analysis.

Results: There were a total of 267 patients admitted for AP, of whom 196 underwent a contrast-enhanced CT. Our cohort was 58.2% male; mean age of 46 ± 14 years; most common etiology was alcohol (55.6%); and 60% were experiencing their first episode of AP. The mean OME/day was 60 ± 53 mg. Mild, moderate and severe morphologic severity was seen in 50%, 45.9% and 4% of patients, respectively. The mean OME/day was higher in patients with moderate to severe AP (69.5 ± 55) compared to mild AP (50 ± 40) [P = 0.008]. This difference remained significant in the adjusted analysis (P = 0.011). PSIRS, POF, and ICU admission were not associated with a higher mean OME/day.

Conclusion: Patients with morphologically moderate-severe AP required more opioid analgesics during the early phase of hospitalization suggesting that pain is related to the extent of acute inflammatory changes.

Therapeutic Targeting of MLL3 Mutant Pancreatic Cancer

S. Ferri-Borgogno, M.R. Reisenauer, A.K. Gupta, A. Maitra, S. Gupta. Department of Pathology, The UT MD Anderson Cancer Center, Houston, TX.

Myeloid/lymphoid or mixed-lineage leukemia 3 (MLL3) is a histone 3-lysine 4 methyltransferase, frequently mutated in a variety of solid tumors including pancreatic ductal adenocarcinoma (PDAC). Our previous results showed loss of MLL3 function in conjunction with oncogenic Kras mutation drives oncogenesis in genetically engineered mouse model (GEMM) of pancreatic cancer. Similar to other tumor suppressor genes, direct targeting of MLL3 is not feasible, and thus our aim was to find biological pathways which are synthetic lethal targets in MLL3-deficient PDAC tumors. Identification of drug targets in such a specific genetic context could further dictate stratification of patients based on the mutational profile of their tumor. Using cell lines generated from spontaneous tumors arising in KC (KrasG12D alone) and KMC (KrasG12D; MLL3d/d) mice, we performed gene expression analyses and found differential regulation of oncogenic pathways, previously known to be active in pancreatic tumors. We selected a well-known oncogenic pathway to study further and through a series of cellular and biochemical assays, validated selective activation in KMC cells, in contrast with KC cells. Next, we picked multiple pharmacological inhibitors of this pathway, which are already approved at various phases of clinical trials, and tested for their efficacy on growth of KC and KMC cells in both two- and three-dimensional growth assays. In agreement with our data showing preferential activation in KMC cells, we found KMC cells to be significantly more sensitive to growth inhibition than KC cells, when treated with these agents. Thus, identification of synthetic lethal hits in context of MLL3 functional loss could potentially enable us to design strategies to diminish tumor burden and prevent spread in patients with surgically-resectable tumors.

The Role of Nuclear Lamina Dynamics in KRAS-Induced Pancreatic Transformation

L.F. Flores, E. Tolosa, W. Barham, M.E. Fernandez-Zapico. Schulze Center for Novel Therapeutics, Mayo Clinic, Rochester, MN.

Work from Theodore Boveri suggested a higher-order organization of chromatin in the nucleus, thus he introduced the term chromosome territory. Boveri postulated that the nucleus was well-organized and chromosomes were nonrandomly distributed. Over the years, several studies have observed nonrandom organization of chromosomes, which also had a relevant functional aspect, confirming Boveri’s theory. The nuclear lamina, which lies underneath the inner nuclear membrane, is a fundamental component involved in nuclear organization. The nuclear lamina is composed of lamins A, B, and C, in addition to lamin-binding proteins, such as LEM proteins (e.g. Emerin), both of which directly bind chromatin. In most normal cells, the nuclei have a regular ellipsoid shape but an irregular nuclear contour is seen in cancer cells. Furthermore, alterations in nuclear morphology have been well characterized and have become the ‘gold standard’ for cancer diagnosis and grading. Thus, changes in nuclear shape have been extensively associated with cancerous cells, however, there has been no mechanistic link established between oncogenic transformation and disruption of nuclear morphology. Here, we aim to determine the role of components of the nuclear lamina in KRAS-induced transformation. Using KRAS-driven cancer cells, we investigated KRAS mediated effects on nuclear shape and investigated the interplay between KRAS and lamina proteins, particularly Emerin. Our preliminary experiments indicate that induction of KRAS modulates Emerin protein levels. We also observe that KRAS causes the localization Emerin, Lamin A/C, and Lamin B1 to associate to the nuclear periphery. These changes in protein localization were also associated with changes in nuclear shape; upon induction of KRAS, the normal round shape of the nuclei reformed into distorted irregularly shaped nuclei. Emerin modulation appears to have a biological significance, as knocking down Emerin appeared to partially restore nuclear morphology.

Oral Pancreatic Enzyme Replacement Therapy (PERT) in Patients With Pancreatic Cancer (Pca) is Infrequent and Suboptimal: A National Level Analysis

C.E. Forsmark,¹ G. Tang,² M. Tuft,² H. Xu,¹ S.J. Hughes,³ D. Yadav.⁴¹Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL; ²Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA; ³Department of Surgery, University of Florida, Gainesville, FL; ⁴Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: Exocrine pancreatic insufficiency (EPI) is common in PCa patients. PERT is effective in treating EPI, but survey data note infrequent use of PERT in PCa patients. No population level studies exist for PERT use in PCa patients in the US.

Methods: The PharMetrics Patient-Centric Legacy database of all claims (medical, pharmacy) for >80 US health plans was used. Among 48.67 million enrollees with ≥12 months of continuous enrollment from 2001–2013, we identified 32,461 patients who received ≥1 claim for a primary diagnosis (dx) of PCa. We determined details and determinants of PERT use including demographics, comorbidity, US region, enrollment details, diagnostic tests for EPI, pancreatic surgery, and presence of diabetes, osteoporosis, or osteopenia. Appropriate PERT use was defined by daily dose of >120,000 lipase units/day.

Results: Mean age at index PCa claim was 63.4.2±12.3 years, 51% were male, and the median enrollment duration was 52.2 months (17.9 after PCa dx). 3420 patients had a claim for acute or chronic pancreatitis prior to PCa dx. PERT was prescribed in 7125 patients (22%), of which only 1800 (5.5%) received appropriate dosing. Predictors of PERT use included pancreatic surgery (OR, 3.25), performance of any diagnostic test for EPI (OR, 2.94), GI evaluation (OR, 1.88), diabetes (OR, 1.22), and osteoporosis/osteopenia (OR, 1.21). The median duration of PERT use was 8.5 months (IQR, 1–10), with 7.5 months after PCa dx.

Conclusion: PERT is used in ~one in 5 patients with a PCa dx in the US, and 1 in 20 receive appropriate dosages. Several patient and disease-related factors predict PERT use. The lack of PERT therapy in these patients has a negative impact on nutrition and the ability to tolerate surgery or neoadjuvant therapy. Improved awareness of appropriate use and dosing of PERT is needed in PCa patients.

The Safety and Effectiveness of Duodenal Stent for Patients Who Undergo Preoperative Chemoradiotherapy for Pancreatic Cancer

T. Fujii,¹ M. Kishiwada,¹ A. Hayasaki,² T. Takeuchi,¹ Y. Iizawa,³ T. Ito,³ H. Kato,³ A. Tanemura,³ Y. Murata,³ N. Kuriyama,³ Y. Azumi,³ S. Mizuno,³ M. Usui,³ H. Sakurai,³ S. Isaji.³¹Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University, Tsu, Japan; ²Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan, ³Hepatbiliary Pancreatic and Transplantation Surgery, Mie University, Tsu, Japan.

Objectives: The duodenal invasion of pancreatic ductal adenocarcinoma (PDAC) makes it difficult to underwent the preoperative treatments for PDAC because the obstruction of duodenum causes eating disorder and malnutrition. Duodenal stent has been indicated for the palliative treatment of duodenal obstructions instead of bypass surgery and it is rare that it is used for preoperative treatment. Our institution has been performing chemoradiotherapy (CRT) followed by surgery for PDAC. The aim of the present study is to prove the safety and relevancy of duodenal stent during the preoperative CRT.

Methods: We analyzed the clinical data on 181 consecutive patients who underwent CRT for PDAC without distant metastasis from January 2012 to December 2016 (CRT regimen: gemcitabine-based in 5 and gemcitabine plus S1-based in 176). The patients were divided into two groups in the presence or absence of duodenal stent (S vs. no-S group). The completion rate of CRT and resection rate, incidence of adverse events interrupting CRT and the factors of nutrition (albumin, total cholesterol and prognostic nutritional index) after CRT were compared between these two groups.

Results: 181 patients were classified into S (n = 7) and no-S group (n = 174). The completion rate of CRT were 100% (7/7) and 97% (169/174) in S and no-S group respectively, showing no significance between the two groups. The rate of pancreatectomy were 28% (2/7) and 60% (104/174). The incidence of severe adverse events which interrupted CRT were 28.6%(2/7) and 4.6% (8/174) in S and no-S group respectively. There is no patients who developed the perforation or obstruction of gastrointestinal tract in S group. There was no significant difference in the rate of decrease of each nutrition factor.

Conclusion: Our data demonstrated the safety and effectiveness of duodenal stent even if during CRT.

Relationship of Molecular Abnormalties to Pathology of Pancreatic Neuroendocrine Tumor (pNET)

Y. Fukumura,¹ C. He,¹ O. Mamat,¹ H. Mitomi,¹ M. Takase,¹ N. Fujiwara,² S. Kawasaki,² H. Isayama,³ K. Suda,¹ T. Yao.¹Departments of ¹Human Pathology, ²Hepatobiliary & Pancreatic Surgery, and ³Gastroenterology, Juntendo University, Tokyo, Japan.

Background & Aims: Pathogenesis of well-differentiated pNET includes abnormalties of mTOR pathway, von Hippel Lindaw (VHL), MEN1, ATRX/DAXX, and so on. However, how these abnormalties relate to pathological features of pNET is not well-known.

Methods: 47 surgically-resected pNET [tumor size of 8-85mm (Mean 27mm), G1/G2/G3=34:13:0, scirrhous hitology/medullary histology: 21:25] were studied. Non-functioning microadenoma/serotonin-producing NET/poorly differentiated NEC were excluded. Cases suspected for familial tumor were also excluded. Immunohistochemical expression of ATRX/DAXX, PIK3, pAkt, pS6, p4EBP1, and HIF-1a were evaluated comparing with background islet cells. The homogeneity of immunohistochemical expression was also evaluated. Expression of miR 21, 140, 210, and 642 was analyzed by ▵▵method of qPCR with normal pancreatic islet cells/RNU48 as control.

Results: ATRX/DAXX loss was seen for 17.0% of the cases, which related to higher ki-67 index. Homogeneous and strong pS6/p4EBP1 was seen for 46.8% of the cases and related to scirrhous histology of the tumor but not to Ki-67 index. Among pS6-positive cases, 70% were positive for pAkt. HIF-1a expression was seen only for 5% of the cases. The upregulation of miR210 and miR642 were related to higher Ki-67 index, while those of miR21/140 were not.

Conclusion: ATRX/DAXX mutation might contribute on G1 to G2 progression of pNET. Abnormalties of mTOR pathway were relatively frequent event in pNET and it might contribute to fibrotic reaction of the pNET. No evident relationship between miR642 expression and HIF-1a expression was seen.

CDKN2A Deletion Confers Resistance to MEK Inhibition in Pancreatic Cancer

A. Gaidarski,¹ J. Castellanos,² C. Roberts,¹ P. Lamichhane,³ X. Dai,¹ M. Vansaun,¹ N. Nagathihalli,⁴ N. Merchant.¹¹Department of Surgery, University of Miami, Miami, FL; ²Department of Surgery, Vanderbilt University, Nashville, TN; ³Department of Surgery, University of Miami, Miami, FL; ⁴Department of Surgery, University of Miami, Miami, FL.

Background: Identifying markers of drug resistance is paramount to the goal of personalized cancer therapy. Pancreatic cancer is especially resistant to chemotherapy and demands greater exploration into how its diverse mutations provide venues of resistance.

Methods: The majority of pancreatic ductal adenocarcinoma (PDAC) features activating mutations in KRAS and deletion of CDKN2A, a cell cycle inhibitor. We specifically targeted these aberrations by combining a MEK inhibitor, downstream of KRAS, and a CDK4/6 inhibitor to reconstitute the function of CDKN2A. We treated KRAS- and CDKN2A-mutant human PDAC cells with this therapy in vitro and assessed for changes in signal transduction, cell proliferation, invasion, and colony formation. We also assessed tumor growth in a xenograft model using the same cell lines and compared them to KRAS-mutant, CDKN2A-wildtype xenografts.

Results: MEK inhibition disrupted KRAS signal transduction in multiple cell lines in vitro, while CDK4/6 inhibition prevented destructive phosphorylation of Retinoblastoma, a key cell cycle regulator. Cell proliferation, invasion, and colony formation were moderately reduced by either monotherapy and greatly reduced by dual therapy. Both KRAS-mutant, CDKN2A-mutant xenografts grew despite MEK inhibition alone but were suppressed by dual therapy. On the contrary, growth of KRAS-mutant, CDKN2A­­-wildtype xenografts was successfully suppressed by MEK inhibition alone.

Conclusion: We demonstrated that combining MEK inhibition and CDK4/6 inhibition is effective in multiple forms of PDAC in vitro. Interestingly, PDAC with functional CDKN2A is sensitive to MEK inhibition alone, while PDAC with absent CDKN2A requires MEK and CDK4/6 inhibition, suggesting CDKN2A may be a marker of resistance in pancreatic cancer.

Pancreatitis-Induced Depletion of Syntaxin-2 Deregulates Autophagy and Enhances Basolateral Exocytosis

H.Y. Gaisano, S. Dolai. Department of Medicine, University of Toronto, Toronto, Canada.

Background & Aims: Zymogen granule (ZG) exocytosis release digestive enzymes & autophagy maintains cellular homeostasis in pancreatic acini. Acinar SNARE Syntaxin (Syn)-2 was previously purported to mediate physiologic apical exocytosis. Using human pancreas and Syn-2-KO mice we determined the role of Syn-2 in ZG exocytosis and autophagy.

Methods: Acute pancreatitis (AP) was induced on human pancreatic slices and by i.p. cerulein treatment of Syn-2-KO mice; pathological parameters of AP then assessed by in vivo and in vitro biochemical and histological markers. Pathologic exocytosis was assessed by FM1-43 exocytosis and Ca2+ imaging, and formation of exocytotic SNARE complexes. Dysregulated autophagy was assessed by biochemical and histological markers, binding, EM and trypsinogen activation assays.

Results: Pancreatitis-inducing treatments (CCK hyperstimulation; alcoholic injury) deplete Syn-2 in human and mouse pancreas. Paradoxically, Syn-2-KO acini exhibited augmented apical exocytosis in response to physiological CCK stimulation. With supraphysiological CCK stimulation known to cause pancreatitis, Syn-2-KO acini exhibited enhancement in pathologic basolateral exocytosis leading to ectopic release of proteases. Enhanced apical and basolateral exocytosis were attributed to increased fusogenic SNARE complexes driven by Syn-3 & Syn-4. Syn-2 binds Atg16L1, effectively sequestering Atg16L1 from binding clathrin. Promotion of Atg16L1-clathrin assembly by Syn-2 deletion increases pre-autophagosome growth, which results in enhanced accumulation of autolysosomes with consequent autolysosomal trypsinogen activation.

Conclusion: In the context of pancreatic acini, Syn-2 plays a negative regulatory role in physiologic and pathologic fusions events. Pancreatitis-induced Syn-2 depletion is a major contributor to acinar injury by enhancing basolateral exocytosis and dysregulated autophagy, causing increased trypsinogen activation.

Gel Forming Mucin MUC5AC Employs Multimodal Mechanism(s) to Augment Gemcitabine Resistance in Pancreatic Cancer

K. Ganguly,¹ S.R. Krishn,¹ R. Jahan,¹ C. Hayashi,¹ Y. Lu,² X. Huang,² Y. Lu,² S. Rachagani,¹ S.K. Batra,¹ S. Kaur.¹¹Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE; ²Department of Electrical and Computer Engineering, University of Nebraska, Lincoln, NE.

Background: Secretory mucin MUC5AC has emerged as a hallmark for pancreatic cancer (PC) with its de-novo expression common across all neoplastic lesions (PanIN, IPMN and MCN). With high accuracy to distinguish early versus late and primary versus metastatic PC, MUC5AC has been associated with poor prognosis of PC. However, till date, MUC5AC mediated molecular impact on PC pathogenesis remains obscure. Hypothesis: “MUC5AC imparts biological and physiological chemoresistance to PC cells by abrogating apoptosis and modulating the tumor desmoplasia”.

Methods: Spontaneous mouse model of PC in MUC5AC KO (KrasG12D; Pdx1-Cre; Muc5ac−/− (KCM−/−)) and wildtype (KCM+/+) background were generated. Pancreas sections from 10–50 week animals were observed for alterations in the extracellular matrix composition and desmoplasia using multiplex (H&E, α-SMA, trichrome stain, TPEF, SHG, and CARS) imaging. Impact of MUC5AC on gemcitabine resistance was studied via Annexin-V based flow cytometry and expression of apoptotic markers via immunoblotting and confocal microscopy using parental PC cell lines (SW1990 and Colo357) and sh-mediated and CRISPR/Cas9-mediated MUC5AC knockout (KO) cells.

Results: Significant variation in collagen composition and distribution were observed across KCM−/− and KCM+/+ mice during PC progression. RNA seq analysis from pancreatic tissues showed downregulation in genes involved in ECM organization (FN1, VTN, NID1, MMP1, MMP7 and others) in the KO animals. Further, a dose dependent, significant reduction (P < 0.001) in viability of the MUC5AC KO cells was observed upon gemcitabine treatment. Mechanistically, MUC5AC KO PC cells exhibited greater propensity for apoptosis with decreased anti-apoptotic (Bcl2/XIAP) markers and increased caspase 3 and 9 activation.

Conclusions: MUC5AC, by the virtue of its polymeric gel forming property, aggravates stromal deposition leading to physiological chemoresistance and averts apoptotic pathway to bolster biological chemoresistance during PC development.

Enhanced Recovery Program Following Pancreaticoduodenectomy

V. Ganzha, O. Simonov, B. Tsubera, S. Chaykovska, A.J. Skums, I. Galochka, O. Gulko, V. Serdyuk, A. Skums. Department of Combined Pathology and Retroperitoneal Surgery, Shalimov Institution of Surgery and Transplantology, Kiev, Ukraine.

Background: Despite the decrease in mortality after PD to 1-3%, the number of early postoperative complications remains at a high level, reaching 29.5 - 70%. There is a need in new methods of perioperative management of patients after PD to improve the immediate and long-term results. The most promising area is the multimodal program of enhanced recovery (ERAS).

Aim: To evaluate the effectiveness of ERAS program in the early postoperative period in patients after the PD.

Methods: Group I included 20 patients, perioperative management of which was carried out in accordance to the ERAS. Group II included 24 patients, the perioperative management of which was carried out according to the traditional method.

Results: Oral nutrition at 1 POD was observed in 70% patients, on the 4 POD in 10%, on the 7 POD in 5%, on 8 POD in 5%, on the 12 POD in 10% patients of the group I. Enteral nutrition was conducted in 20% patients of the group I. Parenteral nutrition was not used. The number of complications in group I was comparing to group II - 30% vs 70,8% (P < 0.05). Complications grade I-II were in 25% vs 45.8%patients in I and II group accordingly, grade IIIA in 12.5% patients of the II group, grade IIIB in 5% vs 12.5 % patients in I and II group accordingly. The incidence of pancreatic fistula was in I group 10% comparing to 25% in the II group. Biochemical leak was in 4.17% patient in the group II, fistula grade B were 5% vs. 12,5% in I and II group, grade C in 5.0% vs 8.33% patients accordingly. The frequency of gastrostasis was lower in group I - 20% patients, comparing to group II - 25% patients. Gastrostasis grade A was in 12.5% patients in group II, grade B in 15% vs 8.33% patients in I and II group accordingly, grade C in 5% and 4.17% in both groups. The frequency of wound infection was in the group I - 10% vs 33.3% patients in group II. There was no mortality in both groups of patients. Length of hospital stay significantly decreased from 22.54 ± 2.67 days in group II to 14.75 ± 0.81 days in group I, P < 0.001.

Conclusion: Preliminary results of ERAS program reduces the number of postoperative complications, length of hospital stay.

Pancreatic Acinar Cell-Derived Exosomes: Mediators of Injury?

M. Garcia-Contreras,¹ H. Cheema,² R. Dawra,¹ V. Dudeja.²¹University of Miami, Miami, FL; ²Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL.

Background: Acute Pancreatitis is an inflammatory disease of pancreas. Despite the numerous advances in this field, many aspects of the disease remain poorly understood. Autocrine and paracrine interactions occur between cells and play an important role in disease progression. Exosomes (EXOs) are small microvesicles (30–100 nm in diameter) involved in cell-to-cell communication by providing local signals (autocrine and paracrine) and distant (endocrine) signals. In the present study, we hypothesized that pancreatic acinar-derived exosomes may play a role in local injury during acute pancreatitis.

Methods: To investigate the functional role of exosomes during acute pancreatitis, pancreatic acinar cells were stimulated with maximal or supra-maximal cerulein for 3 hours. Exosomes were isolated from cell culture media by differential ultracentrifugation. The impact of exosomes, isolated from acinar cells in basal condition or when stimulated with maximal or supra-maximal cerulein, on NFκB activation in normal untreated acinar cells was evaluated by western blotting.

Results: Nanoparticle tracking analysis, western blot and flow cytometry analysis of CD63, CD9, CD81 and HSP70 exosomal markers confirmed the presence of acinar-secreted exosomes in basal condition as well as when stimulated with maximal or supra-maximal cerulein. Stimulation of normal untreated acinar cells with exosomes obtained from supra-maximal cerulein treated acini but not maximal cerulein treated acini led to NFκB activation.

Conclusion: Collectively, our results demonstrate that acinar-secreted exosomes play a role in cell-cell interaction during acute pancreatitis and may play a role in injury to surrounding acinar cells.

Stromal Fibroblasts in PDAC Promote an Immunosuppressive Microenvironment Through Elevated SDF-1/CXCL12

B. Garg,¹ B. Giri,¹ V. Sethi,¹ S. Ramakrishnan,¹ E. Gilboa,² A.K. Saluja,¹ V. Dudeja.¹¹Department of Surgery, University of Miami, Miami, FL; ²Department of Microbiology and Immunology, University of Miami, Miami, FL.

Introduction: Pancreatic cancer is believed to be an immunologically ‘cold’ tumor. Our data suggests that stroma plays an important role in creating this immune-privileged sanctuary. The chemo-repellent CXCL12/SDF-1 has been shown to play an immunosuppressive role in several cancers. In this study, we evaluated the role of SDF-1 in the stroma induced immunosuppression by pancreatic cancer.

Methods: Pancreatic cancer cells isolated from tumors forming in KPC genetically engineered mouse model were either injected alone or co-injected with pancreatic stellate cells (PSCs) extracted from WT (C57/BL6) mice to induce tumors in WT mice. SDF-1 expression was evaluated in the tumor by IHC. SDF-1 inhibitor, AMD3100 (2mg/kg) or vehicle was administered i.p. for 21 days in mice bearing tumors. At end point, tumor growth and immune infiltration was assessed by flow cytometry. In vitro, in a boyden chamber assay, the impact of antibody mediated SDF-1 neutralization on T cell migration towards cancer-PSC co-culture was evaluated.

Results: Tumors from mice where cancer cells were co-injected with PSCs had greater secretion of SDF-1 compared to tumors from mice where only cancer cells were injected. Inhibiting SDF-1 with AMD3100 led to reduced tumor growth and increased CD8+ cytotoxic T-cells infiltration in tumors compared to vehicle treated mice. In vitro, when T-cells were co-cultured with cancer cells and PSCs, SDF-1 neutralization led to increased T cell migration.

Conclusion: Our findings indicate that stroma contribute to tumor progression by keeping cytotoxic immune effectors away from the tumor via secretion of SDF-1. Targeting SDF-1 or other stroma derived immune-repellents may render the ‘cold’ pancreatic tumors responsive to immunotherapy.

Treatment With Volanesorsen (VLN) Reduced Triglycerides and Pancreatitis in Patients With Familial Chylomicronemia Syndrome (FCS) and Severe Hypertriglyceridemia (sHTG) vs Placebo: Results of the Approach and Compass Studies

A.A. Gelrud,¹ A. Digenio,² V. Alexander,³ K.R. Williams,⁴ A. Hsieh,⁵ I. Gouni-Berthold,⁶ E. Bruckert,⁷ E. Stroes,⁸ R. Geary,⁹ S. Hughes,⁹ S. Tsmikas,¹⁰ J.L. Witztum,¹¹ D. Gaudet.¹²¹Pancreas Center, University of Chicago, Pancreas Center, Chicago, IL; ²Clinical Development, Akcea Therapeutics Inc, Cambridge, MA; ³Clinical Development, Ionis Pharmaceutical, Carlsbad, CA; ⁴Medical Affairs, Akcea Therapeutics, Cambridge, MA; ⁵Medical Affairs, Akcea Therapeutics Inc, Cambridge, MA; ⁶Polyclinic for Endocrinology Diabetes and Preventative Medicine, University of Cologne, Cologne, Germany; ⁷Institut E³M et IHU Cardiométabolique (ICAN), Hôpital Pitié-Salpêtrière, Paris, France; ⁸Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands; ⁹Ionis Pharmaceuticals, Carlsbad, CA; ¹⁰Clinical Development/Cardiology, Ionis Pharmaceuticals, Carlsbad, CA and UC San Diego, La Jolla, CA; ¹¹Ionis Pharmaceuticals, Carlsbad, CA and UC San Diego, La Jolla, CA ¹²Universite de Montreal, Montreal, Canada.

Aim: To evaluate if VLN, an antisense inhibitor of apoC-III, reduced pancreatitis in patients with FCS and severe HTG (sHTG) participating in 2 Phase 3 trials.

Background: FCS is a rare genetic disease characterized by severe chylomicronemia, sHTG and consequent risk of potentially fatal recurrent and acute pancreatitis (AP). HTG-induced AP has a more severe course, leading to worse outcomes.

Methods: The APPROACH study included 66 *FCS Pts with fasting TGs ≥750 mg/dL randomized 1:1 to 52 weeks of wkly VLN (300mg) or placebo (PBO). The COMPASS study included 113 sHTG* Pts with fasting TG ≥500 mg/dL randomized 2:1 to VLN or PBO wkly for 26 wks. Endpoints included % reduction in plasma TGs at 13 wks and TX-emergent pancreatitis.

Results: results from COMPASS & APPROACH combined showed a significant reduction (P = 0.0185) in pancreatitis (1event in 1 patient in VLN group; 9 events in 6 patients in PBO group). Also, in APPROACH, pts with ≥2 episodes of pancreatitis in the 5 yrs before randomization suffered no attacks in the study TX period (P = 0.02). In APPROACH, TGs at month 3 decreased by 77% in VLN group (n = 33) and increased by 18% in PBO group (n = 33) (P < 0.0001). In COMPASS, VLN decreased TG 73% (P < 0.0001) (n = 75) after 3 months, compared with 2% decrease in PBO (n = 38). The most common AE with VLN was injection site reactions (% of injections affected: 12% FCS/24% sHTG). Declines in platelet counts led to 5 early terminations in APPROACH, 2 of which had platelets <25,000/μl; platelet counts recovered to normal after VLN stopped. There were no serious platelet events in COMPASS, but 1 potentially related SAE reported as serum sickness occurred 2 wks after the last study dose.

Conclusion: VLN treatment reduced TGs and consequent AP risk in FCS and sHTG Pts.

Relative Effects of ADAM 10&17 Inhibition in a Mouse Model of Severe Acute Pancreatitis With Acute Lung Injury

J. George, H. Cheema, V. Dudeja, R. Dawra, A.K. Saluja. Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL.

Background: Severe Acute Pancreatitis (SAP) is associated with high morbidity and mortality. There is a huge unmet need for novel disease modifying therapies for SAP. ‘A Disintegrin & Metalloproteinases’ (ADAM) are enzymes that can modulate activity of cytokines by cleavage and release of soluble ecto-domains. The aim of the current study was to evaluate the role of ADAM 10&17 in the pathogenesis of SAP.

Methods: SAP was induced by 8 hourly injections of cerulein 50ug/kg/h on two consecutive days. ADAM 10&17 together or ADAM10 alone were inhibited using specific pharmacologic inhibitors. Effect of ADAM 17 depletion in leukocytes on SAP severity was studied by using leukocyte specific ADAM17 knockout mice. Pancreatic necrosis, edema, inflammatory infiltrates were quantitated (scale of 1–4, averaged from 10 fields) using H&E stained histology sections. Pancreas and lung MPO were used as marker of pancreatic and systemic inflammation. All results are expressed below as percentage reduction in comparison to SAP alone.

Results: Combined ADAM10&17 inhibition in a therapeutic setting resulted in significantly better reduction in pancreatic necrosis (60% vs 42%) and inflammatory infiltrate (52% vs 39%) compared to ADAM 10 inhibition only. ADAM 17 deletion in leukocytes only resulted in a marginal reduction in SAP when compared to littermate controls. The reduction in pancreatic MPO (46% vs 34% vs 31%) and lung MPO (70% vs 45% vs 33%) was highest in the combined ADAM 10&17 inhibition when compared to ADAM 10 inhibition and leukocytic ADAM 17 inhibition.

Conclusion: Combined inhibition of ADAM 10&17 has better therapeutic potential in SAP compared to inhibition of ADAM 10 or 17 alone. Our data shows that broad spectrum ADAM 10 &17 inhibitors have immense therapeutic potential in reducing the severity of acute pancreatitis.

Pirfenidone Treatment Attenuates Local and Systemic Inflammation in Acute Pancreatitis and Reduces Fibrosis in Chronic Pancreatitis

J. George, H. Cheema, B. Giri, R. Dawra, A.K. Saluja, V. Dudeja. Department of Surgery and Sylvester Comprehensive Cancer Centre, University of Miami, FL.

Background: Acute pancreatitis (AP) and chronic pancreatitis (CP) represent two ends of a continuum of inflammation. Anti-inflammatory strategies can lead to development of novel therapies. Pirfenidone, an anti-inflammatory & anti-fibrotic molecule is currently approved by FDA for lung fibrosis. Goal of the current study was to study the effect of pirfenidone on severity of AP and CP.

Methods: Cerulein and L-arginine model of AP and CP were used to evaluate impact of pirfenidone. Necrosis and inflammation were quantitated (scale of 1–4) using H&E stained histology sections. Pancreas MPO and lung MPO were used as marker of pancreatic and systemic inflammation. Histology and pancreas/mouse weight ratio was used to quantitate changes in CP. Data is expressed as mean±SEM. MPO units:IU/mg protein.

Results: Pirfenidone treatment in a therapeutic setting significantly reduced pancreatic necrosis (1.1±0.1 vs 2.3±0.2) and inflammation (1.3±0.1 vs 2.5±0.2) when compared to AP alone. Similarly, pancreatic (5.8±0.5 vs 10.3±0.8) and lung MPO (5.5±0.4 vs 13.4±0.8) were significantly decreased with pirfenidone. In CP, Pirfenidone significantly improved pancreas/mouse wt. ratio in both cerulein (7.4±0.2 vs 4.5±0.2) and L-Arginine model (6.4±0.2 vs 3.1±0.2). Pirfenidone markedly decreased acinar cell loss and chronic inflammatory infiltrate (H&E) and reduced stellate cell activation (IHC for α-SMA, desmin, vimentin).

Conclusion: Our data clearly demonstrates the therapeutic potential of pirfenidone in reducing local and systemic injury in AP as well as chronic inflammation and fibrosis in CP. Our approach of therapeutic repurposing pirfenidone, a FDA approved drug, as a disease modifying agent for the treatment of pancreatitis has immense translational potential.

HSP70 in Immune-Environment Promotes Growth of Pancreatic Cancer

B. Giri, B. Garg, V. Sethi, M. Tarique, Z. Malchiodi, S. Lavania, S. Banerjee, R. Dawra, S. Ramakrishnan, V. Dudeja, A.K. Saluja. Department of Surgery, University of Miami, Miami, FL.

Introduction: While it is known that Heat shock protein 70 (HSP70) in cancer cells promotes growth of pancreatic cancer (PDAC), the impact of HSP70 in the tumor microenvironment on PDAC growth is not known. Current study evaluated the impact of HSP70 in tumor stroma and immune environment on PDAC growth.

Methods: KPC and PKT PDAC cells (Cancer cells from tumors arising in genetically engineered mouse models) were used. To simulate lack of HSP70 in stroma and/or immune cells, PDAC cells (with HSP70 intact) were co-injected with WT (stromal HSP70 intact) or HSP70−/− (stromal HSP70 lacking) pancreatic stellate cells into pancreas of WT (immune HSP70 intact) or HSP70−/− (immune HSP70 lacking) mice. To further evaluate the impact of HSP70 in immune cells on PDAC growth, the ability of WT or HSP70−/− splenocytes to inhibit growth of tumors in immunocompromised was evaluated. Ability of primed WT or HSP70−/− T cells to kill PDAC cells was evaluated in vitro.

Results: Experiments evaluating differential impact of HSP70 in immune vs stromal components demonstrated that, even when HSP70 is intact in tumors, lack of HSP70 in immune-environment but not stroma inhibits PDAC growth. Similarly, adoptive transfer of HSP70−/− immune cells led to inhibition of PDAC growth when compared to tumor bearing immunodeficient mice receiving WT splenocytes. Additionally, HSP70−/− T cells were more effective than WT T cells in killing PDAC cells in vitro.

Conclusion: HSP70 in immune cells protects PDAC from immune mediated cell death. Elucidation of the mechanism of this process will lead to identification of novel targets. Inhibition of HSP70 in immune cells, either alone or in combination with immune checkpoint blockade, could emerge as novel immune-therapeutic strategy against PDAC.

Modelling Pancreatic Cancer Resection and Recurrence in an Immuno-competent Mouse Model

B. Giri, V. Sethi, B. Garg, L. Hellmund, S. Lavania, S. Ramakrishnan, A.K. Saluja, V. Dudeja. Department of Surgery and Sylvester Comprehensive Cancer Centre, University of Miami, FL.

Introduction: Pancreatic cancer patients, even after resection of primary tumor, universally develop local and/or distant metastasis requiring additional chemotherapy. This scenario is not recapitulated in traditional animal models of pancreatic cancer. Thus, there is an urgent need of a valid model of pancreatic cancer resection to help understand the pathogenesis of recurrence and metastases and to investigate potential therapeutic strategies. In the current study, we describe development and characterization of an immunocompetent mouse model of pancreatic cancer resection that recapitulates the recurrence and metastases patterns observed in human disease.

Methods: KrasLSLG12D/+;p53R172H/+; PdxCre−/+ (KPC) Cancer cells were co-injected with stromal cells into the pancreas of immunocompetent C57B6 (WT) mice to re-capitulate the stroma rich human pancreatic cancer. Tumors were allowed to grow and at varying interval tumors were resected and mice followed for recurrence. In a separate model the effect of resection alone, adjuvant and neo-adjuvant chemotherapy on recurrence patterns was evaluated.

Results: Co-injection of cancer cells and stromal cells recapitulated the desmoplasia seen in human disease. On microscopic assessment resection margins were free of tumor. Almost all resected animals had intra-abdominal disease recurrence strongly recapitulating human disease. Adjuvant therapy and neo-adjuvant therapy (gemcitabine + Paclitaxel) was able to delay recurrence and prolong survival.

Conclusion: Our study describes a reliable immunocompetent tumor model that closely resembles human disease post resection. This model provides a valuable tool to evaluate pathogenesis of recurrence and to evaluate novel chemotherapy in the adjuvant and neo-adjuvant setting.

The Prevalence of Diabetes Mellitus is Significantly Higher for Patients Undergoing Surgery for Pancreatic Ductal Adenocarcinoma Compared to Surgery for Other Pancreatic Pathologies

R. Gopala Rao,¹ E. Costello,¹ C.M. Halloran,¹ L. Oldfield,¹ W. Greenhalf,¹ P. Ghaneh,¹ J.P. Neoptolemos,¹ T. Purewal,² A. Evans,¹ K. Mann.¹¹Department of Molecular and Clinical Cancer Medicine, The University of Liverpool, Liverpool, United Kingdom; ²Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, United Kingdom.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is frequently associated with diabetes mellitus (DM) at the time of cancer diagnosis. The prevalence of DM with other pancreatic pathologies is less well described.

Aim: To prospectively assess the preoperative glycaemic status of patients undergoing surgery for a variety of pancreatic pathologies, and compare the prevalence of DM across disease types.

Methods: Between June 2016 and May 2017, 116 patients who underwent pancreatic surgery at the Royal Liverpool University Hospital were screened preoperatively for glycated haemoglobin (HbA1c) and fasting plasma glucose levels (FPG). A pre-existing diagnosis of DM was confirmed by review of clinical records and a duration of DM of less than 3 years was considered as new-onset DM. Where HbA1c levels fell in the prediabetes range (41-48mmol/mol), FPG levels >7.0 mmol/L were taken as confirmation of DM.

Results: Patients with PDAC (n = 53), chronic pancreatitis (CP; n = 18), ampullary/peri-ampullary lesions (n = 16), intraductal papillary mucinous neoplasm (IPMN, n = 15), cholangiocarcinoma (n = 14) were included in the study. The prevalence of glycaemic dysregulation (DM and prediabetes) was significantly higher in PDAC (47%), compared to IPMN (20%; P = 0.04) and ampullary lesions (19%; P = 0.02). The prevalence of glycaemic dysregulation was 22% in CP and 14% for patients with cholangiocarcinoma. New-onset DM featured most prevalently in PDAC (43.4%), followed by CP (22%) and was less than 20% in the remaining pathologies.

Conclusion: Our findings confirm the high prevalence of glycaemic dysregulation in patients undergoing surgery for PDAC and show glycaemic dysregulation to be significantly higher in this group than in patients with IPMN or ampullary lesions. A larger study is merited.

Inhibiting Angiogenesis to Improve Anti-Stromal Therapy for Pancreatic Cancer

S. Grimaldo, M. Khatibeghdami. GI, University of Illinois, Chicago, IL.

A hallmark feature of pancreatic cancer (PC) is a dense fibrotic stroma that surrounds the tumor and sequesters blood vessel growth, resulting in poor perfusion- a prohibition to most therapies. Anti-stromal therapy via sonic hedgehog (SHH) targeting is a controversial approach to improving drug distribution for PC. While this approach has shown to be initially effective, over time stroma-depletion results in accelerating aggressive cancer. Yet, it is unknown if inhibiting angiogenesis will improve the long-term success of anti-stromal therapy. Hence, we are pursuing two therapeutic strategies that couple an anti-angiogenic component with SHH inhibition employing two novel inducible models: iKPC and iKPC-SHH mice. Preliminary survival analysis shows an overall survival of 8 months and 5 months for the iKPC and iKPC-SHH respectively. Furthermore, increased CD31 blood vessel staining is observed in iKPC-SHH mice, suggesting increased angiogenesis. Using iKPC mice to evaluate the effect on median survival, we have initiated co-treatment of gemcitabine with a SHH inhibitor, itraconazole, which was found to have the highest efficacy on vascular endothelial cells. Thus, we expect this molecule to target both the SHH pathway and blood vessels. The second approach we are pursuing is to determine if the anti-angiogenic drug, sunitinib, improves median survival in the iKPC-SHH. The iKPC-SHH serves as a surrogate of anti-stromal therapy and allows for a focused investigation with anti-angiogenic compounds. Sunitinib was chosen for its direct efficacy on primary pancreatic tumor cells, thereby it is expected to target blood vessels and PC cells in vivo. While both treatments are on-going, current data show that itraconazole co-treatments are living over 7.5 months in the KPC model. Previous reports with a SHH inhibitor in the KPC model showed a survival at approximately 3–4 months. Thereby our initial data shows promise that inhibiting angiogenesis can improve the long-term efficacy of anti-stromal therapy in PC.

Utilizing Proteomic Analysis to Identify Biomarkers in Ethanol Induced Acute Pancreatitis

A. Gulla,^1,2 R.T. Waldron,³ A. Lugea,³ S.J. Pandol.³¹Department of Surgery, Georgetown University Hospital, Washington, DC; ²Department of Surgery, Vilnius University, Vilnius University Hospital, Santaros Clinics, Vilnius, Lithuania; ³Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA and University of California, Los Angeles, CA.

Introduction: Acute pancreatitis (AP) is a painful and potentially life-threatening disorder with no effective therapeutic remedies. The severity of the disease varies widely and only limited biomarkers and severity scores are available to assess its severity. Therefore, an urgent need is to develop additional biomarkers that can improve clinical course and minimize mortality in AP.

Methods: Patient serum was obtained from 12 male AP patients of alcohol related etiology (median age of 40) within 24 h of presentation, and 12 controls. Severity in AP patients was as a correlate of tissue damage was estimated by blood lactate dehydrogenase, with an average value of 1127 mg/dl. Median APACHEII score was 5.5, and IMRIE score was 3.5, indicating moderate to severe AP (please see the accompanying table for details). For proteomic analysis, less abundant proteins in plasma samples were enriched using Top 12 abundant protein depletion columns. Further processing was performed by a modified filter-associated sample preparation combined with tandem mass tag labeling for quantitation. Samples were analyzed by Orbitrap Elite instrument for state-of-the-art high resolution liquid chromatography-tandem mass spectrometry.

Results: Our analysis revealed that 44 proteins exhibited 1.5-fold or higher increase in the AP compared to control patients. Gene ontology analysis indicated a strong correlation with exosomal origin in the elevated proteins, with 35/44 (80%) associated with this extracellularly-secreted compartment. Elevated proteins included established and proposed biomarkers of AP including C-reactive protein, LPS-binding protein, intercellular adhesion molecule-1, and von Willebrand factor, as well as several novel potential biomarkers.

Conclusion: These results suggest that we are discovering novel biomarkers which can be used for measuring the severity of pancreatitis at any point in time during the course of disease.

Lipid Raft Integrity is Required for Functional Properties of CD133+ Tumor Initiating Cells in Pancreatic Cancer

V.K. Gupta,¹ N.S. Sharma,¹ K.K. Kesh,¹ P. Dauer,² A. Nomura,¹ B. Giri,¹ V. Dudeja,¹ A.K. Saluja,¹ S. Banerjee.¹¹Department of Surgery, University of Miami, Miami, FL; ²Department of Pharmacology, University of Minnesota, Minneapolis, MN.

Introduction: Pancreatic cancer remains a significant health burden associated with limited patient survival and poses a major therapeutic challenge. Among cancer cells, tumor initiating cells (TICs) are instrumental in inducing chemoresistance and metastasis in pancreatic cancer. CD133 has been identified as a CSC surface marker in several malignancies including pancreatic cancer. However, the functional role of CD133 in CSCs still not clear.

Aim: The present study investigates the role of caveolar lipid raft integrity in functional properties of CD133+ TICs.

Methods: Detergent-free purification of Caveolin-rich membrane fractions was done by sucrose density gradient ultracentrifugation. Caveolar lipid rafts were disrupted by Cav-1 silencing and lovastatin treatment. For invivo studies, Mice with tumors were treated with lovastatin (2 mg/kg daily), or paclitaxel (10mg/kg weekly) and both. After 4 weeks treatment, animals were sacrificed and tumor tissues were collected and measured.

Results: Current study showed first time that CD133 localizes to caveolar lipid rafts in pancreatic cancer cells, and associates with Caveolin1 (Cav-1) and cholesterol to form an integral signaling complex which drives the downstream processes of chemoresistance and metastasis. Further analysis showed that the integrity of the lipid-raft is crucial for maintenance of the functional properties of pancreatic TICs, and its disruption leads to increased chemo-sensitivity to chemotherapeutic compound paclitaxel both in vitro as well as in vivo. Additionally, disruption of lipid raft results in decreased invasiveness and metastatic ability of the cells by deregulation of FAK signaling. The study also reveals that pancreatic cancer cells that lack the TIC population marker, CD133, did not respond to lipid raft disruption.

Conclusion: Our results indicated that targeting the lipid-raft integrity in pancreatic cancer can specifically eradicate the CD133+ TICs in pancreatic tumors, leading to a better prognosis for the disease.

Thrombocytosis Following Pancreatectomy With Islet Autotransplantation in Children: Cincinnati Children’s Hospital Experience

J.P. Gurria,¹ P. Badia,² L. Hornung,³ M. Abu- El-Haija,⁴ D.A. Elder,³ T.K. Lin,³ L. Luchtman-Jones,⁵ J.S. Palumbo,⁶ J.D. Nathan.⁷¹General and Thoracic Surgery, Pancreas Care Center, ²Cancer and Blood Diseases Institute, ³Pancreas Care Center, ⁴Division of Pediatric Gastroenterology, Hepatology and Nutrition, ⁵Cancer and Blood Diseases Institute, Hemangioma and Vascular Malformation Program, ⁶Pancreas Care Center, Comprehensive Thrombophilia Center, ⁷Pancreas Care Center, Liver, Kidney and Intestinal Transplant Programs, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.

Background: Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical option for patients with debilitating chronic pancreatitis. Pancreatic islets are isolated and autotransplanted into the liver via the portal vein. A significant and sustained postoperative thrombocytosis is common, but poorly understood. The degree and duration of thrombocytosis are not typical of a reactive postsplenectomy process. Given that hepatocytes represent a major source of thrombopoietin (TPO), we hypothesized that increased TPO production drives post-TPIAT thrombocytosis.

Methods: We performed a retrospective chart review of 13 patients (4/2015-12/2016) who underwent TPIAT (with splenectomy) with focus on platelet counts, thrombopoietin (TPO) levels, and hydroxyurea treatment.

Results: There were 12 total and 1 subtotal pancreatectomies, median age 12.6 years, BMI 20.9 kg/m2, length of stay 26 days. All patients were discharged on basal and bolus insulin. TPO levels were normal preoperatively (mean 45 pg/mL, normal 7–99 pg/ml), then increased significantly reaching a mean of 219 pg/mL 4 days postoperatively (P < 0.0001). Preoperative platelet counts were normal, and increased dramatically reaching a median of 835 K/μl by postoperative day 3 (P < 0.0001). Hydroxyurea, started on average 7.8 days postoperatively, significantly decreased the platelet count (P < 0.0001). TPO levels remained elevated 20 days post-hydroxyurea (mean 82 pg/mL). There were no major surgical or thrombotic complications.

Conclusion: All patients developed sustained and prolonged thrombocytosis after TPIAT. The significant rise in TPO postoperatively suggests an association between thrombocytosis and increased TPO production. Further studies are needed to explore the mechanism of thrombocytosis post-TPIAT.

Differential Secretion of CA 19-9 or sTRA Into the Circulation Potentially is a Consequence of Distinct Subtypes of Pancreatic Cancer: Molecular and Morphological Evidence

B.B. Haab,¹ Y. Liu,¹ D. Barnett,¹ B. Staal,¹ K. Partyka,¹ H. Tang,¹ G. Hostetter,¹ A.D. Singhi,² R.E. Brand,² R.R. Drake.³¹Center for Cancer and Cell Biology, Van Andel Research Institute, Grand Rapids, MI; ²Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA; ³Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC.

Serum CA 19-9 is a useful serological biomarker for pancreatic cancer, but it is not elevated in about 25% of patients. The tumors with low serum values of CA 19-9 potentially are a distinct subtype. Here we tested for molecular and morphological differences between tumors with low and high serum-CA 19-9. In a cohort of 52 patients with matched serum and tumor specimens, the serum and tissue measurements of CA 19-9 significantly correlated across patients, but a subset had tumor expression in the absence serum elevation. This subset had significantly lower tumor co-expression of a glycan called sTRA than in tumors with elevated serum-CA 19-9. The tumors expressing both sTRA and CA 19-9 tended to be conventional PDAC with well-to-moderate differentiation and heavy marker staining in the lumens, but the tumors expressing exclusively CA 19-9 had CA 19-9 staining in glands with compact nuclei and flat epithelia without CA 19-9 secretion into the lumens. Eight of the 16 patients with low serum-CA 19-9 showed serum elevation of sTRA. Such tumors showed sTRA staining in glands with extremely large and unpolarized nuclei and foamy cytoplasm, especially if no co-staining of CA 19-9 was present. In the tumors expressing neither marker, we did not observe any marker staining or glandular lesions. These findings suggest that co-expression of CA 19-9 and sTRA is necessary for secretion of CA 19-9 into the circulation; that tumors expressing exclusively CA 19-9 or sTRA are distinct subtypes; and that the sTRA biomarker is a valuable complement to CA 19-9 in both serum and tissue.

Stroma-Derived, Extracellular Vesicles Deliver Tumor-Suppressive miRNAs to Pancreatic Cancer

S. Han,¹ M. Feely,¹ D.H. Gonzalo,¹ M.H. Gerber,¹ B.B. Divita,¹ C.E. Forsmark,² S.J. Hughes.¹¹Department of Surgery and ²Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL.

Objective: Our group previously demonstrated that interactions between pancreatic adenocarcinoma (PDAC) and tumor-associated stroma (TAS) cells impact the respective expression of miRNAs within each cell type, and hinted that an exchange of miRNAs between these distinct cell types was occurring within the tumor microenvironment. We aimed to determine if extracellular vesicles (EVs) deliver miRNA signals from TAS cells to PDAC cells and to assess the biological impact of such a potential exchange.

Methods: A non-human miRNA (cel-miR-39) was employed to explore cell-cell communication in an in vitro model of the human PDAC tumor microenvironment (TME). Expression of cell-type-specific miRNAs was investigated in both microvesicles (MVs) and exosomes (EXOs). The effects of TAS-EVs (exosomes derived from human TAS cells) on primary cultures of PDAC cells were assessed.

Results: We identified two-way, cell-cell contact independent miRNA exchange between PDAC and TAS cells via EVs. Selective packaging of miRNAs into EVs led to enrichment of epithelial specific miR-205 and stromal specific miR-145 in EVs secreted by PDAC and TAS cells, respectively. Treatment of PDAC cells with TAS-derived exosomes, but not microvesicles, resulted in reduced PDAC cell viability. This effect was mitigated by anti-miR-145 sequences.

Conclusion: Our data suggest that TAS-derived miRNAs are delivered to adjacent PDAC cells via EXOs and suppress tumor cell growth. This finding provides a mechanism for previously observed protective role of stroma in PDAC and has therapeutic implications for both novel and ongoing strategies that target PDAC-associated stroma.

A Phase 1/2 Trial to Evaluate the Pharmacokinetics, Safety, and Efficacy of NI-03 in Patients With Chronic Pancreatitis

P.A. Hart,¹ J. Nuttall.²¹Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; ²KC Specialty Therapeutics LLC, Kansas City, KS.

Background: Currently, there are no approved agents for the treatment of pain associated with chronic pancreatitis (CP). NI-03 (camostat mesilate) is a serine protease inhibitor approved at 200 mg 3 times daily (TID) in Japan for treatment of this indication. Therefore, a phase 1/2 study (NCT02693093) was designed to assess the pharmacokinetics, safety, and efficacy of NI-03 in CP in the United States.

Methods: The phase 1, single-dose study to determine the pharmacokinetics and safety of NI-03 at 100, 200, or 300 mg was completed in subjects with CP. Subsequently, a phase 2, double-blind, randomized, parallel-group, dose-ranging study has begun to assess safety and efficacy of NI-03 versus placebo in CP. At least 128 patients from multiple centers will be randomized to receive placebo or NI-03 at 100, 200, or 300 mg TID for 28 days. Eligible adults must be receiving ≤40 mg morphine equivalents per day and have a baseline average daily worst pain score ≥4. The primary endpoint of the phase 2 study is the change from baseline to week 4 in average daily worst pain score using a numeric rating scale. Secondary endpoints include the change from baseline to week 4 in patient-reported outcomes using the Brief Pain Inventory, assessment of quality of life using the Pancreatitis Quality of Life Instrument, pharmacokinetics, and safety. Estimated study completion date is February 2018.

Results: The single-dose phase 1 study was completed in 18 patients with CP, with no serious treatment-related adverse events. The phase 2 study recently started and has enrolled 7 patients as of June 23, 2017.

Discussion: Assessment of the safety and efficacy of NI-03 for the treatment of pain related to CP is currently underway.

Sexually Dichotomous Cellular Signaling in Human Pancreatic Acinar Cells

B. Hasdemir,¹ G. Szot,² A. Bhargava.³¹Osher Center, UCSF, San Francisco, CA; ²Transplant Surgery, UCSF, San Francisco, CA; ³OB/GYN and Osher Center, UCSF, San Francisco, CA.

Background: Although Acute pancreatitis (AP) appears to be equally prevalent in both sexes chronic pancreatitis (CP) is more common in men. In men, gallstones are a major contributing factor; in women, it’s chronic cholecystitis and biliary colic. Since the initiating insults are different between the sexes, we hypothesized that the signaling pathways and cellular mechanisms that lead to pancreatitis can be distinct as well as common between the sexes.

Aim: We ascertained whether human acinar cells exposed to supraphysiological concentrations of cerulein that mimic AP in rodent acinar cells result in sex-specific alterations in gene expression and signaling pathways.

Methods: Acini were obtained from healthy organ donors. Acini were treated with 10nM cerulein or 100nM Ucn1 as an ex-vivo model of AP. Untreated acini served as controls. Changes in expression of pancreas-specific genes were determined using nanostring methodology.

Results: The heatmap for gene expression from acinar cells treated with either cerulein or Ucn1 confirmed clustering by sex. Treatment with Ucn1 resulted in opposite effects on expression of genes involved in metabolism and fibrosis between the sexes. For genes involved in fibrosis, most genes (7/8) were common between our ex-vivo human acinar model of AP and gene expression data obtained from CP tissue. Subsets of genes involved in fibrosis were also identified as differentially expressed in the pancreatic tissue from the mouse model of cerulein-induced AP.

Conclusion: 1) Cellular signaling and pathways show sex-specific differences in gene expression. 2) Pancreatitis-causing agents result in altered gene expression that is shared between rodent and human acinar cells, thus validating rodent models of pancreatitis.

Assessment of UICC 8th TNM Classification for Pancreatic Ductal Adenocarcinoma, Focusing on Tumor Size and Tumor Invasion of Portal Vein Assessed by Dynamic CT

A. Hayasaki, M. Kishiwada, T. Ito, T. Takeuchi, T. Fujii, Y. Iizawa, H. Kato, A. Tanemura, Y. Murata, N. Kuriyama, Y. Azumi, S. Mizuno, M. Usui, H. Sakurai, S. Isaji. Hepatobiliary Pancreatic And Transplantation Surgery, Mie University, Mie, Japan.

Objectives: T factor for pancreatic cancer in UICC 8th TNM classification was defined based on tumor size and tumor invasion to major artery, regardless of tumor invasion to extrapancreatic lesion in UICC 7th. But it remains controversial which of tumor size or tumor invasion to extrapancreatic lesion is the adequate factor for T factor. The aim of the current study is to assess which of tumor size or tumor invasion to extrapancreatic lesion is stronger prognostic factor for pancreatic cancer patients, focusing on tumor size and tumor invasion to portal vein (PV).

Methods: The subjects were 308 patients with cytologically/histologically proven pancreatic ductal adenocarcinoma who had no distant metastatses at the time of diagnosis and underwent chemoradiotherapy (CRT) from February 2005 to December 2016 (CRT regimen: gemcitabine-based in 128 and S-1+gemcitabine-based in 180). At the time before CRT, tumor size and degree of tumor invasion to PV (no invasion, <180, and >=180) were measured by thin slice dynamic CT scan. Clinical T factor was classified based on both of UICC 7th and UICC 8th. Disease specific survival (DSS) was compared according to T factors and PV factors.

Results: Among 308 patients, CRT was completed in 298 (96.8%), curative-intent resection and R0 resection after CRT were performed in 183 (59.4%) and in 145 (47.1%), respectively. The 308 patients were classified into T1/T2/T3/T4: 1/none/115/192 based on the UICC 7th, and 21/66/13/207 based on the UICC 8th. In UICC 8th, T3 patients had the best prognosis comparing with T1, T2 and T4 patients (5-year DSS rate of T1/T2/T3/T4: 47.5/27.2/61.4/12.2%, P = 0.008), although T1 had the best prognosis in UICC 7th. As for PV factors, the degree of PV invasion was significantly correlated with the prognosis of each groups (5-year DSS rate of no invasion/<180/>=180): 32.5/24.8/13.7%, P = 0.042).

Conclusion: The PV factor is a stronger prognostic factor than the T factors except for T4 based on UICC 8th. Therefore, the PV factor is essential for T factor of TNM classification in the next edition.

Naturally Purified Islets in Total Pancreatectomy and Islet Autotransplant (TPIAT) for Chronic Pancreatitis (CP): A Model to Evaluate Impact of Exocrine Co-transplant on Graft Function

D.T. Heller,^1,2 M.D. Bellin,^1,3 K.L. Berry,² G.J. Beilman,² T. Dunn,² T. Pruett,² S. Chinnikotla,^2,3 B. Hering,^1,2 J. Wilhelm.¹¹Schulze Diabetes Institute, Departments of ¹Surgery, and ³Pediatrics, University of Minnesota, Minneapolis, MN.

Background: After pancreas digestion for TP IAT, we occasionally observe highly enriched, “naturally purified” (NP) islets, which appear similar to COBE purified (CP) islets, where exocrine tissue has been eliminated by CP. We sought to understand what allows intact endocrine tissue to survive, whether these islets are fully functional, and the impact of transplanted exocrine tissue on graft function.

Methods: Patients, age ≥20 years, who received IAT products with ≥50% observed purity were grouped as NP or CP, and adjusted so mean islet dose transplanted (IEQ/kg body weight) was equivalent. Two cohorts with <50% purity were designed as unpurified, impure controls for both NP and CP groups (NC and CC, respectively), and matched to fibrosis and mean islet dose.

Results: All raw (basal & max-stim C-pep, insulin dependence) and composite (SUITO, Beta Score) metabolic outcomes were insignificant between pure cohorts and respective impure controls. Fibrosis severity, digest pellet (DP), pellet/pancreas ratio, and viability by oxygen consumption rate (OCR) varied significantly between pure cohorts (P < 0.001, 0.001, 0.001, & 0.05). Digest pellet, pellet/pancreas ratio, and IEQ/cc tissue transplanted (purity) was significantly different between each pure cohort and matched control (NP vs NC: P < 0.01, 0.05, & 0.05; CP vs CC: P < 0.001, 0.001, & 0.05).

Conclusion: NP islets result from severe, prolonged fibrosis (or rarely, lipomatosis). Purity and tissue volume between pure (NP or CP) and unpurified groups varied significantly, suggesting there is no clinical detriment from acinar cotransplant in TPIAT. Although literature suggests density-gradient purification negatively affects islet function, our comparison has not exposed any gross differences in post-transplant graft function.

Quantitative Analysis of Microbial Contamination in Islet Isolation for Total Pancreatectomy and Islet Auto Transplantation (TPAIT): Development of Bioburden Reduction Strategies

D.T. Heller,^1,2 M.D. Bellin,^1,3 K.L. Berry,² M. Cook,² G.J. Beilman,² T. Dunn,² T. Pruett,² S. Chinnikotla,^2,3 V. Kirchner,² B. Hering,^1,2 J. Wilhelm.^1,21Schulze Diabetes Institute, Departments of ¹Surgery, and ³Pediatrics, University of Minnesota, Minneapolis, MN.

Background: In TPAIT, current final islet product (IP) sterility testing identifies microbial contamination for rapid antibiotic prophylaxis. We sought to (1) quantify “bioburden” (BB) during manufacturing, (2) understand which processes may reduce BB, and (3) develop patient-specific strategies to lessen BB in IP.

Methods: Pancreas preservation solution (PS) and IP were analyzed using the BACTEC system, and growth reported qualitatively (Y/N). Quantitative data were collected by a Plate Count Method (PCM): PS and IP (n = 84), and post-digestion Recombination Solution (RS) and pre-product/COBE (PC) supernatants (n = 46) were incubated on TSA plates for 7 days. BB was defined as total CFU from PCM. Donor pancreas fibrosis was stratified as mild/moderate (MF; 1–8 out of 10) or severe (SF; 9–10).

Results: BACTEC and PCM concordance was observed for PS and IP (P < 0.01). In cases with detectible BB (n = 14), none required COBE purification, and mean BB was higher in SF group at all sample time points [PS: 178,318 ± 236,269 vs 8017 ± 12,543; RS: 118,459 ± 134,443 vs 3683 ± 6380; PC: 29,113 ± 38,978 vs 1250 ± 2165; and IP: 11,727 ± 14712 vs 467 ± 808, (P < 0.05)]. In SF group, mean BB was reduced from PS to PC (P < 0.05) and IP (P < 0.01).

Conclusion: Although BB varies remarkably between patients, we characterized a subset with the highest IP BB (fibrosis ≥9, unpurified) where BB reduction may be inadequate. Current dilution during washing steps is ~1x106-fold from PS to IP; further dilution offers potential to reduce BB in high risk patients. A proposed novel method to reduce BB involves additional washes to dilute IP an added 1x104 and requires <20 minutes of processing. Further study is needed to identify high risk subsets and evaluate BB reduction strategies.

Acute Pancreatitis (AP) is the Initial Pancreatic Event in Half of the Patients With Chronic Pancreatitis (CP): Large Single Center Study of 499 Consecutive Patients of CP in the Recent 3 Years

Y. Hori,¹ M. Topazian,¹ S.T. Chari,¹ F. Gleeson,¹ M.J. Levy,¹ R.K. Pearson,¹ B.T. Petersen,¹ M.B. Farnell,² M.L. Kendrick,² L. Pisney,¹ N. Takahashi,³ M. Truty,² R. Smoot,² S.S. Vege.¹¹Division of Gastroenterology and Hepatology, Departments of ²Surgery and ³Radiology, Mayo Clinic, Rochester, MN.

Background: Relationship between acute pancreatitis (AP) and chronic pancreatitis (CP) is complex. AP, especially if recurrent, can lead to CP. It is controversial, however, if in these cases AP leads to CP by sentinel acute pancreatitis event (SAPE) hypothesis or if CP is the underlying disease that presents first to the clinician as AP. Our aim was to evaluate the relationship between AP, recurrent AP (RAP) and CP in recent large CP cohort.

Methods: From January 2013 to December 2015, we retrospectively reviewed consecutive 758 patients who were diagnosed as CP in Mayo Clinic. We excluded 83 cases of autoimmune pancreatitis, 176 cases of obstructive pancreatitis and categorized the remaining 499 cases as “usual CP”.

Results: Etiology of usual CP was alcohol in 43.9% (219/499) of patients, hereditary in 5.8% (29/499) and idiopathic in 50.3% (251/499), respectively. Two hundred fifty patients (50.1%) had a prior episode of AP before CP was diagnosed; while 18 patients had AP after the diagnosis of CP, and 231 (46.3%) had no AP diagnosis at any time. Among those in whom AP proceeded CP, 53.2% (133/250) presented as RAP due to alcohol (17.3%), hereditary causes (15.0%), iatrogenic (0.8%), idiopathic (40.6%), and mixed (26.3%). Among CP patients presenting with AP, 74.8% (187/250) were diagnosed as CP over 12 months from the first episode of AP.

Conclusion: The most recent and largest consecutive cohort of 499 patients with usual CP from a single center revealed: (a) Half of the patients first presented as AP; (b) Half had RAP; (c) It appears that in nearly 40% of cases of usual CP, SAPE hypothesis might be the underlying mechanism for CP as the diagnosis of CP was made > 12 months after the diagnosis of AP; (d) This information might be useful for future epidemiologic studies of CP.

Clinical Profiles and Outcomes of Obstructive Chronic Pancreatitis: A Large Recent Series of 176 Patients With This Uncommon Entity

Y. Hori,¹ M. Topazian,¹ S.T. Chari,¹ F. Gleeson,¹ M.J. Levy,¹ R.K. Pearson,¹ B.T. Petersen,¹ M.B. Farnell,² M.L. Kendrick,² L. Pisney,¹ N. Takahashi,³ M. Truty,² R. Smoot,² S.S. Vege.¹¹Division of Gastroenterology and Hepatology, Departments of ²Surgery and ³Radiology, Mayo Clinic, Rochester, MN.

Background: Definition of obstructive chronic pancreatitis (OCP) lack unity and the etiologies still remain unknown. The aim of this study is to clarify the definition from morphological features, organize etiology of OCP, and compare clinical features and outcomes based on the etiology.

Methods: We retrospectively reviewed consecutive 758 patients who were diagnosed as chronic pancreatitis (CP) in Mayo Clinic, from January 2013 to December 2015. OCP was defined as: (i) stricture of the main pancreatic duct, (ii) relatively normal proximal pancreas and (iii) distal pancreas atrophy with dilated pancreatic duct.

Results: One hundred seventy-six (23.2%) of 758 CP patients were identified as OCP. While tumors (n = 100) were the most common cause for OCP, acute pancreatitis (AP) was the second (n = 59). All cases of OCP caused by AP is related to necrotizing pancreatitis (OCP due to NP; NPOCP). Compared with other OCP group (n = 117), NPOCP was significantly associated with younger age (P < 0.001), male (P = 0.02), and smoker (P = 0.01). Furthermore, characterized by higher percentage of new onset diabetes and required for endoscopic intervention, and lower surgical intervention (P < 0.001).

Conclusion: OCP is an independent group among CP both morphologically and etiologically. In this large series of OCP, nearly two thirds of OCP were due to tumor and one third due to NP. To prevent OCP, new research is crucial to prevent necrosis in AP and to identify the pathogenic events leading to fibrosis in order to arrest after the development of necrosis.

Stabilized Incidence of Pediatric Acute Pancreatitis

L. Hornung,¹ H.J. Kalkwarf,³ F.K. Szabo,² M. Abu-El-Haija.³¹Division of Biostatistics and EpidemiologyCincinnati, Children's Hospital Medical Center, Cincinnati, OH; ²Division of Pediatric Gastroenterology, and Nutrition, Children’s Hospital of Richmond, Virginia Commonwealth University, Richmond, VA; ³Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.

Objective: The annual incidence of acute pancreatitis (AP) in children increased from 2/100,000 in 1993 to 13/100,000 in 2004. Reports on AP incidence from the last decade are lacking. The aim of this study was to estimate the incidence of pediatric AP from 2010 to 2014.

Methods: Admission data of patients at Cincinnati Children’s Hospital Medical Center (CCHMC) with the diagnosis of AP using the International Classification of Diseases, Ninth Revision, code 577.0 was extracted from electronic health records from 2010–2014. Population data were obtained from the 2010 U.S. census in order to estimate incidence.

Results: Between 2010–2014 there were 583 admissions to CCHMC with a diagnosis of AP for children <20 years; 388 were new AP cases. For the primary CCHMC catchment area (8 counties), there were 332 AP admissions of which 229 (69%) were new AP cases. Median length of stay was 4.0 (25th, 75th percentile: 2.0, 14.0) days and median admission age was 13.8 (9.1, 16.2) years for new AP cases in the primary catchment area. The number of new cases per year ranged from 36 to 53. The annual incidence of new AP cases per 100,000 was 7.9, 9.6, 8.4, 9.1 and 6.6 in years 2010–2014, respectively, and did not significantly change over the 5 years (P = 0.47). The estimated annual incidence of all AP cases ranged from 10.1-14.6/100,000 and also did not significantly change during this time (P = 0.84).

Conclusion: The incidence of pediatric AP seemed to stabilize between 2010 and 2014, and was not different from reported incidence in 2004 from previous studies. Further studies on national estimates for pediatric AP incidence should be done in the future.

PYK2 as a Novel Therapeutic Target for Pancreatic Cancer

J. Hu. University of Pittsburgh, Pittsburgh, PA.

Since nearly 100% of pancreatic ductal adenocarcinoma (PDAC) carried mutational activation of KRAS, KRAS and its effectors are theoretically ideal candidates for PDAC therapeutic intervention. Unfortunately, attempts to directly inhibit oncogenic KRAS or known RAS effector pathways have been either unsuccessful or proven ineffective. As a result, there is significant interest in identifying novel downstream effectors of oncogenic KRAS signaling that could be amenable to pharmacologic intervention. Our results suggest that PYK2 (proline-rich tyrosine kinase 2, a non-receptor cytoplasmic tyrosine kinase) is a novel downstream mediator of mutant KRAS signaling and a new actionable therapeutic target for PDAC. Specifically, our studies revealed: (1) mutant KRAS activated PYK2 gene transcription in a YAP1 (Yes-associated protein 1)-dependent manner. Hippo pathway effector YAP1 is a transcription cofactor and a powerful downstream effector of mutant KRAS in PDAC. (2) PYK2 levels were drastically elevated in mouse PanINs (pancreatic intraepithelial neoplasia) and human PDAC tissues. (3) Functionally, Whole-body deletion of PYK2, even heterozygous deletion, remarkably suppressed PanIN formation and progression to PDAC in the Pdx1-Cre KRASG12D mice model. Further, knockdown of PYK2 abrogated tumor growth in a PDAC cell line xenograft model, indicating that PYK2 is required for PDAC maintenance. (4) Mechanistically, PYK2 directly phosphorylated β-catenin at tyrosine (Y) 654 to promote the Wnt/β-catenin pathway and increased RelA/p65 phosphorylation at serine (S) 536 to promote the NF-κB pathway in PDAC cells. Because both pathways are essential for PDAC development in mice, we propose that PYK2 contributes to PDAC through upregulating Wnt/β-catenin and NF-κB pathways. Overall, our study has revealed that PYK2 is a new actionable target for treating PDAC.

Ethanol and Smoking Promote Inflammation and Cell Death in Pancreas of Humanized PRSS1-R122H Transgenic Mice

C. Hu,^1,2 H.Y. Su,¹ R.T. Waldron,¹ A. Lugea,¹ Q. Xia,² B. Ji,³ S.J. Pandol.¹¹Cedars-Sinai Medical Center, Los Angeles, CA; ²Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre, West China Hospital, Sichuan University, Sichuan, China; ³Department of Cancer Biology, Mayo Clinic, Rochester, MN.

Background: The R122H mutant cationic trypsin (PRSS1) gene increases acute and recurrent pancreatitis (AP and RP) risk in humans. Pancreatitis is also influenced by environmental factors such as heavy drinking and smoking.

Methods: We studied the severity of cerulein pancreatitis +/− alcohol and smoking compounds in mice expressing human PRSS1-R122H (R122H) and wild-type (WT) mice. Cerulein pancreatitis was induced in two-month-old mice in one (AP) or two episodes, one day apart (RP), and mice sacrificed at different times. Separately, WT and R122H mice fed ethanol diets were treated with cerulein or smoking compounds, and pancreatitis responses were evaluated by analysis of pancreata and pancreatic acini.

Results: Young R122H mice exhibited PRSS1-R122H protein expression in pancreas, but not spontaneous pancreatitis. Naive WT and R122H acini expressed similar levels of mouse trypsinogen, amylase and endoplasmic reticulum (ER) marker proteins. Yet, AP was more severe in R122H mice, with extensive inflammatory cell infiltration and acinar cell death further exacerbated by a second episode. A 3-fold increase in pancreatic trypsin activity, dysregulated ER stress signaling, and elevated pancreatic inflammatory cytokines accompanied these effects. SPINK3 protein increased during AP in WT, but not in R122H mice. After RP, pancreas recovered more promptly in WT than in R122H mice. All pancreatitis scores were down at 48 h after RP in WT, but remained high in R122H mice, which also had severe acinar cell loss/acinar-ductal metaplasia. Compared to WT, ethanol-fed R122H mice had higher local cytokine levels in AP, and combined ethanol+smoking induced acinar cell death.

Conclusion: Our data suggest that a combination of alcohol abuse, smoking and trypsinogen mutations promote pancreatitis.

Establishment of the Pancreatic Cancer Treatment Predicted for the Types of Recurrence

J. Itakura, M. Watanabe, N. Hosomura, H. Amemiya, H. Kawaida, H. Okamoto, H. Kouno, D. Ichikawa. Department of Surgery, University of Yamanashi, Yamanashi, Japan.

Background: The adaptation of the preoperative treatment for the pancreatic cancer has not been established yet. But prospective studies are currently pushing forward and the result will be expected. We examined a treatment strategy predicted for the types of recurrence from the resected cases of our institute.

Methods: Hundred forty pancreatic ductal adeno-carcinoma (PDAC) patients that enforced R0-1 resection from 2000 to 2016 were enrolled in this study. The recurrence cases of these were analyzed for the period from surgery, the site of the recurrence and the highest preoperative CA 19-9 value (CA 19-9).

Results: Seventy-five of these cases (53.6%), 41 male and 34 female, showed recurrence. They consist of 3 stage IA cases, 32 stage IIA cases, 32 stage IIB cases, and 8 stage III cases. As for the surgery, 42 PD, 25 DP, and 3 TP were performed. Mean survival time was 21.3 months, and the one-year, three-year and five year survival rate were 77.3%, 21.0% and 8.6%, respectively. In regard to the first recurrence form, 24 cases had local recurrence, 28 cases had liver metastasis, 10 cases had pulmonary metastasis, 11 cases had peritoneum dissemination, and 2 cases showed ignorance. The average period of liver metastasis was 8.4 months, peritoneum dissemination was 10.4 months, local recurrence was 12.7 months, and pulmonary metastasis was 13.4 months. The CA 19-9 was 596ng/dl in the recurrence cases and 327ng/dl in the non-recurrence cases. According to the recurrence form, CA 19-9 was 140ng/dl in the pulmonary metastasis, 410ng/dl in local recurrence, 688ng/dl in peritoneum dissemination, and 923ng/dl in liver metastasis. To distinguish the early recurrence case and the delayed recurrence case we developed ROC curve, and based on this analysis 520ng/dl was suggested for the best cut-off value.

Conclusion: Even if in the macroscopically resectable cases, the high value of preoperative CA 19-9 may indicate potential distant metastasis, and neo-adjuvant treatment should be in consideration for these cases.

The Late Benign Biliary Complication After Pancreatoduodenectomy

T. Ito, T. Sugiura, Y. Okamura, Y. Yamamoto, R. Ashida, K. Uesaka. Division of Hepatobiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan.

Background: Pancreatoduodenectomy (PD) sometimes causes late benign biliary complications such as anastomotic stenosis and/or hepaticolithiasis which need intervention. The risk factors and the timing of late biliary complication remain unclear.

Methods: A total of 732 patients who underwent PD between 2002 and 2016 were included in this retrospective study. Postoperative late biliary complication was defined as symptomatic benign biliary stricture and hepaticolithiasis which required radiologic or endoscopic intervention. Perioperative variables were collected to analyze the risk factor of late biliary complication. Treatment of late biliary complication was evaluated.

Results: Twenty-eight patients (3.8 %) developed late biliary complications with median interval of 23.4 (0.7-98.9) months. Late biliary complications consisted of hepaticolithiasis (n = 11) and stricture (n = 25) (including overlap). The 5-year cumulative late biliary complication rate was 7.3%. Multivariate analysis showed the CHD <4 mm was an independent risk factor for late biliary complication. The 5-year late biliary complication rates in patients with CHD <4 mm and *>*4 mm were 27.6% and 1.3%, respectively (P < 0.001). For initial treatment, endoscopic intervention (balloon dilation and/or lithotomy) were successfully performed in 21 patients (75.0%), and percutaneous transhepatic intervention in 7 (25.0%). No patient underwent surgery.

Conclusion: Occurrence of late biliary complication was associated with hepatic duct diameter <4 mm. Endoscopic or radiologic intervention is appropriate procedure for late biliary complication.

BM-Derived Cells Are Involved in the Tumor Microenvironment and Promote Invasion of Pancreatic Cancer

C. Iwamoto,¹ K. Ohuchida,² T. Okumura,² K. Koikawa,² S. Takesue,² H. Nakayama,² S. Endo,² S. Kibe,² Y. Ando,² T. Abe,² K. Miyawaki,³ M. Murata,⁴ K. Akashi,³ M. Nakamura,² M. Hashizume. ¹ Departments of ¹Advanced Medical Initiatives, ²Surgery and Oncology, and ³Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; ⁴Center for Advanced Medical Innovation, Kyushu University, Fukuoka, Japan.

Introduction: Tumor-stroma interactions affect cancer phenotype. Cytokines secreted by tumor cells differentiate activated macrophages into tumor-associated macrophages (TMAs), which produce several factors to form tumor microenvironment. In breast cancer, a subset of stromal cells was descended from bone marrow (BM)-derived cells. While BM-derived cells seem to be involved in remodeling of microenvironment and tumor progression in pancreatic cancer, this mechanism remains unknown. We aimed to investigate an association between pancreatic cancer progression and BM-derived cells.

Methods: BM-derived GFP+ cells were intravenously transplanted into KPC mice after sublethal irradiation. The phenotypic characterization of engrafted GFP+ cells was analyzed by flow cytometry. Derivation of stromal cells and distribution of TAMs were examined using immunohistochemical staining. To evaluate invasive capacity of cancer cells co-cultured with BM-derived cells, we performed cell invasion assay.

Results: The engraftment of BM-derived GFP+ cells was detected in recipients’ peripheral blood, BM, pancreas, liver, and ascites. The engrafted GFP+ cells expressed CD45 consisting of CD4+/CD8+ T cells, NK cells, or macrophages. In recipients’ pancreas, GFP+ cells, F4/80+ macrophages, and CD163+ TAMs were accumulated around ADM/PanIN and at invasive front. Invasive capacity of cancer cells co-cultured with BM-derived macrophages significantly increased compared to the control. BM-derived GFP+ cells showed a distribution similar to aSMA+ cells, and a few GFP+aSMA+ cells were detected.

Conclusion: BM-derived macrophages and TAMs were found in recipients’ pancreas, and their distribution was biased. The present data also suggest that BM-derived cells is involved in infiltration of cancer cells.

Derivation and Validation of a Prediction Model for the Early Diagnosis of Acute Pancreatitis in the Emergency Department

D.X. Jin,¹ R. Lacson,² L.R. Cochon,² E.C. Alper,² J. McNabb-Baltar,¹ P.A. Banks,¹ R. Khorasani.²¹Center for Pancreatic Disease, Division of Gastroenterology, Hepatology, and Endoscopy and ²Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA.

Background: Early computed tomography (CT) imaging is common in acute pancreatitis (AP) despite guidelines recommending against routine usage.

Aim: To derive and validate a clinical prediction model that identifies AP risk prior to emergency department (ED) imaging.

Methods: ED patients presenting 9/1/2013-8/31/2015 with serum lipase ≥3x upper limit of normal (ULN) were identified retrospectively. Those with intra-abdominal metastatic disease, trauma, or altered mentation were excluded. An AP diagnosis was established by expert review of hospitalization and post-discharge courses in the electronic health record. Inter-rater agreement was measured by Cohen’s kappa (ĸ). Candidate predictors were demographics, comorbidities, lifestyle factors, symptoms, and laboratory studies at presentation. Using a derivation set, multivariable logistic regression modeled covariates on the occurrence of AP. Discrimination accuracy was measured in an independent validation set using area under the receiver operator characteristic curve (AUC). Calibration was assessed with the Hosmer-Lemeshow test (HL).

Results: In 319 patients with lipase ≥3x ULN at presentation, 182 (57%) had AP (inter-rater ĸ = 0.90; 95% CI, 0.76–1.00). The most common non-AP diagnosis was enteritis/colitis (26%). The final model (AUC, 0.91; HL P = 1.0) included number of prior AP episodes (OR, 3.2; 95% CI, 1.7-7.5); history of gallstones (6.8, 1.3-45.3); abdominal surgery in the prior 2 months (0.16, 0.03-0.87); time from onset to presentation (0.89, 0.78-0.97); pain localized to the epigastrium (13.9, 4.9-46.1), of progressively worsening severity (4.7, 1.3-19.2), and rated as moderate (10.1, 1.8-68.9) or severe (36.1, 9.2-197.0); and lipase ≥20x ULN (6.2, 1.6-28.3). At a predictive threshold of 99%, the model had a specificity and PPV of 100%, while capturing 40% of patients with AP.

Conclusion: In ED patients with serum lipase ≥3x ULN, this novel prediction model helps identify AP risk prior to CT. Prospective studies should confirm diagnostic accuracy and assess impact on unnecessary imaging.

Systemic Inflammatory Response Syndrome at Presentation is Associated With Severe Acute Pancreatitis

D.X. Jin,¹ V.K. Singh,² S.L. Suleiman,¹ P.A. Banks,¹ J. McNabb-Baltar.¹¹Center for Pancreatic Disease, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, MA; ²Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD.

Background: Systemic inflammatory response syndrome (SIRS) during the initial 24 hours of hospitalization is associated with severe acute pancreatitis (SAP). However, the prognostic value of SIRS at presentation is unknown.

Aim: To assess the role of SIRS at time of emergency department (ED) presentation for distinguishing SAP from mild and moderately-severe acute pancreatitis (MAP/MSAP).

Methods: All ED patients presenting from 2005–2007 and 2014–2015 with AP were identified retrospectively. Transferred patients were excluded. AP was diagnosed and severity stratified according to the Revised Atlanta Classification 2012. Clinical and laboratory parameters (age >60 years, male sex, BMI ≥30 kg/m2, Hct ≥44%, BUN >20 mg/dl, presence of SIRS) at time of ED triage were examined for association with severity. Multivariate logistic regression identified predictors of SAP.

Results: The final cohort was 440 patients; 290 (66%) with MAP, 120 (27%) with MSAP, and 30 (7%) with SAP. At presentation, SIRS was present in 150 patients (34%). A greater proportion of patients who developed SAP compared to MAP/MSAP had SIRS at presentation (63% vs. 32%; P = 0.001), Hct≥44% (30% vs. 15%; P = 0.04), and BUN >20 mg/dl (60% vs. 19%; P < 0.001). There were no significant differences in age >60 years (P = 0.28), sex (P = 0.19), or BMI ≥30 kg/m² (P = 1.0). Multivariate logistic regression revealed SIRS at presentation (OR, 2.9; 95% CI, 1.2-7.1; P = 0.02) and BUN >20 mg/dl (6.4, 2.5-16.5; P < 0.001) to be independently associated with SAP. The combination of SIRS and BUN >20 mg/dl at presentation had a sensitivity 40%, specificity 92%, positive predictive value 27%, and negative predictive value of 95%.

Conclusion: At presentation, SIRS and BUN >20 mg/dl are independently associated with SAP. The absence of either is predictive of non-severe AP.

Establishment of Novel Gemcitabine-Resistant Mouse Pancreatic Cancer Cell Line

Y. Kadoi,¹ K. Shimizu,¹ A. Nishimura,¹ Y. Takegaki,¹ M. Miyoshi,¹ T. Akagi,² K. Sasai,² Y. Hori.¹¹Department of Pathobiology, Kobe University Graduate School of Health Sciences, Kobe, Japan; ²Kan Research Institute, Kobe, Japan.

Background and Aim: Gemcitabine (GEM) is used as adjuvant chemotherapy for pancreatic ductal adenocarcinoma (PDAC). However, GEM-resistance is critical issue. To understand GEM-resistance might provide the second line treatment. We have already established mouse PDAC (mPDAC) cells derived from oncogene transduced stem/progenitor cells. In this study, we made GEM-resistant tumor and established GEM-resistant mPDAC cells.

Methods: We previously isolated CD133+ stem/progenitor cells from mouse pancreas, then, transferred GFP, CDK4 and a dominant negative p53, activated Kras and established mPDAC cells (parental mPDAC). We transplanted these cells subcutaneously to formed tumor, then administered 100 mg/kg GEM. Once we detected regrowth of tumor, cells were isolated and designated as GEM-resistant mPDAC cells. These cells were characterized by real-time PCR, half maximal inhibitory concentration (IC50) for GEM and tumorigenesis.

Result: We detected regrowth of tumor from parental cells and could establish GEM-resistant mPDAC cells. GEM-resistant mPDAC cells expressed Pdx1 and CD133, suggesting both are originated from stem/progenitor cells. Parental mPDAC cells had IC50 value of 0.08 μM, while GEM-resistant mPDAC cells had that of 30.0 μM. In vivo, tumor from GEM-resistant mPDAC cells showed no response to GEM treatment. Moreover, matrix metalloproteinase −10 (MMP-10), expression in GEM-resistant mPDAC cells had 3.7 times higher than parental ones.

Conclusions: We successfully established GEM-resistant mPDAC cell from mouse model similar to human clinical setting. Kras-MMP-10 signaling pathway in GEM-resistant mPDAC cell were enhanced as well as human GEM-resistant PDAC cells. It might help to understand the mechanism underlying GEM-resistance.

Evaluation of the Fukuoka Guidelines for the Management of BD-IPMN: Single-Center Experience With 543 Patients Selected for Resection or Observation

J. Kaiser, O. Strobel, J. Lebert, W. Niesen, T. Hank, M. Heckler, C.W. Michalski, M.W. Büchler, T. Hackert. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Background: Despite their malignant potential branch duct intraductal papillary mucinous neoplasms (BD-IPMN) of the pancreas are often kept under surveillance. The International Consensus Guidelines (ICG) of Fukuoka have been widely accepted for the management of BD-IPMN. The present study compared the histological outcome of resected BD-IPMN with the indications for resection according to the current ICG of Fukuoka.

Methods: Patients were divided into three groups based on treatment type: initial resection, delayed resection and observation. All resected BD-IPMN were classified as bearing "high risk stigmata", "worrisome features" or without suspicious features.

Results: 1057 IPMN patients were treated between 2004 and 2015. BD-IPMN were identified in 543/1057 patients (51%). 169/543 BD-IPMN patients (31%) underwent surgery <3 months of diagnosis and 369/543 patients (68%) were initially observed. 136/369 patients (37%) ultimately underwent resection after a follow-up period of >3 months and 233/543 patients (63%) were not operated. Using the ICG of Fukuoka, "high risk stigmata" had a sensitivity/specifity in initially and delayed resected patients of 72%/86% and 58%/89%, respectively. In contrast, "worrisome features" had a low specifity and positive predictive as well as a high negative predictive value in initially and delayed operated patients (23%, 7%, 90% and 19%, 10%, 95%, respectively).

Conclusion: The management strategy advocated by the ICG of Fukuoka to classify BD-IPMN lesions shows a high accuracy with regard to "high risk stigmata", but – in contrast – "worrisome features" offer little help in clinical decision making. Differentiation between malignant and benign lesions cannot be done sufficiently by "worrisome features" and there is still a high rate of malignancy found in asymptomatic BD-IPMN patients with only "worrisome features".

A Randomized Trial of Rectal Indomethacin and Papillary Spray of Epinephrine Versus Rectal Indomethacin Alone for the Prevention of Post-ERCP Pancreatitis in High Risk Patients

A. Kamal,¹ V. Akshintala,¹ R. Talukdar,² M.K. Goenka,³ R. Kochhar,⁴ S. Lakhtakia,² M.K. Ramchandani,² S. Sinha,⁴ R. Goud,² V.K. Rai, Vijay K,³ B.J. Elmunzer,⁵ M. Khashab,¹ A. Kalloo,¹ N. Reddy,² V.K. Singh.¹¹Divisionf of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD; ²Asian Institute of Gastroenterology, Hyderabad, India; ³Apollo Gleneagles Hospital, Kolkata, India; ⁴Postgraduate Institute of Medical Education and Research, Chandigarh, India; ⁵Medical University of South Carolina, Charleston, SC.

Background: Rectal indomethacin and topical spray of epinephrine have separately shown efficacy for the prevention of post-ERCP pancreatitis (PEP) in randomized controlled trials. We hypothesized that the combination of topical spray of epinephrine and indomethacin may further reduce PEP over indomethacin alone.

Methods: We conducted a comparative effectiveness, multicenter, double-blind, randomized trial of rectal indomethacin alone versus a combination of topical spray of epinephrine and rectal indomethacin for the prevention of PEP in high risk patients. Patients with suspected sphincter of Oddi dysfunction (SOD) type 3 and those who received a pancreatic stent were excluded. The primary outcome was the incidence of PEP and the secondary outcome was the severity of PEP, both defined by the consensus criteria. A total of 948 patients (474 in each group) would provide a power of 80% at a 2-sided significance level of 5% to detect a 50% difference in the rates of PEP, assuming PEP rates of 10% and 5%, respectively, for rectal indomethacin and the combination. A two-tailed Fisher’s exact test was used to analyze the difference in the proportion of patients with PEP in the indomethacin alone versus the combination group.

Results: A total 959 of patients (mean age 52.33±14.96 years; 551 (57.4%) females) were randomized for this trial. The baseline demographic and clinical characteristics were similar between the two groups. Females <50 years of age (25.4%) and difficult cannulation (84.9%) were the most common patient and procedural risk factors, respectively. The incidence of PEP was 6.4% in the indomethacin alone group (n = 482) compared to 6.7% in the combination group (n = 477) (P = 0.87). Severe PEP was found in 5 (12%) versus 7 (16%) of patients in the indomethacin alone and combination groups, respectively (P = 0.88). The overall mortality was 0.6% which was unrelated to the primary outcome.

Conclusion: The combination of topical spray of epinephrine and rectal indomethacin does not reduce the incidence of PEP compared to rectal indomethacin alone in high risk patients.

Bone Health Assessment in Patients With Chronic Pancreatitis

A. Kanakis, K. Vipperla, G. Papachristou, R.E. Brand, A. Slivka, D.C. Whitcomb, D. Yadav. University of Pittsburgh Medical Center, Pittsburgh, PA.

Objectives: CP patients are at high risk of major osteoporotic fractures (MOF). We evaluated bone health using the Fracture Risk Assessment (FRAX®) score (standardized 12-item screen), prevalence of MOF, performance of bone mineral density testing (DEXA scan) and prevalence of osteoporosis or osteopenia in a well-defined CP cohort.

Methods: Medical records of CP patients age ≥40 years prospectively enrolled in the NAPS2 studies from UPMC from 2000–2014 were retrospectively reviewed to gather relevant data.

Results: 239 patients (mean 56±11 yrs, 54% men, 84% white, 55% current smokers, median follow-up 5.9 [IQR, 6.5] yrs) were evaluated. About 54% had alcohol etiology, 33% were diabetic, 34% had exocrine insufficiency, and 46% used pancreatic enzyme replacement therapy (PERT). While 10-yr FRAX® score probability of MOF >20% was 5%, and of hip fracture (HF) >3% was 19% (P > 0.05 vs. US population), the observed prevalence of MOF at last follow-up was much greater (8% in those aged 45–65; 13% in those >65 yrs, P < 0.01 vs. US population). Patients with nonalcoholic etiology had higher FRAX® probabilities of MOF (P < 0.05) and HF (P < 0.01). There was no relationship between vitamin D levels, exocrine or endocrine insufficiency, or PERT and prevalence of MOF or HF. DEXA was performed in only 49 (20.5%): more often in females, presence of secondary cause of osteoporosis, and longer follow-up (all P < 0.05), and these patients had higher prevalence of MOF (P < 0.05). Among patients who had DEXA scan, 25% had osteopenia and 48% had osteoporosis (P < 0.01 vs. US population).

Conclusions: Assessment and management of bone health should be incorporated into routine clinical care of CP patients. Future studies should evaluate mechanisms that affect bone health in CP patients.

PD2 Functions as the Master Regulator of Stem Cell Network Genes in Pancreatic Cancer

S. Karmakar,¹ S. Barkeer,¹ D. Ghersi,² M.W. Naseer,¹ M. Ponnusamy,¹ S.K. Batra.¹¹Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE; ²School of Interdisciplinary Informatics, College of Information Science and Technology, University of Nebraska-Omaha, Omaha, NE.

Background: Cancer stem cells (CSCs) mediate drug resistance and metastasis of solid cancers including pancreatic cancer (PC), mandating the elucidation of their mechanisms of maintenance. PD2 (Pancreatic Differentiation2), human homolog of RNA Polymerase II-Associated Factor 1 (hPaf1), is a novel pancreatic CSC marker, that mediates their drug resistance and enhances metastatic potential of PC. PD2 also maintains the self-renewal of mouse embryonic stem cells and ovarian CSCs via its interaction with OCT3/4. Hypothesis: We hypothesize that “PD2 works as the master-regulator for maintaining pancreatic CSCs”.

Methods: PD2 was silenced in CSCs isolated from PC cells SW1990 and Capan1, followed by RNA-Seq and PCR array analyses. Further, interaction of PD2 with Phf5a, a known regulator of pluripotency, was evaluated using co-immunoprecipitation. Moreover, CRISPR/Cas9-based conditional PD2 knockout mouse model was developed.

Results: CSCs from SW1990 and Capan1 demonstrated higher expression of PD2 along with CSC and self-renewal markers and its knockdown caused a significant decrease in CSC and self-renewal markers. Tumor burden was decreased on orthotopic implantation of PD2-silenced CSCs compared to control CSCs in nude mice. Finally, PD2 knockdown showed significant down regulation of tumorigenic and stemness maintenance genes by RNA-Seq and PCR array analyses. Reciprocal co-immunoprecipitation revealed that PD2 interacted with Phf5a in CSCs, suggesting PD2 to be a major regulator of pancreatic CSC maintenance. In addition, CRISPR/Cas9-based knockout of PD2 led to abrogation of exocrine pancreas development with peri-ductal sclerosis and inflammation.

Conclusion: Altogether, PD2 functions as the master-regulator for CSC-maintenance via controlling CSC-network genes in PC.

Morphological and Immunohistochemical Comparison of Intrapancreatic Nerves Between Chronic Pancreatitis and Type 1 Autoimmune Pancreatitis

K. Kato,¹ T. Ikeura,¹ K. Uchida,¹ H. Yamada,² K. Okazaki.¹¹The Third Department of Internal Medicine, and ²Department of Anatomy and Cell Science, Kansai Medical University, Kansai, Japan.

Objectives: The abdominal pain associated with chronic pancreatitis (CP) may be related to the increased number and size of intrapancreatic nerves. On the other hand, patients with type 1 autoimmune pancreatitis (AIP) rarely suffer from the pain syndrome, and there are no previous studies concerning the histopathological findings of intrapancreatic nerves in patients with type 1 AIP. The current study is aimed at investigating the differences in the histopathological and immunohistochemical findings of intrapancreatic nerves in patients with CP and type 1 AIP.

Methods: Neuroanatomical differences between CP and type 1 AIP were assessed by immunostaining with a pan-neuronal marker, protein gene product 9.5 (PGP9.5). The number (neural density) and area (neural hypertrophy) of PGP9.5-immunopositive nerves were quantitatively analyzed. Furthermore, the expression of nerve growth factor (NGF), and a high affinity receptor for NGF, tyrosine kinase receptor A (TrkA), was assessed by immunohistochemistry. Inflammatory score (IFS) was calculated based on the degree of pancreatic inflammation by staining with hematoxylin and eosin.

Results: The mean number of PGP-positive intrapancreatic nerves (neural density) in the severe CP group (0.169 ± 0.045/mm2) was significantly greater than that in the type 1 AIP groups (0.071 ± 0.017/mm2). In addition, the proportion of PGP9.5-immunopositive nerve bundles (neural hypertrophy) in the severe CP group (0.468% ± 0.119%) was significantly higher than that in the type 1 AIP groups (0.062% ± 0.019%). NGF immunoreactivity in type1 AIP was stronger than CP despite fewer neural density and hypertrophy. On the other hand, TrkA immunoreactivity in type 1 AIP was poorer than in CP.

Conclusion: Although CP and type 1 AIP are both characterized by the presence of sustained pancreatic inflammation, they are different in terms of the density and hypertrophy of intrapancreatic nerve fibers. It is possible that this may be related to the difference in the activity of the NGF/TrkA-pathway between the two types of pancreatitis.

Targeting Cancer Stem Cells: A Major Improvement for Therapeutic Efficacy in Lethal Pancreatic Cancer

G. Kaushik, P. Seshacharyulu, S. Rachagani, I. Lakshmanan, R.K. Nimmakayala, M. Ponnusamy, S.K. Batra. Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE.

Background: Cancer stem cells (CSCs) are the principle contributors for aggressive, drug-resistant, metastatic and highly lethal pancreatic cancer (PC). Current therapies for PC fail to target CSCs and hence a dismal prognosis of patients is observed. The EGFR family of proteins is essential for CSCs self-maintenance, and its inhibition has been shown to decrease CSCs. Our previous study demonstrated that EGFR inhibition reduces tumor burden in PC. Afatinib is an FDA approved pan-EGFR inhibitor, which has promising effects on CD133+ CSCs. Hypothesis: Based on these studies, we hypothesized that afatinib targets CSCs and in combination with gemcitabine can serve as an effective therapy for metastatic PC.

Methods: PC cell lines (SW1990 and T3M4) and CSCs isolated and treated with afatinib, gemcitabine alone and in combination to test the functional and biochemical effects of the therapy. These studies were carried on forward in, mouse 3D organoids derived from Kras; PdxCre and Kras; p53; PdxCre autochthonous mouse models. Studies were validated in vivo using an orthotopic nude mouse and human patient-derived tumor organoids.

Results: Our in vitro and in vivo findings showed that afatinib treatment decreased CSC markers and functional properties of CSCs in PC cells. Our results were corroborated by 3D-organoid studies which showed inhibition of progression and an over 50% reduction in organoid size upon the combination therapy. Our in vivo experiments in orthotopically implanted nude mouse showed significantly reduced metastatic incidence and reduced tumor burden upon treatment with Afatinib in combination with gemcitabine.

Conclusion: Altogether, afatinib targets CSCs by downregulating CSC markers and vital transcription factors and with gemcitabine can provide an effective therapy for aggressive metastatic PC by targeting CSCs for eradication of tumor burden and prevention of relapse.

IL 6 Driven Metabolic Reprogramming Induces Stemness in Pancreatic Cancer

K.K. Kesh,¹ V.K. Gupta,¹ P. Dauer,² N.S. Sharma,¹ P. Gnamlin,¹ A.K. Saluja,¹ S. Banerjee.¹¹Division of Surgical Oncology, University of Miami, Miami, FL; ²Department of Phamacology, University of Minnesota, Minneapolis, MN.

Introduction: Pancreatic Ductal Adenocarcinoma (PDAC) is one of the most devastating human malignancies with poor survival rate owing to chemoresistance and relapse. Small population of cancer stem cells (CSCs) or Tumor Initiating Cells (TIC) are considered major players driving these traits. Recent literature has demonstrated the importance of microenvironment “niche” in enrichment of these TIC populations. The desmoplastic stroma in pancreatic cancer comprising of stromal cells and immune cells are instrumental in pathogenesis and progression of PDAC. Among many cytokines, IL-6 a pro-inflammatory cytokine plays a major role in it. In this study, we show that stromal cell secreted IL6 altered metabolic reprogramming in PDAC cells leading to increased cancer stemness.

Method: PDAC cells cultured with pancreatic stellate cells (PSC) condition media or recombinant IL6 and stem ness marker expression were investigated. Cytometry Bead Array (CBA) were used for cytokine profiling.

Results: Mia-PaCa-2 cells (having no endogenous CD133+ cells) when cultured with PSC condition media exhibited an enrichment of CD133+ population. An analysis of the conditioned media using CBA reveled that PSC condition media is enriched with cytokine IL-6 and TNF-α. Treatment of Mia-PaCa-2 cells with recombinant IL-6 increased expression of self-renewal genes SOX2, OCT4 and Nanog-1. In addition, TIC marker CD133 and invasion marker gene MMP7 expression also increased upon IL6 induction. Moreover, IL6 treatment increased glucose uptake in Mia-PaCa-2 and inhibition of glucose uptake by a small molecule inhibitor STF31 (inhibitor of GLUT1-4), alter stemness gene expression.

Conclusion: Our study shows that stromal IL6 altered metabolic reprogramming in cancer cells that leds to increased cancer stemness and invasion.

PA2G4 and PCDH10 Gene Mutations Differentiate Benign and Malignant IPMN

A. Khalid,¹ K. McGrath,² G. Papachristou,¹ K. Fasanella,² T. Hoteck,² J. Chennat,² H.J. Zeh,² A. Slivka,² A.D. Singhi,² M. Lyons,² J. Hirmas,³ C. Drescher,³ W. Laframboise.²¹VA Pittsburgh Health Care and University of Pittsburgh, Pittsburgh, PA; ²University of Pittsburgh, Pittsburgh, PA; ³GenomeNext, Columbus, OH.

Aim: To dentify genetic alterations associated with development of malignancy in IPMN.

Methods: Patients with pancreatic cysts >2cm were enrolled from 2012–2014. EUS aspirates were placed in reagent and stored at −80°F. Patients were followed till 2016 to maximize lesions with pathological confirmation. Cyst fluid DNA from benign (LGD & IGD) and malignant (HGD & IPMC) IPMN underwent whole exome sequencing. One to 10 ng DNA were used to create libraries (Accel-NGS 2S Hyb DNA Library Kit Swift, Ann Arbor, MI), undergo exome hybridization (V6 probeset, SureSelect XT Capture, Agilent, Santa Clara, CA) and sequencing on a NextSeq 500 (2x76 PEx150 cycles; Illumina, San Diego, CA) to ~100x target depth. FASTQ files were aligned using BWA and variants called using GATK for non-synonymous, coding mutations. Variants were ranked by gene for mutations exclusive to 1 tumor classification only (GenomeNext, Columbus,OH). All discriminating variants were confirmed in the raw BAM files.

Results: 96 patients were enrolled; 11/12 histologically confirmed IPMN had sufficient DNA for analysis. 4 malignant and 7 benign IPMN were compared for mutations across the whole exome. Mutations in 5 genes had absolute discrimination (PA2G4, OR56A4, OR7E31P only in malignant IPMN, P = 0.003; PLA2G15, PCDH10 only in benign IPMN, P = 0.003). Mutations in 16 genes associated with IPMN or pancreatic cancer (KRAS, GNAS, TP53, PTEN, CDKN2A, SMAD4, MLL, TGFBR2, EPC1, SF3B1, ATM, ZIM2, MAP2K4, NALCN, SLC16A4 and MAGEA6) were seen in both malignant and benign IPMN (P = ns).

Conclusion: This study identifies new gene mutations associated with different grades of IPMN. Damaging PA2G4 mutations may affect an RNA-binding protein that interacts with the cytoplasmic domain of the ErbB3 receptor and has been implicated in growth regulation and differentiation of human cancer cells. PCDH10 is a protocadherin that plays a role in inhibiting cancer cell motility and cell migration. Further studies investigating these new gene mutations are warranted.

Bone Health Parameters Among Chronic Pancreatitis Patients Who Are at High-Risk or Have Exocrine Pancreatic Insufficiency (EPI)

N. Khandelwal,¹ B. Johns,¹ N. Gupta,² J. Vora,¹ J. Castelli-Haley.¹¹HEOR, AbbVie, Mettawa, IL; ²Health Policy, American Dental Association Health Policy Institute, Chicago, IL.

Introduction: Chronic Pancreatitis (CP) is the persistent inflammation of pancreas that may lead to ‘Exocrine Pancreatic Insufficiency’ (EPI), a condition characterized by deficiency in pancreatic enzymes, leading to malnutrition. Due to vitamin deficiencies, patients with CP and who have EPI may have a higher risk for developing bone-related conditions. Objective: Examine bone health measures in CP patients who may have EPI.

Methods: This is a retrospective study using MarketScan® claims data. Cases were identified as patients *>18 years and who had >1 claims for ICD-diagnosis of CP from Jan 2010-Dec 2015. Patients continuously eligible in one year pre and post-index date (date of first ICD claim for CP) were included. Bone health measures such as osteoporosis, fracture, and Vitamin D deficiency were examined in one year follow-up period for (i) patients in the CP group (ii) EPI, defined as those who filled >*2 prescriptions for Pancreatic Enzyme Replacement Therapy; (iii) high EPI-risk and (iv) low EPI-risk patients. Individual and composite bone health measures were compared across all patient groups using chi-square statistic.

Results: 74,335 CP patients were analyzed in the study. Subjects who had EPI or who were grouped as high-risk reported higher events of fracture, osteoporosis, and Vitamin D deficiency compared to low-risk patients. High-EPI risk patients had significantly higher number of fractures and osteoporosis events compared to low-risk patients, P < 0.05. Moreover, the composite bone health measure was also found to be significantly higher for EPI and high-risk patients than low-risk patients, P < 0.05.

Conclusion: Chronic pancreatitis patients who have EPI or who are at high-risk for developing EPI are associated with higher bone health-related issues.

Hypothermic Interference With Bile Acid (BA) Micellar Breakdown (MBD) Reduces Systemic Bile Acid Toxicity

B. Khatua, C. De Oliveira, B. El-Kurdi, K. Patel, V. Singh. Department of Medicine, Mayo Clinic, Scottsdale, AZ.

Background: BAs exist in a micellar form in bile. Persistent biliary obstruction in pancreatic cancer, biliary AP may cause inexplicable progressive clinical decline and worse outcomes during surgery or chemotherapy. We aimed understanding MBD and targeting it using hypothermia.

Methods: Micellar breakdown of BA was studied using isothermal titration calorimetry (ITC). BA enriched in bile and human pancreatic necrosis collections were used. Hypothermia’s effect on BA toxicity was studied in acinar cells, and after infusing 5% of the trihydroxy BA sodium taurocholate (STC) into the rat pancreatic duct (biliary AP).

Results: Trihydroxy BAs were the most abundant class in bile. MBD of STC was endothermic (heat rate -349nJ/mM/s at 37C) till the critical micellar concentration (CMC; 5mM) was reached, after which heat rate rapidly decreased. Cooling, temperature dependently reduced heat rate of MBD. This was −42 nJ/mM/s at 25C, when no change was detectable corresponding to CMC. MBD of the dihydroxy BA (TCDC) was reduced by 60%, and of TLCS (monohydroxy BA) by only 12% at 25C. While LDH leakage by sub-micellar STC (4mM) was reduced by 60%; cell injury and Cai induced by supramicellar (10mM) STC was unaffected by cooling. Pancreatic cooling to 25C; achieved 1 hour after AP induction did not affect STC induced pancreatic necrosis, but reduced systemic injury evidenced by reduced cardiac injury, shock, Lung MPO increase, Serum IL-6, TNF-a, serum dsDNA, histone complexed DNA fragments, and improved survival at 6 hours (100% vs. 35%, P < 0.01). Cooling reduced Sr. BA from 1.5±0.2mM to 0.2±0.1mM (P = 0.001).

Conclusion: Micellar breakdown of BA is endothermic and temperature dependent. Cooling reduces micellar breakdown of BAs present in bile, preventing their systemic entry and associated injury. Thus local hypothermia can be used to prevent BA toxicity.

Therapy With Agent 767 After Established Severe Acute Pancreatitis (SAP) Reduces Severity and Improves Survival

B. Khatua, V. Singh. Department of Medicine, Mayo Clinic, Scottsdale, AZ.

Background: Visceral fat lipolysis by pancreatic lipases worsens AP outcomes. While the FDA approved lipase inhibitor orlistat improves SAP; it needs repeated high dosing (50mg/kg BID x 2 days) and administration within 2 hours of AP induction. We generated agent 767- and compared it to orlistat for potency, stability and therapeutic efficacy as a single dose during SAP.

Methods: Agent 767 or orlistat (stock in 0.3% ethanolic PBS) were incubated with recombinant human lipases (hPTL, hPLRP2, hCEL) colipase, and glyceryl trilinoleate (GTL; 1mM) and IC50 for FFA generation was measured. In vitro efficacy in reducing GTL induced injury was studied. In vivo efficacy of agents (20mg/kg x1 IP) administered 7 hours into SAP (cerulein 50mcg/kg/hr, n = 7-8/group), when serum lipase was > 5 fold normal were compared. End points were renal failure (Sr. BUN), Sr. Ca, shock (pulse distention; PD), SIRS [WBC<4000/mm3 and hypothermia], unbound fatty acids (UFAs) and survival.

Results: Agent 767 was 7-100x more potent than orlistat against lipases (IC50 from 10-500nM vs. 5-10mM) and more stable overnight (60x). In vitro 10mM of agent 767 effectively reduced GTL induced LDH leakage from 40±5.1.5% to 1.9±2.9%, P < 0.001 vs. 11.6±5.9% by 10mM orlistat. In vivo all untreated mice developed renal failure (BUN 85±18mg/dl), hypocalcemia (Sr. Ca 4.9±0.2mg/dl), shock and 100% mortality. 767 was more efficacious than orlistat in normalizing BUN (peak 18.5±0.9 vs. orlistat 50±4.4mg/dl; P < 0.05), Sr. Ca (8.8±1.0 mg/dl vs. 4.2±0.3 mg/dl, P < 0.05), UFAs (2.4±0.4 mM vs. 5.4±0.9 mM), preventing shock (PD: 290±20 μm vs. 171±21 μm, P < 0.05), leucopenia (in 0/8 mice vs. 4/7mice, P < 0.03), hypothermia (94.1±0.8 vs. 86±0.9°F, P < 0.01) and improving 5 day survival (8/8 vs. 2/7, P < 0.01).

Conclusions: Agent 767 is more potent, stable and efficacious than orlistat in treating SAP. Agent 767 is a candidate drug to advance into clinical trials of AP.

Nanoceria Reduces Oxidative Stress, Inflammation and Display Anti-Fibrotic Properties in Animal Models of Chronic Pancreatitis

A. Khurana,¹ M.A. Saifi,¹ C. Godugu.²¹Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India; ²Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India.

Aim: To assess the pharmacological potential of nanoceria in L-Arginine and cerulein induced chronic pancreatitis.

Background: Nanoceria has emerged as an excellent antioxidant and anti-inflammatory agent. Pancreatitis is an exocrine disorder of the pancreas and comprises of acute and chronic subtypes with varying degree of inflammatory insult. Currently, there are no clinically approved medications to resolve the inflammation and fibrosis linked with chronic pancreatitis.

Methods: Nanoceria was characterized by DLS, FT-IR, SEM and pXRD. Nanoceria was administered at two dose levels (0.2 and 2.0 mg/Kg). The levels of serum amylase, lipase and hydroxyproline were estimated. The proinflammatory cytokines and nuclear p65-NF-κB levels were estimated by ELISA. Masson trichrome and PSR staining were performed. Expression of vimentin, α-SMA and fibronectin were assessed immunohistochemically.

Results: Interestingly, in case of cerulein CP we observed significant improvement in serum amylase and lipase levels with P < 0.05 and P < 0.001 respectively, after treatment with nanoceria. The levels of hydroxyproline were impressively reduced in nanoceria treated rats (P < 0.001) as well as mice (P < 0.05) indicating the translation of effects in different models of pancreatic fibrosis. In both the models nanoceria could significantly attenuate the levels of oxidative stress markers (MDA, GSH, NO) and inflammatory cytokines (IL-1β, IL-6, TNF-α). The TGF-β1 levels were significantly reduced in both the models. The PSR staining exhibited ameliorative effect of nanoceria in both the models (P < 0.05). Estimation of nuclear p65-NF-κB in pancreas revealed the inhibition of NF-κB activity behind the observed protective effect. The immunohistochemistry for vimentin, α-SMA and fibronectin supported our findings.

Conclusion: We, to the best of our knowledge, report for the first time that nanoceria can significantly reduce the pancreatic fibrosis induced by cerulein and L-Arginine and this novel rare earth nanoparticle holds a substantial potential for the therapy of pancreatic fibrosis.

Pancreatic Juice Culture in Acute Pancreatitis and Other Pancreatic Disorders

M. Kikuyama,¹ T. Kamisawa,¹ S. Kawaguchi,² Y. Yokoi,³ S. Terada,² T. Satoh,² S. Kuruma,¹ K. Chiba.¹¹Division of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hopital, Tokyo, Japan; ²Department of Gastroenterology, Shizuoka General Hospital, Shizuoka, Japan; ³Department of Surgery, Shinshiro Municipal Hospital, Shinshiro, Japan.

Aim: We retrospectively evaluated the results of pancreatic juice cultures of patients with acute pancreatitis (AP) and other pancreatic disorders.

Methods: Twenty-two patients who underwent pancreatic juice culture were studied. Eleven had AP due to alcohol (n = 7), idiopathic causes (n = 2), drugs (n = 1), or gallstones (n = 1), and remaining 11 had other pancreatic disorders such as an intraductal papillary mucin-producing neoplasm (n = 3) and main pancreatic duct dilatation with a stricture due to a tumorous lesion suspected of pancreatic cancer (n = 7) or chronic pancreatitis (n = 1) without symptoms. Nasopancreatic drainage tubes were placed for pancreatic duct drainage in AP and for pancreatic juice cytology in other disorders. Pancreatic juice was obtained through the drainage tube and cultured.

Results: Pancreatic juice cultures were positive in all patients with AP for Staphylococcus epidermidis, Streptococcus species, and others. Six among 11 patients (54.5%) with other disorders showed positive results for Escherichia coli, Streptococcus salivarius, and others. The rate of positive pancreatic juice cultures was significantly higher in AP (P = 0.035). Eight of the 11 patients with AP were classified as having severe acute pancreatitis, and all survived treatment.

Conclusion: Pancreatic juice culture was highly positive in acute pancreatitis. Relationship between orally indigenous bacteria identified in the pancreatic juice and acute pancreatitis is suggested, but further study is needed to confirm the relationship.

Impact of Chemoradiotherapy Followed by Surgery for Pancreatic Ductal Adenocarcinoma, Using a New Resectability Classification Defined by Japan Pancreas Society in 2016

M. Kishiwada, A. Hayasaki, T. Fujii, T. Ito, T. Takeuchi, Y. Iizawa, H. Kato, A. Tanemura, Y. Murata, N. Kuriyama, Y. Azumi, S. Mizuno, M. Usui, H. Sakurai, S. Isaji. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan.

Objectives: The standardization of the resectability classification is necessary for PDAC because variations in classification cause confusion and are difficult for clinical use. Japan Pancreas Society (JPS) proposed a new resectability classification since July 2016, which was anatomical criteria based on pancreatic protocol MDCT definition without subjective factors such as the surgeons' skill and experience. Our institution has been performing chemoradiotherapy (CRT) followed by surgery for PDAC. CRT may offer the potential for margin-negative (R0) resection, resulting in improvement of prognosis. The aim of this study was to evaluate the efficacy of CRT for PDAC defined by JPS resectability classification.

Methods: The subjects were 308 patients with cytologically/histologically proven pancreatic cancer who had no distant metastatses and underwent CRT from February 2005 to December 2016. CRT regimen: radiation therapy (45 to 50.4 Gy) with chemotherapy which included GEM-based in 128 or GEM plus S1-based in 180. Tumor resectability was classified into resectable (R), borderline resectable (BR): JPS sub-classified into BR-PV (SMV/PV invasion alone) and BR-A (major arterial invasion), and locally unresectable (UR-LA).

Results: The 308 patients were classified into R/BR-PV/BR-A/UR-LA: 69/31/52/156, resepectively. CRT was completed in 298 (96.8%). In R/BR-PV/BR-A/UR-LA, resection rate was 78.3%/80.6%/67.3%/44.2% and R0 resection rate was 100%/92%/80%/59.4%, respectively. Patient survival showed significant difference among the four groups (P = 0.021): the 2-year survival rate was 52.6%/46.8%/49.9%/38.5%, resepectively. Resected cases (54/25/35/69) showed also nearly significant survival difference (P = 0.053) : the 2 year- survival rate was 67.3%/61.5%/61.5%/54.2%, respectively.

Conclusion: JPS classification of respectability is simple and reliable for clinical use, even for the doctors who are not specialist of pancreatology. Our CRT protocol can select the patients who are likely to benefit from aggressive resection even if UR-LA PDAC.

Delayed Gastric Emptying and Morbidity After Pylorus-Preserving Versus Pylorus-Resecting Pancreaticoduodenectomy: Systematic Review and Meta-Analysis

U. Klaiber, P. Probst, C.W. Michalski, M.W. Büchler, T. Hackert. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Background: Delayed gastric emptying (DGE) is a frequent complication after pylorus-preserving pancreaticoduodenectomy (ppPD). Recent studies have suggested that resection of the pylorus is associated with decreased DGE rates. However, superiority of pylorus-resecting PD (prPD) was not shown in a current randomized controlled trial (RCT). This systematic review and meta-analysis summarizes the existing evidence for the effectiveness and safety of ppPD compared to prPD.

Methods: RCTs and non-randomized controlled studies (NRS) comparing outcomes of ppPD and prPD were searched systematically in MEDLINE, Web of Science and CENTRAL. Additional hand searches were applied to identify all eligible trials. Random effects meta-analyses were performed and the results presented as weighted odds ratios (OR) or mean differences (MD) with their corresponding 95% confidence interval (c.i.). Subgroup analyses were performed to account for inter-study heterogeneity between RCTs and NRS.

Results: Of 3873 articles screened for eligibility, 3 RCTs and 8 NRS with a total of 992 patients were finally included. Quantitative synthesis across all studies showed superiority of prPD for the outcomes DGE (OR 2.71, 95% c.i. 1.48 to 4.96; p = 0.001) and length of hospital stay (MD +3.26 days, 95% c.i. 1.04 to 5.48; p = 0.004). Subgroup analyses including only RCTs showed no significant statistical difference between the two procedures regarding DGE rate and all other effectiveness and safety measures.

Conclusion: PrPD is not superior to ppPD regarding DGE and other relevant outcomes. The implicit methodological limitations of non-randomized trials bear relevant sources of bias leading to overestimation of treatment effects. Based on the present level I evidence studies, this meta-analysis shows no superiority of prPD – consequently, ppPD should remain the standard of care.

Pancreatic Organoids Elucidate the New Mechanisms of Pancreatic Cancer Local Invasion

K. Koikawa,¹ K. Ohuchida,¹ Y. Ando,¹ S. Kibe,¹ H. Nakayama,¹ S. Takesue,¹ Z. Yan,¹ T. Abe,¹ T. Okumura,¹ C. Iwamoto,² T. Moriyama,¹ K. Nakata,¹ Y. Miyasaka,¹ Y. Okabe,¹ T. Ohtsuka,¹ K. Mizumoto,¹ M. Nakamura.¹Departments of ¹Surgery and Oncology and ²Advanced Medical Initiatives, Graduate School of Medical Sciences Kyushu University, Fukuoka, Japan.

Background and Aim: Pancreatic stellate cells (PSCs) promote the pancreatic cancer cells invasion and metastasis, but their detailed mechanisms are still unclear. Local micro invasion from basement membrane (BM) destruction to stroma invasion is the first step for pancreatic adenocarcinoma (PDAC) development, therefore, suppress the local micro invasion may regulate the cancer progression. Here, we investigated the mechanism of BM destruction in PDAC using organoid and time-lapse imaging.

Methods: We established human PDAC organoids from human PDAC resected tissues and co-cultured with PSCs in collagen gel three-dimensional invasion assay, and observed how the organoids destroy BM and invade into collagen gel using time-lapse imaging. We also investigated factors involving in BM destruction using quantitative RT-PCR.

Results: Organoids showed a ductal structure and had a BM structure stained with laminin α5 and collagen IV. The organoids co-cultured with PSCs in collagen gel more frequently lost a ductal structure and invaded into collagen gel than mono-cultured organoid (P < 0.01). Interestingly, direct contact of PSCs to organoids was observed before BM destruction. MMP2 and MT1MMP were low expression in organoids, but high expression in PSCs. Whereas, TIMP2 was high expression in both organoids and PSCs. MMP2 or MT1MMP knockdown in PSCs significantly attenuated the BM destruction abilities of PSCs and kept a ductal structure of organoid (P < 0.01).

Conclusion: BM destruction of PDAC organoids was promoted by direct contact of PSCs. The PSCs-induced BM destruction may be caused by MMP2 secreted by PSCs. PSC-secreted MMP2 possibly binds to MT1MMP expressed in PSCs membrane via TIMP2 derived from PSCs and organoids leading to activation of MMP2.

Adenoviral Based Radioiodine Therapy and Imaging for Pancreatic Cancer

L. Koodie,¹ E. Kawakami,² B. Eidenschink,¹ K. Jacobsen,¹ E. Tolosa,² M. Fernandez-Zapico,² J. Davydova.¹¹Dept. of Surgery, University of Minnesota School of Medicine, Minneapolis, MN; ²Division of Endocrinology, Mayo Clinic, Rochester, MN.

Radioiodine therapy has been successfully applied in the diagnosis and treatment of thyroid cancer but is currently not applicable to pancreatic ductal adenocarcinoma (PDAC) due to the lack the sodium iodide symporter (NIS), the transporter mediating iodine uptake. Previously, we described NIS-expressing Oncolytic Adenoviruses (NIS-OAd) which was designed to eliminate PDAC through tumor-selective replication. In this study, we evaluated NIS-OAd ability to deliver a functionally active NIS capable of supporting radioiodine uptake in vivo. Here we provide an invaluable tool for the diagnosis and treatment of pancreatic cancer. SPECT-CT imaging was used to visualize human Panc1 tumors and Patient-derived PDAC xenografts in mice through the monitoring of radiotracer technetium (99mTc). As early as 2-days and up until 32-days post intra-tumoral injection, NIS-OAd therapy supported 99mTc accumulation within tumors far superior than replication-deficient AdCMV-NIS, currently in clinical trials for prostate cancer therapy. Improved viral spreading and higher NIS expression within the tumor microenvironment contributed to NIS-OAd ability to enhance tumor imaging, detection and monitoring. To further evaluate the clinical potential of OAd therapy, we assessed the effect of combining NIS-OAd with a therapeutic dose of Iodine-131 (I131) on the growth of pre-established panc1 tumors in mice. Remarkably, I131 in combination with NIS-OAd further reduced pre-established Panc1-tumor growth by 31% as when compared to NIS-OAd therapy alone. These studies support the clinical applicability of NIS-OAd to facilitate radioiodine therapy for early diagnosis (I123) and treatment (I131) of pancreatic cancer. We have begun performing bio-distribution and toxicology studies utilizing a large animal swine model for further clinical development.

C-Src Is Involved in Zymogen Granule Formation

S. Kostenko, C. Heu, C. De Oliveira, B. Khatua, V. Singh. Department of Medicine, Mayo Clinic, Scottsdale, AZ.

Background: While Src family kinases are involved in trypsinogen activation, the exact family member(s) regulating this are unknown, as are the levels at which Src may regulate these phenomena. We therefore explore the identity of the Src family member involved in this trafficking and the steps at which this may occur.

Methods: In vivo the effect of the Src inhibitor Dasatinib (50mg/kg/day) on the trafficking of zymogens and zymogen granule formation were studied post refeeding along with determining the localization of c-Src. Immunofluorescence (IF), western blotting and subcellular fractionation were used. In vitro AR42J cells were used to study the effects of Src overexpression (adenoviral; c-Src, Fyn, Lyn, Yes) on Golgi morphology, and of Dasatinib on dexamethasone induced trafficking of amylase.

Results: c-Src co-localized with the Golgi marker GM130 on IF and subcellular fractionation. Dasatinib reduced granule number by 30-50% post refeeding, along with reducing zymogen protein (e.g. chymotrypsin) by WB. This was associated with retention of amylase in the ER, basal to the Golgi. In vitro c-Src but not other family members co-localized with the Golgi and induced its fragmentation, which was prevented by Src inhibition. Src inhibition also caused retention of amylase in the Golgi stacks and ER, this was also associated with a reduction in amylase, chymotrypsin protein and mRNA.

Conclusion: c-Src resides on the Golgi of acinar cells and when active is involved in Golgi dynamics. The inhibition of Src causes retention of zymogens in the ER and Golgi along with reducing zymogen granule formation. There is also a reduction in of digestive enzyme synthesis. The utility of reducing zymogen granule formation in ameliorating the severity of pancreatitis remains to be explored.

The Diagnostic Accuracy of Endoscopic Ultrasonography (EUS)-guided Needle Based Confocal Laser Endomicroscopy (nCLE) is Superior to Current Standard of Care for Differentiating Mucinous From Non-mucinous Pancreatic Cystic Lesions (PCLs)

S.G. Krishna,¹ A. Malli,¹ S.T. McCarthy,¹ S. Eldika,¹ J.P. Walker,¹ P.A. Hart,¹ A.D. Singhi,² Z. Cruz-Monserrate,¹ D.L. Conwell.¹¹Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; ²Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background and Aims: EUS-nCLE is a novel imaging biomarker for the evaluation of PCLs. Cyst fluid next-generation sequencing (NGS) has a high specificity for mucinous PCLs. We have validated EUS-nCLE patterns of mucinous PCLs among external observers and ex vivo models.

Aim: To compare the diagnostic accuracies of EUS-nCLE versus standard of care (cyst fluid CEA and cytology) for diagnosing mucinous PCLs.

Methods: In a prospective (INDEX) study at a single center, 72 subjects underwent EUS-nCLE and standard of care. The final diagnosis of PCLs was based on surgical histopathology (n = 40) or clinical diagnosis (n = 32). Clinical diagnosis included a combination of NGS, imaging features, follow-up>1 year, and/or resolution of PCL.

Results: Among 72 subjects [36 F, mean age 60.3 years], we idenfied 47 mucinous PCLs (36 IPMNs, 8 mucinous cystic neoplasms, adenocarcinoma 3), 11 serous cystadenomas, 5 pseudocysts, 4 cystic-neuroendocrine tumors, and 5 others. Mean cyst size was 35±13 mm. The sensitivity (SN), specificity (SP), and accuracy of nCLE for diagnosing mucinous PCLs were 96%,100%, and 97% respectively. The SN, SP, and Acc of CEA and/or cytology were 64%, 60%, and 63% respectively. Among subjects with surgical histopathology (n = 40), SN, SP, and Acc of nCLE for diagnosing mucinous PCLs were 93%, 100%, and 95% respectively. Comparatively, SN, SP, and Acc of standard of care (CEA and/or cytology) were 75%, 55%, and 69% respectively. The diagnostic accuracy of EUS-nCLE was significantly greater than the accuracy of CEA and/or cytology (P = 0.005).

Conclusion: Among the current diagnostic modalities, EUS-nCLE detection of mucinous-PCL is more accurate than current ‘standard of care’. These preliminary results warrant further validation in larger, multi-center studies.

BET Inhibitors Suppress PD-L1 in Pancreatic Cancer and Stellate Cells

K. Kumar. Department of Hematology/Oncology, Northwestern University, Evanston, IL.

Despite advances in the understanding of pancreatic cancer biology and new treatment strategies, pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal malignancy. Successful treatment of PDACs is challenged by their biological complexities. PDAC tumors exhibit dense and heterogeneous stromal content, and a highly immune-suppressive microenvironment. Therefore, single agent treatment with T-cell checkpoint inhibitors has not been effective in pancreatic ductal adenocarcinoma (PDAC) patients. Mouse models for PDAC have shown that ablation of pancreatic stellate cells (PSCs), key regulators of fibrosis in vivo, can sensitize PDAC tumors to immune checkpoint therapies. Inhibitors targeting bromodomains and extra-terminal (BETi) proteins, a number of which are currently being evaluated in clinical trials for solid tumors, including PDAC. Recently, we have shown that BETi induce stellate cells to become quiescent and decrease collagen production. We have now found that PSCs express significantly increased programmed death-ligand 1 (PD-L1) levels compared to pancreatic cancer cell lines. We show that BETi, and in particular specific knockdown of BRD4 protein, decrease endogenous and IFN-γ-induced PD-L1 expression in primary stellate cells. We also show that, in contrast to a recent report using cancer cells, c-MYC does not mediate endogenous or IFN-γ-induced PD-L1 expression in stellate cells. Instead, we show that the IFN-γ-induced PD-L1 expression is regulated by IRF1, suggesting cross talk between BRD4 and IRF1 in the regulation of PD-L1 expression. Our ongoing in vivo experiments will evaluate the efficacy of combination therapy of BETi with T-cell checkpoint inhibitors in mouse models of pancreatic cancer.

Pancreatic Sphincterotomy as a Rescue Method in Difficult Biliary Cannulation: Start to Count

L. Kylänpää, S. Ismail, M. Udd, O. Lindström, M. Rainio, J. Halttunen. Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland.

Background: Biliary cannulation of native papilla is defined as difficult in the presence of more than 5 contacts of the papilla, or more than 5 minutes cannulation time or more than one unintended pancreatic duct cannulation. The aim of the study is to test, if these criteria can be confirmed predicting the risk of post-ERCP pancreatitis (PEP) and to find out the efficacy and safety of pancreatic sphincterotomy (PS) as a rescue method for deep biliary cannulation.

Methods: Prospectively collected data of 821 patients with native papilla with recorded biliary cannulation time was retrospectively analyzed: demographics, indications, counts of papilla contacts and pancreatic guidewire passages, cannulation time, technical data of ERCP, complications and mortality.

Results: Primary cannulation succeeded in 599(73%) patients in 2.1/1.1(0.02-19.7) minutes. PS with additional needle knife incision when needed resulted in 90% success rate. Final cannulation success was 814 (99.1%) cases in 5.3/2.0 (0.02-29.4) min. PEP risk was 4.0%. When primary cannulation succeeed, PEP rate was 2.3%. After the second cannulation method the PEP rate was 6.3% and when multiple cannulation methods were needed, the PEP rate increased to 13.5%. Total of 311 (37.9%) patients fulfilled at least one of the criteria for difficult cannulation. In patients without these criteria, the primary cannulation succeeded in 79.6% (n = 477), compared to 122 (20.4%) with the criteria, P < 0.001. In patients without fulfilling the criteria of difficult cannulation, 2.3% had PEP, but if all the criteria were present, the risk of PEP was 12.7%.

Conclusion: In biliary cannulation, ERCP endoscopist should count and use 5-5-2 criteria. Counting these factors helps in definition of difficult cannulation and decision making when to change the cannulation method or ERCP endoscopist. Pancreatic sphincterotomy seems to be an efficient and safe rescue method.

RAS Pathway Inhibition With STAT3 Inhibition Reprograms the Tumor Microenvironment To Enhance Immunotherapy in Pancreatic Cancer

P. Lamichhane, N. Nagathihalli, F. Messaggio, X. Dai, J. Barretta, M. Vansaun, N. Merchant. Department of Surgery, University of Miami, Miami, FL.

Background: The major contributors to therapeutic resistance in pancreatic cancer (PDAC) are mutations in the KRAS oncogene, its dense desmoplastic stroma that acts as a barrier to drug delivery and effector immune cell infiltration, and the immunosuppressive tumor microenvironment (TME) that renders the tumor ineffective to immunotherapy. Our aim was to address all of these barriers with combined RAS pathway inhibition and STAT3 inhibition.

Methods: PKT (Ptf1aCre/+;LSL-KrasG12D/+;Tgfbr2flox/flox) mice were treated with a MEK inhibitor (MEKi) and a STAT3 inhibitor (STAT3i) +/− PD-1 blocking antibody. At endpoint, tumor burden, tumor area, microvessel density (MVD), fibrosis, and immune cell infiltration were assessed. CD8+ T cells in the tumor were quantified by immunofluorescence and flow cytometry.

Results: Combined MEKi/STAT3i led to decreased tumor fibrosis and increased MVD while decreasing immunosuppressive Tregs and MDSCs in TME. Infiltration of CD8+ T cells was significantly increased in pancreas of MEKi/STAT3i treated mice compared to vehicle treatment. Anti-tumor efficacy of MEKi/STAT3i was T cell dependent. Despite target inhibition, levels of PD-L1 on tumor tissues and tumor infiltrating CD11b+ myeloid cells, and PD-1 on tumor infiltrating T cells were unchanged. Combined MEKi/STAT3i with PD-1 blockade improved cellular and humoral responses and led to a further significant decrease in tumor burden compared to MEKi/STAT3i alone.

Conclusion: Changes in the PDAC TME induced by MEKi/STAT3i reprograms the tumor stroma to activate T-cell anti-tumor immunity through increased CD8+ T cell infiltration and reverses immune tolerance such that addition of checkpoint inhibition results in an improved anti-tumor response.

RAGE Triggers a Proliferative Phenotype to PANC-1 Cells

E. Leclerc, P. Swami, S.W. Vetter. Pharmaceutical Sciences, North Dakota State University, Fargo, ND.

Pancreatic cancer is one of the deadliest cancer and is characterized by late diagnosis, aggressive clinical course and resistance to existing therapies. Several reports have suggested that the Receptor for Advanced Glycation End products (RAGE) contributes to the development of pancreatic cancer. RAGE has been shown to be involved in apoptosis, autophagy, and tumor cell bioenergetics. RAGE has also been reported to be required for optimal mitochondrial function of tumor cells. However, the effect of RAGE expression on the proliferative and migratory properties of pancreatic cancer cells has not been extensively studied. Our objective was to investigate the effect of RAGE up-regulation on the proliferation and migration properties of the PANC-1 pancreatic cancer cell-line. We generated cells that overexpress RAGE four-fold compared to non-transfected PANC-1 cells. We then compared the proliferation and migration properties of the transfected cells with those of the wild-type cells. We also compared the signaling pathways affected by RAGE overexpression in these cells. We showed that four-fold up-regulation of RAGE in PANC-1 cells resulted in increased cell proliferation at the expense of cell migration. Both Boyden chamber and wound healing supported the reduced migratory properties of the RAGE overexpressing cells. Further analysis showed significantly reduced levels of integrins in the RAGE transfected cells. We suggest that in the PANC-1 cells, which exhibit a mixed epithelial – mesenchymal phenotype, RAGE expression switches the phenotypic balance toward a proliferative phenotype.

Disease Course Differences in Acute Pancreatitis Based on Etiology Using the Pancreatitis Activity Scoring System (PASS)

D. Lew,¹ B.U. Wu,² S.J. Pandol,¹ C.A. Sugar,³ D. Senturk,³ E. Afghani.¹¹Cedars-Sinai Medical Center, Los Angeles, CA; ²Division of Gastroenterology, Kaiser Permanente Los Angeles, Los Angeles, CA; ³UCLA, Los Angeles, CA.

Background: Common causes of acute pancreatitis (AP) are gallstones, alcohol, and idiopathic, but their respective clinical courses have not been well described. The objective of this study was to evaluate the variations of AP disease course based on etiology using our newly described Pancreatitis Activity Scoring System (PASS).

Methods: Among all admissions (age≥18 years) with discharge diagnosis of AP based on ICD 9 code 577 in 2014 at a tertiary care center, AP was confirmed by chart review if two of three criteria were met: abdominal pain, serum lipase/amylase ≥3 times upper limit of normal, and typical findings on imaging. Different causes of AP were also confirmed through chart review. The dynamic disease course was monitored with PASS, a tool recently developed to assess AP disease activity at any time. PASS has five weighted parameters: organ failure, systemic inflammatory response syndrome (SIRS), abdominal pain, analgesic requirement, and tolerance of oral solid food intake.

Results: 175 patients were included: 30 (17%) alcohol, 64 (37%) gallstones, and 81 (46%) idiopathic. The baseline and discharge PASS, respectively, were: alcohol 237.5(Interquartile Range, IQR, 148.8-266.3), 90 (52.5-123.1); gallstones 160 (125–220), 65.6 (38.1-100.6); and idiopathic 215 (145–295), 80 (45–125). Common among the different etiologies was having the largest improvement in PASS occur in the first day of admission. Patients with alcoholic AP had higher values for SIRS throughout the admission compared to the other etiologies of AP.

Discussion: Our data reveals that alcoholic AP has a distinct clinical course compared to other etiologies with a prolonged increase in SIRS. This information can be used to monitor and design interventions based on etiology of pancreatitis.

Stromal Fibroblasts Drive Single Cell Heterogeneity in Pancreatic Cancer

M. Ligorio,^1,2 S. Sil,¹ S. Misale,¹ M. Karabacak,¹ J. Malagon-Lopez,³ N.V. Jordan,¹ N. Desai,¹ K.S. Arora,^1,2,3 A.S. Kulkarni,¹ M. Rajurkar,¹ M. Di Pilato,⁴ M. Boukhali,¹ J.P. Fatherree,¹ E. Tai,¹ K.D. Vo,¹ L.J. Damon,¹ K. Xega,¹ R. Desai,¹ M. Choz,¹ F. Bersani,¹ V. Thapar,^1,3 M.N. Rivera,^1,3 V. Deshpand,^1,3 C. Benes,¹ L. Nieman,¹ S. Maheswaran,^1,2 D.A. Haber,^1,4,5 C. Fernández-Del Castillo,^1,2 C.R. Ferrone,^1,2 W. Haas,¹ M.J. Aryee,^1,3,6 D.T. Ting.^1,71Massachusetts General Hospital Cancer Center, Boston, MA; Departments of ²Surgery, ³Pathology, and ⁴Division of Rheumatology, Allergy, and Immunology, Center for Immunology and Inflammatory Diseases, Harvard Medical School, Boston, MA; ⁵Howard Hughes Medical Institute, Chevy Chase, MD; ⁶Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; ⁷Department of Medicine, Harvard Medical School, Boston, MA.

Introduction: Pancreatic cancer (PDAC) lethality is linked to its rapid growth and metastatic propensity, which is thought to be driven by cancer associated fibroblasts (CAFs). However, CAF-driven intratumoral heterogeneity remains still undefined.

Methods: Single cell RNA-sequencing (RNA-Seq) was used to characterize the CAF-driven PDAC cell heterogeneity in vitro. Xenograft mouse models and RNA in situ hybridization (RNA-ISH) were used to validate the functional relevance of these findings and the significance for human PDACs, respectively.

Results: Single cell RNA-Seq of 92 PDAC and 92 CAF single cells was performed with different co-culture ratios (100:0, 50:50, 30:70, 10:90 - PDAC:CAF). A set of 315 genes (FDR = 0.20) was differentially expressed in the 10:90 PDAC:CAF condition relative to PDAC cells alone (100:0), and enrichment analysis identified 121 gene sets that were linked to proliferation (PRO) and invasive (EMT) activity. We identified a novel CAF-driven subpopulation of cells with the dual upregulation of PRO and EMT, double positive (DP) cells. This was associated with increased in vitro proliferation (P < 0.0001) and migration assays (P < 0.01) with concordant in vivo xenograft tumor growth (P < 0.01) and metastases (P < 0.05) when PDAC cells were co-cultured with increasing amounts of CAFs (30:70 and 10:90 - PDAC:CAF). We validated stroma-driven single-cell tumor heterogeneity in 136 primary PDACs with digital analysis of 206,710 single cells and showed that DP cells correlate with worsened survival (Log-Rank, P = 1.3x10⁻⁶). Moreover, stromal content was highly correlated to the number of DP cells (r = 0.87; P < 0.0001).

Conclusion: Stromal driven PDAC cell interactions can significantly alter single cell tumor heterogeneity with relevant implications for tumor progression and in designing novel therapeutic strategies.

Chai-Qin-Cheng-Qi Decoction Improves Intestinal Motility by Regulating CPI-17/MLCP Pathway in Small Intestinal Smooth Muscle in Rats With Acute Necrotising Pancreatitis

Z. Lin,¹ C. Zhang,¹ X. Zhang,¹ N. Shi,¹ J. Guo,¹ W. Huang,¹ J.A. Windsor,² R. Sutton,³ P. Xue,¹ Q. Xia.¹¹West China Hospital, Sichuan University, Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre, Sichuan, China; ²Department of Surgery, University of Auckland, Auckland, New Zealand; ³Royal Liverpool University Hospital NHS Trust, University of Liverpool, NIHR Liverpool Pancreas Biomedical Research Unit, Liverpool, United Kingdom.

Background: Chai-Qin-Cheng-Qi decoction (CQCQD) improves intestinal motility in acute pancreatitis (AP). Protein kinase C-potentiated phosphatase inhibitor of 17 ku (CPI-17) inhibits myosin phosphatase (MLCP) to increase the Ca²⁺ sensitivity of myosin phosphorylation and thus intestinal smooth muscle contraction. Objective: To investigate the effect of CQCQD on CPI-17/MLCP pathway in small intestinal smooth muscles (ISMs) in experimental AP.

Methods: Necrotising AP was induced in rats by intraperitoneal injections of L-ornithine (3.0 g/kg, 2 injections, 1 hour apart); controls received saline. Intraperitoneal injection of carbachol (known to activate CPI-17; 60 μg/kg) or intragastric gavage CQCQD (20 g/kg, 2 hourly × 3 doses) was begun 24 hours after disease induction; controls received saline. All animals were humanely sacrificed 30 hours after the first ornithine/saline injection. Pancreatic histopathology, intestinal histopathology, serum cytokines and intestinal indirect motility markers (ELISA) were assessed. Small intestine segments were collected to measure CPI-17 and cytokine expression (RT-PCR and Western Blot).

Results: Both treatments halved pancreatic histopathology scores vs no treatment (both P < 0.05). Both treatments reduced intestinal histopathology scores, serum intestinal fatty acid binding protein, vasoactive intestinal peptide, interleukin (IL)-1β and tumor necrosis factor-alpha levels (all P < 0.05 in CQCQD group). Both CQCQD and carbachol significantly up-regulated CPI-17 mRNA and protein, while down-regulating IL-1β mRNA and protein (all P < 0.05).

Conclusion: These data indicate that CQCQD reduces the severity of AP and improves intestinal motility by up-regulating CPI-17 in ISMs. Further work is required to characterise the role of the CPI-17/MLCP pathway in ISMs during AP.

Total Flavonoids From Psidium Guajava Leaves Prevent NLRP3 Inflammasome Activation and Alleviate the Pancreatic Fibrosis in a Mouse Model of Chronic Pancreatitis

H.B. Liu, G.X. Zhang. Tianjin Institute of Medical & Pharmaceutical Sciences, Tianjin, China.

Objectives: To investigate the role of purinergic 2X7 receptor (P2X7R) and NLRP3(NACHT, LRR and PYD Domains-Containing Protein 3) inflammasome activation in the process of pancreatic fibrosis in a mouse model of chronic pancreatitis (CP).

Methods: CP was induced by repeated intraperitoneal injections of 50μg/kg cerulein for 6 weeks in mice. P2X7R antagonist oxidized ATP (OxATP) or Brilliant Blue G (BBG) was administered after the last cerulein injection for 2 weeks. Pancreatic chronic inflammation and fibrosis were evaluated by histological score, Sirius red staining and α-SMA immunohistochemical staining. We further determined pancreatic P2X7R, NLRP3 and Caspase-1 expressions in gene and protein levels and the pancreatic concentrations of caspase-1, IL-1β and IL-18.

Results: The pancreatic P2X7R, NLRP3 and Caspase-1 expressions in gene and protein levels and the pancreatic concentrations of caspase-1, IL-1β and IL-18 were all reduced significantly in both OxATP and BBG groups (P < 0.05). The pancreatic chronic inflammation and the fibrosis indices were all remarkably attenuated (P < 0.05).

Conclusion: P2X7R antagonist OxATP and BBG significantly decreased pancreatic chronic inflammation and fibrosis in a mouse CP model and suggested that blockade of P2X7R-NLRP3 inflammasome signaling pathway may represent a novel therapeutic strategy for CP and its fibrotic process.

A Zinc-dependent Integrin-Paxillin-GSK-3β Signaling Axis Mediates Cell Adhesion and Tumor Growth of Pancreatic Cancer

M. Liu,¹ Y. Zhang,¹ J. Yang,¹ C. Houchen,¹ R. Postier,² M. Li.^1,2Departments of ¹Medicine and ²Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK.

Background: Cell adhesion plays a critical role in the development of pancreatic cancer. Integrins have been reported as a mediator of adhesion dependent growth of tumor cells. In this study, we aim to investigate whether dysregulated zinc transport affects cell adhesion and tumor growth of pancreatic cancer, and whether targeting the zinc transport pathway has therapeutic impact on metastatic pancreatic cancer.

Methods: AsPC-1, PANC-1, and MIA PaCa-2 were chosen for adhesion and tumor growth study. ZIP4 overexpression or knocking down stable cell lines were constructed. Zinc-depleted medium was used and exogenous zinc at different concentration (0.25, 0.5, 1 and 2μM of ZnCl2) was supplemented. MTT assay was performed to measure the cell adhesion. Correlations between ZIP4, integrins and downstream targets Paxillin and GSK-3B were investigated with Western blot. Orthotopic xenograft model was used for in vivo studies.

Results: We found that ZIP4 could induce cell adhesion and tumor growth of pancreatic cancer cells. Integrin-α3 and integrin-β1 were upregulated by ZIP4. Knocking down integrin-α3 and integrin-β1 diminished cell adhesion and tumor growth even in the presence of high ZIP4 in MIA-ZIP4 and Panc-ZIP4 cells. We also found that knocking down integrin-α3 and integrin-β1 inhibited pPaxillin but enhanced pGSK-3β which are downstream targets of integrin in MIA-ZIP4 and Panc-ZIP4 cells. We found ZIP4 promoted cell adhesion and tumor growth in a zinc dependent manner: low concentrations of zinc accelerated ZIP4 induced adhesion and proliferation while high level of zinc attenuated ZIP4 induced cell adhesion and proliferation. And expression of integrin-α3, integrin-β1 was mediated by ZIP4 and zinc is required for ZIP4-integrin upregulation in pancreatic cancer.

Conclusion: High level of zinc transport ZIP4 promotes pancreatic cancer adhesion and proliferation in a zinc-dependent manner. ZIP4-integrin-Paxillin, GSK-3β pathway may serve as a novel therapeutic strategy of pancreatic cancer treatment.

Impact of High Pancreatic Amylase on Insulin Response in a Pig Model

L. Lozinska,^1,2 J. Woliński,³ K. Goncharova,^1,4 B. Weström,¹ S.G. Pierzynowski.^1,41Department of Biology, Lund University, Lund, Sweden; ²Vitanano Sp. z o.o., Lublin, Poland; ³Animal Physiology, The Kielanowski Institute of Animal Physiology and Nutrition, Polish Academy of Sciences, Jabłonna, Poland; ⁴Anara AB, Trelleborg, Sweden.

Background & Aim: Increasing evidence suggests that the improved insulin sensitivity seen after bariatric surgeries is linked to the duodenal exclusion of pancreatic exocrine functional products. Previously, we have found that enteral pancreatic amylase in young pigs might be involved in glucose utilisation and affect insulin efficiency. This study investigated the relationship between high plasma amylase (parenteral) activity and insulin resistance in a porcine model.

Methods: Three young pigs underwent duodenal-jejunal bypass (DJB) surgery, while three littermates underwent sham-surgery without intestinal rearrangement. Another three intact animals were used to test intravenous (i.v.) infusion of porcine pancreatic amylase (10 kU/pig) prior to i.v.GTT. Blood glucose, plasma insulin, C-peptide levels, and plasma amylase activity were analyzed.

Results: Duodenal-jejunum bypass gradually increased plasma amylase activity (4.9±0.6 U/mL) compared to sham operated animals (2.4±0.3 U/mL) in 5.5 weeks after surgery. Acute i.v. infusion of porcine pancreatic amylase prior to i.v.GTT for healthy intact pigs, resulted in lower insulin and C-peptide levels at 5 min (P = 0.03 and P = 0.006, respectively) and at 15 min (P = 0.06 and P = 0.13, respectively) following glucose loading. The glucose utilization rate was not altered by i.v. amylase infusion.

Conclusion: The results show that intestinal rearrangement in bariatric surgeries affect the exocrine pancreatic function and increase amylase levels. The increase of blood amylase activity has a catabolic influence and regulates insulin response, limiting the amount of insulin needed to metabolise the given amount of glucose. The obeserved effect should be considered for treatment of insulin resistance.

Left-Sided Portal Hypertension Associated With Acute Pancreatitis Treated by Splenectomy: Clinical Characteristics and Outcomesin a Cohort of 79 Cases

S. Lu, L. Zhang, H. Lu, W. Hu. Department of Pancreatic Surgery, West China Hospital, Chengdu, China.

Background: Left-sided portal hypertension (LSPH) secondary to acute pancreatitis is a rare condition. It is unclear whether splenectomy is benefit for the clinical outcomes of LSPH.

Methods: Between January 2010 and June 2015, 79 patients from pancreas department of west china hospital undergoing surgery for LSPH were retrospectively described. All of patients were divided into two groups according to whether underwent splenectomy, including surgery without splenectomy (OS) group and surgery with splenectomy (WS) group. The demographics, perioperative and postoperative characteristics of LSPHwere evaluated.

Result: Male (66, 83.5%) were more than female (13,16.5%) with a average age of 44.37±9.86 years. The pathological diagnosis of 60 patients (75.9%) were pancreatic pseudocyst, however 19 patients (24.1%) were pancreas abscess after operation.The incidence of preoperative GI bleeding in WS group is significantly higher than that in OS group (20.5% vs. 50%; P = 0.006), the incidence of postoperative recurrent GI bleeding in WS group is lower than OS group (0% vs.10.3%; P = 0.055), which is no statistical difference between the two groups. There is no significant difference in postoperative hemoglobin, liver function and renal function between the WS group and the OS group (P > 0.05).

Discussion: Above all, we believe that there is a high mortality when GI bleeding occursin LSPH patients, although the incidence of it is low.So if the symptom of GI bleeding, splenomegaly or hypersplenism occurs in the AP patients, it may be LSPH and need surgical intervention as soon as possible.It is enough to deal with primary lesion in most cases, but if patients have GI bleeding or hypersplenism, splenectomy can effectively prevent recurrent GI bleeding and relieve hypersplenism.

Conclusion: For LSPH, we should be vigilant and treat early. It is enough to deal with primary lesion for most LSPH, but if patients have gastrointestinal bleeding orhypersplenism, splenectomycan effectively prevent recurrent gastrointestinal bleeding and relieve hypersplenism.

Prognostic Nomogram for Resected Pancreatic Adenocarcinoma

Z. Lu, K. Jiang, D. Xu, K. Zhang, C. Dai, J. Wu, W. Gao, Y. Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Introduction: Currently, only one well-validated nomogram existed for survival prediction in pancreatic adenocarcinoma (PC) patients in post-surgery setting; furthermore, this model lacked some important survival predictors discovered recently.

Aims: To identify possible prognostic factors in PC patients after radical resection, and to develop a prognostic nomogram based on independent survival predictors.

Methods: From 2009 to 2014, a total of 435 PC patients underwent curative intended surgeries with complete followed-up data (81.9% of all radical cases) were included in the retrospective survival analysis. Clinicopathological data were extracted from medical records and missing values (percentage: 0.9-8.3%) were imputed 5 times with “pmm” method. Cox proportional hazards models were utilized. A nomogram was then formulated based on results from multivariate regression model to predict OS at 12, 24, 36-months and median OS. Validations including discrimination and calibration were carried out with 500 bootstrap resamples. Additionally, an external validation was conducted to verify accuracy of our nomogram at 12, 24-months with a second cohort of 113 PC patients underwent curative surgeries in 2015.

Results: After a median 37.7 months of follow-ups, 338 patients (77.7%) died. Median OS was 15.0 months (95% CI, 13.0-17.0 months). The cumulative 1-, 3-, 5-year OS rate were 62.3%, 21.3%, 12.6%, respectively. Preoperative neutrophil-lymphocyte ratio, preoperative CA 19-9 (log2), tumor differentiation, maximal diameter, microscopic nerve invasion, microscopic vascular invasion, T stage, positive nodal ratio, M stage, and adjuvant chemotherapy were independent predictive factors for patients’ OS. Bootstrap-corrected concordance-index of internal and external validation were 0.690 and 0.688, respectively.

Conclusion: Our prognostic nomogram based on clinicopathological parameters shows a good performance in predictivity, either in internal or external validation.

Distal Pancreatectomy for the Management of the Disconnected Pancreatic Duct Syndrome Following Necrotizing Pancreatitis

H. Lu, L. Zhang, S. Lu, D. Yang, M. Li, W. Hu. Department of Pancreatic Surgery, West China Hospital, Chengdu, China.

Background: Disconnected pancreatic duct syndrome (DPDS) is are cognized complication of necrotizing pancreatitis. Distal pancreatectomy (DP) is considered to be a effective surgical management for those patients, but the short- and long-term outcomes is unclear. This paper evaluates our experience for patients with DPDS following DP.

Methods: A retrospective review of all patients undergoing DP for DPDS between 2015 and march 2017 were performed at a single center specializing in acute pancreatitis. Patient demographics, perioperative, postoperative, and follow up variables were evaluated.

Results: Seventy-eight patients with DPDS were treated by DP. Seventy patients(89.7%) had a specific disconnect pancreatic duct diagnosed by contrast-enhanced CT and MR cholangiopancreatography. Sixty-seven patients(85.9%) had recurrent pseudocysts preoperatively. The mean value of estimated blood loss is 584 ml (range 50–2,000 ml). Then, the rates of postoperative pancreatic fistula, pancreatitis, worsen endocrine insufficiency and new developed DM are 7.7%, 10.3%, 24.4%, 15.4%. The mean of the distance of segment of disconnected pancreas for subgroups endocrine insufficiency (n = 12) and normal function (n = 66) are 5.28±3.55 and 4.27±3.08, P = 0.339. The data for subgroups exocrine insufficiency (n = 19) and normal function(n = 59) are 4.48±3.21 and 4.24±3.06, P = 0.807.

Conclusion: Distal pancreatectomy won’t increase the risk of endocrine or exocrine insufficiency. It’s a safe and definitive treatment for patients with DPDS.

Sirtuin 3 Genetic Ablation Causes Mitochondrial Dysfunction and Promotes Acinar Cell Death in Acute Pancreatitis

S.R. Malla,¹ N. Shalbueva,² Y. Qin,³ R.T. Waldron,¹ J. Yuan,¹ S. Gretler,⁴ O.A. Mareninova,⁵ S.J. Pandol,⁶ A.S. Gukovskaya.⁷¹Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA; ²Department of Medicine, University of California, Los Angeles, Los Angeles, CA; ³Division of Gastroenterology and Hepatology, Youjiang Medical University for Nationalities, Baise, China, ⁴Department of Medicine, University of California, Los Angeles, Los Angeles, CA; ⁵Medicine, UCLA/VAGLAHS, Los Angeles, CA; ⁶Cedars-Sinai Medical Center, Los Angeles, CA ⁷Medicine, UCLA/VAGLAHS, Los Angeles, CA.

Background & Aims: Sirtuin 3 (SIRT3) is a major mitochondrial protein deacetylase which regulates activities of mitochondrial proteins involved in ATP generation. Mitochondrial dysfunction is a key pathologic event of experimental nonalcoholic and alcoholic pancreatitis. We further found that alcoholic pancreatitis reduced pancreatic SIRT3 level. Here we studied the effect of SIRT3 genetic ablation on mitochondrial functions and AP severity.

Methods: Cerulein (CER-AP) and L-arginine (Arg-AP) pancreatitis was induced in wild type and SIRT3 null (KO) mice. We measured protein acetylation in whole tissue and mitochondrial fractions by immunoblot against acetylated lysine and by mass spectrometry; mitochondrial membrane potential (ΔΨm), with ΔΨm-sensitive fluorescent dye TMRM; oxidative phosphorylation with XF96 SeaHorse.

Results: SIRT3 genetic ablation causes hyperacetylation of mitochondrial proteins resulting in pathologic alterations manifest by reduced maximal respiration capacity of pancreatic mitochondria, their inability to maintain ΔΨm, greater depolarization in response to CCK and Arg (compared to wild type acinar cells), and upregulation of the fragmentation mediator DRP1. There was a dramatic increase in acinar cell death through apoptosis and necrosis in both CER-AP and Arg-AP in SIRT3 KO resulting in a significant loss of acinar tissue. SIRT3 genetic deletion also worsened other pancreatitis responses, such as elevated serum amylase and lipase, and neutrophil infiltration.

Conclusion: SIRT3-mediated deacetylation is critical for maintaining mitochondrial function, and its genetic ablation greatly increases acinar cell death and aggravates experimental pancreatitis. The results indicate an important role of mitochondrial proteins’ acetylation in pancreatitis.

Activin Receptor Type IA in Pancreatic Cancer and its Implications in Tumor Progression

G. Mancinelli,¹ J. Bauer,² R. McKinney,² N. Krett,² B. Jung,² P.J. Grippo.²Departments of ¹Biochemistry & Molecular Genetics and ²Medicine, University of Illinois-Chicago, Chicago, IL.

Activin A cytokine has been shown to have contrasting roles in the context of carcinogenesis. In pancreatic cancer (PC) patients, higher levels positively correlate with shorter survival and greater metastasis. Activin signals through a tetramer receptor complex, and subsequent phosphorylation of ACVR1 (type A or B) is necessary for activation of the downstream signaling cascade. ACVR1B has been shown to play a tumor suppressive role in mouse models of PC and is down-regulated in human PC. Yet, Activin effects through ACVR1A in PC have not been established. There is a significant 80% upregulation of ACVR1A mRNA in human PC compared to normal tissue outside the tumor margin. Indeed, this is further supported by increased ACVR1A mRNA expression in several human PC cell lines. We hypothesize that the opposing effects of Activin signaling in PC may be due to ACVR1A activation of pro-tumorigenic functions including invasion and metastasis. While Activin A does not appear to increase proliferation in cancer cells, it does increase migration. Overexpression of ACVR1A in MIA PaCa-2 cells show increased migration and cellular proliferation as demonstrated in cells with wild type and constitutively active (mutant) Acvr1a, but fail to do so when transfected with the kinase dead mutant. Human and murine tissue show positive staining of ACVR1A, which is stronger in human PC, the neoplastic lesions of KC transgenic mice, and local cancer and metastases of KPC mice. Our current work includes altering the Acvr1a allele in a well-characterized mouse model of PC via pancreas-specific deletion and activation of ACVR1A. Data that supports the contribution of ACVR1A to PC tumorigenesis would suggest that it may serve as a novel therapeutic target in PC metastasis.

Laparoscopic Pancreaticoduodenectomy: A Single Team Preliminary Experience

X. Mao, X. Duan, L. Zhou. Hunan Provincial People’s Hospital, Changsha, China.

Aim: The present study aimed to explore the application and experience of laparoscopic pancreaticoduodenectomy (LPD) for periampullary carcinoma.

Methods: Perioperative clinical data of 101 consecutive laparoscopic pancreaticoduodenectomy procedures performed from January 2014 to March 2017 in the Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital were retrospectively analyzed.

Results: The mean operative time was 325.7 min (range, 220–575) min and the mean intraoperative estimated blood loss was 175.9mL (range 100–550mL). Twenty-three cases (22.8%) had pancreatic fistula according to International Study Group definition, including 17 cases (16.8%) of biochemical fistula, 5 cases (5.0%) of grade B and 1 cases (1.0%) of grade C. Four patient (4.0%) suffered from postoperative intra-abdominal bleeding, 2 cases (2.0%) had bile leakage, 4 cases (4.0%) had delayed gastric emptying, 6 cases (5.9%) had intra-abdominal infection, 3 cases (3.0%) had pulmonary infection and 3 cases (3.0%) had ileus. Postoperative severe complications (Clavien ≥III) were detected in 9 patients (8.9 %), 3 patients required re-operation. The 30-day mortality rate was 1.0% (1 of 101 patients). Mean length of hospital stay was 14.8 days (8–29 days). Pathologic diagnoses were distal common bile duct cancer (n = 27; 26.7%), ampullary adenocarcinoma (n = 23; 22.8%), Papillary carcinoma of the duodenum (n = 39; 38.6%), pancreatic ductal adenocarcinoma (n = 12; 11.9%). R0 ratio of resection margin was 94.1%, the number of harvested lymph nodes was (16.7±4.2),the number of positive lymph nodes was (1.3±1.1).

Conclusions: Laparoscopic pancreaticoduodenectomy is safe and effective for periampullary carcinoma, with a good short-term outcome.

Enhancing Autophagic Activity With Trehalose Normalizes Multiple Pathways and Greatly Ameliorates Experimental Acute Pancreatitis

O.A. Mareninova,¹ E.T. Vegh,^1,2 S.R. Gretler,¹ S.W. French,³ I. Gukovsky,¹ A.S. Gukovskaya.¹¹Department of Medicine, UCLA/VAGLAHS, CA; ²University of Szeged, Szeged, Hungary; ³Harbor-UCLA Medical Center, Torrance, CA.

Background and Aims: Recent studies reveal essential homeostatic role of autophagy in the pancreatic acinar cell: its impairment mediates key pathologic responses of acute pancreatitis (AP); and genetic ablation of mediators of autophagic/lysosomal pathways causes spontaneous pancreatitis in mice. However, approaches to normalize autophagy have not been tested as a therapeutic strategy for pancreatitis. Trehalose is a natural disaccharide recently shown to stimulate autophagic flux and vacuole clearance in models of neurodegenerative diseases. Here, we measured the effect of trehalose on autophagy and AP severity.

Methods: Trehalose was given to mice by daily i.p. injections for 2 weeks followed by induction of L-arginine or cerulein AP. We measured parameters of autophagy and pancreatitis.

Results: Trehalose enhanced autophagic activity in Arg-AP and CER-AP, manifest by decreases in the levels of autophagic vacuole marker LC3-II, the autophagy substrate p62/SQSTM1, and ubiquitinated proteins; and by normalized processing of cathepsin B. Restoring autophagy with trehalose greatly ameliorated AP in both models: pancreatic histology markedly improved (H&E) and there was no accumulation of large autolysosomes containing poorly degraded cargo (EM); necrosis decreased several-fold; and trypsinogen activation was completely prevented. Pretreatment with trehalose reduced NF-κB activation, neutrophil infiltration, and attenuated ER stress.

Conclusion: Restoring efficient autophagy with trehalose markedly ameliorates pancreatic injury, providing further evidence that impaired autophagy drives AP. Manifestations of autophagic/lysosomal dysfunctions are prominent in human disease; thus, approaches to normalize these pathways could be promising for disease treatment.

NF-κB Genetic Ablation Down-Regulates p62/SQSTM1 and Ameliorates Non-Alcoholic and Alcoholic Experimental Pancreatitis

O.A. Mareninova,¹ S.R. Gretler,¹ J.M. Elperin,¹ M. Pimienta,¹ S.J. Pandol,² A.S. Gukovskaya,¹ I. Gukovsky.¹¹Department of Medicine, UCLA/VAGLAHS, Los Angeles, CA; ²Cedars Sinai Medical Center, Los Angeles, CA.

Background and Aims: Although the key transcription factor NF-κB is activated early in acute pancreatitis (AP), its role in disease pathogenesis remains controversial due to complex and diverse actions of NF-κB. Here, we investigate the effects of genetic ablation of p50 and p65/RelA NF-κB proteins in models of pancreatitis induced by cerulein (CER-AP) or combination of ethanol and palmitoleic acid (EtOH+POA). We also examine links between NF-κB and autophagy (which are, in general, poorly understood), particularly the effects on p62/SQSTM1, an important regulator of both autophagy and inflammation.

Methods: AP models were performed on wild type, p50^−/−, and p50^−/−;p65^+/− mice; dispersed acini from these mice were treated with supramaximal CCK or EtOH+POA. We measured histological and biochemical parameters of pancreatitis and autophagy in the acute and recovery phases of AP.

Results: p50 and p65 ablation greatly decreased inflammation and improved pancreatic histology in both models. The beneficial effects were more pronounced in p50^−/−;p65^+/− than in p50^−/− mice. Autophagic flux analysis indicated that NF-κB regulates both autophagosome formation and autophagic degradation in AP. Pancreatic level of p62/SQSTM1 increased in AP models; our and literature data indicate this effect is detrimental, leading, for example, to accumulation of ubiquitinated protein aggregates. The increase was markedly reduced with NF-κB ablation.

Conclusion: NF-κB activation regulates pancreatic autophagy. In particular, it mediates the p62/SQSTM1 increase in AP, a pathway linking autophagy and inflammation. The results indicate that approaches to dampen NF-κB activation could be beneficial in treatment of AP.

Chronic Pancreatitis Localized in Ventral Pancreas Associated With Pancreas Divisum

M. Masataka, K. Kmaei, Y. Yashida, K. Kawaguchi, T. Murase, S. Satoi, I. Matsumoto, T. Nakai, Y. Takeyama. Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Japan.

Background: Most cases with pancreas divisum do not have symptoms, but a few cases develop symptoms which commonly include upper abdominal pain, nausea, vomiting, and acute and chronic pancreatitis. Recommended treatment of those with symptoms is conservative first. However, in the cases with intractable pain or with mechanical obstruction, endoscopic or surgical approach should be considered. We experienced three cases with pancreatic divisum presenting chronic pancreatitis only in ventaral pancreas.

Case 1: Forty one years old man. duodenal stenosis due to chronic pancreatitis appeared.

Case 2: Fifty three years old man. Abdominal pain appeared by huge pancreatic pseudocyst with chronic pancreatitis. So, side-to-side pancreato-jejunostomy was performed. The postoperative course was good, but obstructive jaundice appeared in 1-year postoperatively.

Case 3: Forty three years old man. He repeated acute pancreatitis by alcohol, and obstructive jaundice appeared. Three cases were all with pancreas divisum, and subtotal pylorus preserving pancreaticoduodenectomy (SSPPD) were performed in all three cases.

Discussion: Chronic pancreatitis with pancreas divisum is often limited only dorsal pancreas or ventral oancreas and this condition is called isolated pancreatitis. Frequency is more on dorsal pancreas than on ventral pancreas and occurrance on ventral pancreas is very rare and few reports. Furthermore endoscopic approach is difficult to treat ventral chronic pancreatitis, and surgical approach is appropriate. There are various reports on surgical procedures, and limited surgery is better in order to preserve the function as much as possible. But duodenal stenosis and obstructive jaundice occur in our cases because pancrearic stone is filled only in ventral pancreas, so we decided to perform SSPPD. Postoperative diabetes was observed in no cases.

Conclusion: We experienced three Chronic pancreatitis localized in ventral pancreas associated with pancreas divisum and all cases have good course after SSPPD.

Clinicopathological Characteristics of Recurrent Pancreatic Cancer: Analysis of Autopsies

Y. Matsuda,¹ A. Seki,¹ K. Nonaka,¹ M. Kakizaki,¹ T. Wan,¹ J. Aida,² N. Ishiwaka,² K. Takubo,² T. Ishiwata,² T. Arai.¹¹Department of Pathology and ²Division of Aging and Carcinogenesis, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan.

Introduction: Pancreatic cancer represents a high incidence of recurrence. Local recurrence and distant metastasis are major types of recurrence. This study aimed to investigate the clinicopathological features associated with recurrent pancreatic cancer in whole organs by using autopsies.

Methods: We reviewed all the pathological specimens from 12 patients who received a surgical resection of pancreatic cancer and underwent an autopsy at our hospital. Immunohistochemical analyses were performed for MUC1, MUC2, MUC5AC, MUC6, p53, and SMAD4.

Results: Recurrent pancreatic cancer occurred in 5 female and 7 male patients, whose ages ranged from 66 to 83 years. We found cancers in the remnant pancreas, nerve plexus, duodenum, liver, peritoneum, and sentinel lymph nodes in 7 cases; therefore, we considered these cases to be representative of local recurrence and direct invasion. We found cancers in the lung, liver, lymph nodes, and distant organs in 5 cases; therefore, we considered these cases to be representative of distant metastasis. No significant differences were found among the cases in terms of local recurrence and distant metastasis. Furthermore, histological grading (well, moderately, and poorly differentiated), and mucin, p53, and SMAD4 expression levels were similar in the surgically resected pancreatic cancers and recurrent cancers at autopsy. Dedifferentiation is the frequently observed phenotype of the gastrointestinal cancers, typically presenting as well-differentiated cancers in the mucosal layer and poorly differentiated cancers in the invasive front. However, we did not find dedifferentiation of pancreatic cancers in the samples from the recurrent cases in the present study, which suggests that pancreatic cancer has an aggressive phenotype even in its early stage.

Conclusion: The aggressive phenotype of pancreatic cancer might be related to its poor prognosis.

Preoperative Panel of CA 19-9, Coagulation FVIII, Fibrin Turnover Marker D-Dimer, and Thrombin Time Predicts Postoperative Survival in Pancreatic Ductal Adenocarcinoma

N. Mattila,¹ C. Haglund,² R. Lassila,³ H. Seppänen.¹¹Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, ²Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland, ³Coagulation Disorders Unit, Department of Hematology, Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-associated death worldwide. It is often diagnosed at a late stage, but even after surgery survival is poor. CA 19-9 is the most used tumor marker for PDAC, and it correlates with survival. PDAC associates with enhanced coagulation activity. The aim of this study was to explore whether a combination of CA 19-9, FVIII, D-dimer and thrombin time (TT) predicts outcome after surgery better than CA 19-9 alone.

Methods: Patients (n = 124) were operated during 2010–2015 in Helsinki. Patients were divided into two groups: local (n = 94) and metastasized (n = 30) disease. Neoadjuvant treatments (NT) were recorded. The median (IQR) follow-up time was 1.9 (1.2–2.4) years for local and 0.82 (0.47–0.97) years for metastasized PDAC. The time and causes of death were checked. CA 19-9, FVIII, TT and D-dimer were analyzed preoperatively. The results were analyzed with a 10-point panel score (Mattila et al, submitted 2017). Kaplan-Meirer survival analysis was made.

Results: The median (IQR) panel score was 7 (6–8) for local and 8 (8–9) for metastasized PDAC. Of the local PDAC, 73% had scores of 7 of more and 44 were alive at follow-up. All patients with metastasis were deceased. In local PDAC panel score of 7 or more predicted worse survival (P = 0.001), regardless of NT. The panel did not predict survival in metastasized disease. CA 19-9 alone predicted worse survival only in local PDAC when over 340 kU/L (n = 22).

Conclusion: Preoperative CA 19-9 combined with FVIII, D-dimer and TT can predict survival after PDAC surgery. Further studies are needed to determine whether patients with a high panel score could be benefit from prolonged postoperative anticoagulant medication.

Prevalence of Psychiatric Comorbidities in Patients Undergoing Total Pancreatectomy With Islet Cell Autotransplantation (TPIAT) and Associated Mortality: A Retrospective Review and Case Series

K.R. McEachron,¹ M. Melton,² G.J. Beilman,¹ M.D. Bellin.¹Departments of ¹Surgery and ²Psychology, University of Minnesota, Minneapolis, MN.

Objectives: Total pancreatectomy with islet cell autotransplantation (TPIAT) may be performed to improve quality of life for patients with refractory chronic pancreatitis and recurrent acute pancreatitis. Patients with chronic pancreatitis have a high incidence of depression and other psychiatric comorbidities, but their effects on outcomes and mortality following TPIAT have never been characterized. One of the challenges facing TPIAT centers is appropriate patient selection and exclusion criteria.

Methods: We report a series of five deceased TPIAT recipients where the cause of death was self-harm (suicide or accidental substance overdose). All patients who underwent TPIAT from 2008–2015 were reviewed for the prevalence of psychiatric diagnoses, substance abuse other than alcohol, and past suicide attempts.

Results: Of the 360 patients who underwent TPIAT from 2008–2015, we identified five patients who suffered mortality with mechanisms suspicious for intentional self-harm and report vignettes for each case. Of the 360 cases reviewed, 38% had preoperative psychiatric comorbidities, the most common being depression. In the case series of patients with mortality, there was a high incidence of prior suicide attempts and non-alcoholic substance abuse.

Conclusion: Patients who undergo TPIAT are at high risk for psychiatric comorbidities due to their preoperative chronic illness and complex postoperative cares. Previous suicide attempts and substance abuse may indicate a higher than normal risk for intentional self harm and suicide postoperatively. All patients undergoing TPIAT should receive psychological assessment and care before and after TPIAT. A higher level of care may be required when high risk features are present.

Diagnostic Yield of Mural Nodules (MN) on Preoperative Imaging for Identification of Advanced Neoplasia in Intraductal Papillary Mucinous Neoplasms (IPMNS)

L.K. Mejia Perez,¹ A.C. Rodriguez,¹ P. Kandel,¹ T. Woodward,¹ V. Gomez,¹ M. Wallace,¹ H. Asbun,² J. Stauffer,² M. Raimondo.¹¹Division of Gastroenterology and Hepatology and ²Section of General Surgery, Mayo Clinic, Jacksonville, FL.

Background: A definite mural nodule (MN) is a protrusion on the wall of an intraductal papillary mucinous neoplasm (IPMN). If found on endoscopic ulrasound, it is a worrisome feature for malignancy that warrants surgical resection. Debris or mucous within the cyst can mimic a MN, leading to overtreatment. We aimed to assess the diagnostic yield of MNs on EUS, CT/MRI for identifying malignancy in patients with IPMN.

Methods: We retrospectively identified patients who underwent surgical resection of pancreatic cysts from 2/1997 to 5/2016. The presence of MNs on preoperative EUS, CT and MRI was recorded. Their diagnostic value was assessed, using histopathology as the gold standard.

Results: 88 patients with pancreatic cystic lesions according to preoperative imaging, who underwent surgery during the study period, were included. On surgical pathology 51 (64%) had benign findings; 29 (36%) had high-grade dysplasia or invasive carcinoma on IPMN. Seventeen patients (23%) had MNs on EUS. FNA was performed on 11, revealing malignancy in 2, which was confirmed on pathology. On histopathology, 9/17 (53%) had HGD or invasive cancer. The sensitivity (SN), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) of mural nodules on EUS for identification of advanced neoplasia were 35%, 83%, 53% and 70%, respectively, with an overall accuracy of 66%. CT/MRI had a SN, SP, PPV and NPV of 15%, 93%, 53% 67% and 53%, respectively.

Conclusion: Most patients undergoing surgical resection of pancreatic cysts have benign conditions. Only 53% (9/17) of patients with MN on preoperative EUS had advanced neoplasia on histopathology. The perceived presence of mural nodules on EUS might overestimate the risk of malignancy. Methods of accurate identification of mural nodules should be carefully addressed.

Increasing Adiponectin Receptor Levels Improves Anti-Proliferative Effects of Adiporon in Pancreatic Cancer

F. Messaggio. Department of Surgery, University of Miami, Miami, FL.

Background: The incidence of pancreatic cancer is associated with increased prevalence of obesity. Dysregulation of adipokines is thought to be a key mechanism of obesity-associated cancer progression. Adiponectin acts through two receptors, (ADIPOR1 and ADIPOR2,) to elicit pro-apoptotic, anti-inflammatory responses. We have shown that the level and expression of both adiponectin receptors are decreased in pancreatic tumors relative to normal pancreatic tissue. We hypothesize that increasing adiponectin signaling, by restoring receptor levels, would inhibit pancreatic cancer progression.

Methods: PPARγ agonists (15d-PGJ2 or Rosiglitazone) were applied to pancreatic cancer (PDAC) cells in vitro in order to induce adiponectin receptor transcription. Alternatively, in order to investigate epigenetic regulation of AdipoRs, PDAC cell lines were treated with the methylation blocking drug 5-Azacytidine. Receptor levels were quantified by qRT-PCR or western blot analysis. To determine their functional effects, PPARγ agonists or 5-Azacytidine were used alone or in combination with AdipoRon and assayed for changes in proliferation.

Results: We found that the anti-proliferative effects of AdipoRon positively correlate with AdipoR expression. Adiponectin receptor expression in PDAC cells was significantly increased by stimulation with PPARγ agonists, while suppression of methylation resulted in increased protein levels of both AdipoRs. Importantly, PPARγ stimulation of PDAC cells had an anti-proliferative effect which was synergistic when combined with AdipoRon.

Conclusion: Modulating transcription and epigenetic regulation of adiponectin receptors provides two independent approaches that enhance adiponectin signaling and inhibit PDAC proliferation.

Arterial Sub-Adventitial Dissection: A Novel Technique and Implication for Updated Classification of Artery Invasion

Y. Miao,¹ B. Cai,¹ L. Yin,¹ Z. Lu,¹ K. Jiang,¹ M. Li,² C. Dai,¹ J. Wu,¹ W. Gao,¹ C. Xil,¹ J. Weil,¹ J. Chen,¹ F. Guo.¹¹Pancreas Center and ²Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Previously we have reported the preliminary case series of the novel artery sub-adventitial dissection (ASD) for artery involved locally advanced pancreatic cancer(ai-LAPC). The safety and oncology efficiency of this technique is now present.

Methods: Between June 2014 and June 2016, a consecutive series of 73 ai-LAPC patients identified with contrast-enhanced CT and surgical exploration received curative pancreatectomy with ASD served as the study group (ASD). All other 247 cases of non-artery-invloved PDAC received therapeutic surgery were enrolled as control group (Ctl).

Results: Demographic data, preoperative CA 19-9 and serum albumin showed no difference between two groups. More extended lymph node clearance, combined organ resection, major vessel resection and total pancreatectomy were found in ASD group (ASD vs. Ctl: 15.1% vs. 2.8%, 11.0% vs. 4.5%, 27.4% vs. 13.4%, 4.1% vs. 0.4%; P = 0.004, 0.039, 0.005, 0.037, respectively), of which had longer operation time (ASD vs. Ctl: 265.4±101.4 min vs. 228.7±90.2 min; P = 0.003). But ASD increase neither surgical blood loss(ASD vs. Ctl:347±323 mL vs. 283±315 mL; P = 0.131) nor intra-operative blood infusion(ASD vs. Ctl: 28.8% vs. 21.6%; P = 0.088). There were no significant difference in incidence of overall complication, POPF, DGE and 90-day post-operative mortality (ASD. vs. Ctl: 52.1% vs. 49.0%, 20.5% vs. 19.0%, 17.8% vs. 15.8%, 6.8% vs. 2.8%; P = 0.645, 0.773, 0.681, 0.154, respectively). More post-operative hemorrhage were found in ASD group (ASD vs. Ctl: 16.4% vs. 6.5%; P = 0.016). Survival Analysis revealed even Median OS between two groups (ASD vs. Ctl: 541 days vs 551days; P = 0.559).

Conclusion: ASD technique provided ai-LAPC patients novel treatment options and guaranteed similar survival as earlier T staging patients.

Characteristics and Results of Resected Pancreatic Ductal Carcinoma 2 cm or Smaller in Tumor Size

K. Misawa, Y. Ohshima, K. Saito, M. Tani, T. Uesaka, Y. Terasaki, T. Katayama, K. Okuda, T. Ohshima. Department of Surgery, Sapporo City General Hospital, Sapporo, Japan.

Aim: The purpose of this study is to clarify the clinicopathological characteristics and the results of resected small pancreatic ductal adenocarcinoma 2cm or smaller.

Patients and Method: We retrospectively investigated consequent 102 patients of pancreatic ductal adenocarcinoma who underwent pancreatic resection in our hospital, between January 1998 and December 2014. Sixteen patients were diagnosed small pancreatic carcinoma and we divided them into three groups, T1a, T1b and T1c and analyzed them.

Results: Average tumor size was 1.5 cm; range, 0.3-2.0 cm and there is one patient in T1a, three in T1b and 12 in T1c by measured on the histological cut specimen. Five patients (31.2%) presented symptomatically, three with jaundice, two with abdominal pain. Eleven patients were asymptomatic and to diagnose having pancreatic cancer was by medical checks. Seven patients were found to have pancreatic cancer in the pancreas head region, six patients in the body and three patients in the tail. Seven patients underwent pancreaticoduodenectomy and nine patients underwent panceratosplenectomy, and R0 resections were performed in all cases. Lymph node metastases were found in two in T1ab, and two in T1c. As for histological grade, three patients were G1 and one patient was G2 in T1ab, and four patients were G1 and G2 and G3 respectively in T1c. Adjuvant chemotherapy was performed in four cases. Post-operative recurrence was found in six patients, two in T1ab, and four in T1c. The five-year overall survival rate was 73% in all T1 patients, and there was a significant difference between the T1 patients and the other patients having tumor lager than 2 cm (P = 0.0001).

Conclusion: Prognosis of resected pancreatic cancer is extremely poor, however, if resected early stage, 2cm or smaller in tumor size, good prognosis could be achieved. To diagnose in early stage is crucially important.

Splenic Vein Involvement of Pancreatic Adenocarcinoma is an Adverse Prognostic Factor After Surgery in Consequence of Liver Metastasis

T. Mizumoto, H. Toyama, S. Terai, M. Kido, K. Ueno, T. Fukumoto, M. Tanaka, H. Mukubou. Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.

Background: Prognostic impact of pancreatic adenocarcinoma (PDAC) invasion to the splenic vessel is unclear. The aim of this study was to assess the clinical value of pathological and radiological splenic vessel invasion in PDACs of the body and tail.

Methods: Medical records of patients with PDAC of the body and tail who underwent distal pancreatectomy between 2003 and 2016 at Kobe University Hospital were retrospectively analyzed. Moreover, preoperative computed tomography (CT) images were reviewed in correlation with pathological splenic vessel invasion.

Results: 32 females and 38 males were enrolled. 22 patients (31.4%) were identified on pathological studies as having splenic vein (SV) invasion, while 6 (8.6%) had splenic artery (SA) invasion. Pathological SV invasion (but not SA invasion) was an independent prognostic factor on multivariate analysis (P = 0.049). On analysis of recurrence patterns, patients with PDAC positive for SV invasion were at higher risk of liver metastasis (P = 0.007); the associations were not significant for other recurrence patterns. Liver metastasis occurred earlier among the patients who had PDAC positive for SV invasion (P = 0.022). SV deformity/stenosis/occlusion on preoperative CT effectively predicted pathological SV invasion with a sensitivity of 95.5% and specificity of 79.2%. Radiological SV invasion was identified to be an independent prognostic factor in consequence of liver metastasis, reflecting pathological invasion.

Conclusion: Pathological SV invasion was independently associated with poor survival in consequence of liver metastasis in patients with PDAC of the body/tail. Radiological SV involvement may be a surrogate marker for pathological invasion.

Pancreatobiliary vs Head and Neck Manifestations in IgG4-related Disease: Distinct Subsets of the Same Disease

S. Mohapatra,¹ A. Sharma,² S.T. Chari.²¹Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, NJ; ²Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.

Background and Aim: Immunoglobulin G4-related disease (IgG4-RD) is a chronic multi-organ fibroinflammatory condition. However, the distribution of organs involved is not the same in all series. We compared the clinical profiles and various organ manifestations on either side of the diaphragm: head and neck (HN) versus pancreatobiliary (PB) in IgG4-RD.

Methods: From the Mayo Clinic, Rochester database we identified 141 subjects who met the organ specific criteria for IgG4-RD. The study subjects were further classified into HN (53) and PB (88) IgG4-RD based on the first organ manifestation; 26 of these had both HN and PB involvement. Group differences were tested with the student t test for continuous variables and chi-squared test for categorical variables.

Results: Subjects with PB IgG4-RD were older (median 64.8 vs 50.2 years; P < 0.0001), more commonly males (83% vs 60.4%; P = 0.003) and had a shorter duration of follow-up (24.4 vs 48.7 months; P < 0.0001) compared to HN IgG4-RD. Serum IgG4 levels, serum eosinophil counts and serum IgE levels were not significantly different between the two groups. In the 26 subjects who had both HN and PB manifestations the disease started with HN in 16 patients and PB in 10 patients. In HN IgG4-RD orbital, lacrimal gland, submandibular, parotid gland, asthma, sinusitis, lung manifestations were more common than in PB IgG4-RD (77% vs 4.5%, 21% vs 0%, 32% vs 8%, 13% vs 0%, 36% vs 9%, 51% vs 6.8%; P < 0.0001 and 13.2% vs 5.6%; P = 0.12 respectively). In contrast, compared to HN IgG4-RD, pancreas, biliary and renal manifestations were more frequently observed in PB IgG4-RD (98.8% vs 15%, 56.8% vs 3.7%; P < 0.0001 and 12.5% vs 7.5%; P = 0.36).

Conclusion: HN and PB IgG4-RD have distinct clinical profiles. Proximity matters in organ involvement in IgG4-RD and organs involved tend to cluster close to each. Whether these represent distinct subsets of IgG4-RD needs further study.

Safety and Efficacy of Endoscopic Transmural Necrosectomy for the Management of Symptomatic Walled-Off Pancreatic Necrosis: Korean Multicenter Experience

S.H. Moon,¹ D.H. Koh,² J.H. Cho,³ S.W. Park,² H.J. Choi,⁴ S. Jung.⁵¹Hallym University Sacred Heart Hospital, Anyang, Korea; ²Hallym University Dongtan Sacred Heart Hospital, Hwaswong, Korea; ³Gachon University Gil Medical Center, Incheon, Korea; ⁴Soonchunhyang University Bucheon Hospital, Bucheon, Korea; ⁵Inha University Hospital, Incheon, Korea.

Background: Interventions for symptomatic walled-off pancreatic necrosis (WOPN) have undergone a paradigm shift from open surgical necrosectomy toward endoscopic interventions such as transmural drainage and necrosectomy. Endoscopic transmural necrosectomy (ETN) provides a targeted approach with a reduction of systemic inflammation and avoidance of wound complications. We aimed to assess the clinical outcome and safety profile of ETN in patients with symptomatic WOPN in Korea.

Methods: Between October 2013 and March 2017, 20 patients of infected WOPN underwent ETN in Gachon University Gil Medical Center, Inha University Hospital, Hallym University Sacred Heart Hospital, Dongtan Sacred Heart Hospital, and Soonchunhyang University Bucheon Hospital. All clinical parameter were retrospectively collected and the follow-up data were also retrieved to determine the outcomes of ETN.

Results: Clinical success was achieved in 95% (19/20) of patients after 3 sessions (median, range 1-14) sessions of endoscopic necrosectomy with a total ETN time of 166 (median, range 30-1045) minutes. Remaining one patient underwent operation due to progression of sepsis even after ETN, and finally deceased. Short term complications occurred in 5 patients (3 minor bleeding, 2 stent migration and one Wernicke-Korsakoff syndrome) during the treatment period. Long term complications developed in 3 patients including 3 newly developed diabetes mellitus and one chyloascites. Among 19 patients with clinical success, PFC recurrences did not occur in any patients, but acute pancreatitis recurred in 2 patients.

Conclusion: In terms of therapeutic outcomes and safety, ETN with mechanical debridement was suggested to be an efficacious and reproducible method for treatment of symptomatic WOPN. Given the inherent aggressive properties and complications of ETN, further prospective randomized controlled trials may be warranted.

Alterations in KRAS, CDKN2A, TP53, and SMAD4 Predict Disease-Free Survival in Resected Pancreatic Ductal Adenocarcinoma

V. Morales-Oyarvide,¹ Z. Qian,² D.A. Rubinson,¹ J.A. Nowak,³ R.F. Dunne,⁴ M. Kozak,⁵ M. Welch,¹ L.K. Brais,¹ A. Da Silva,² T. Li,² W. Li,² A. Masuda,² J. Yang,² Y. Shi,² M. Gu,² Y. Masugi,² J. Bui,⁵ C. Zellers,¹ C. Yuan,¹ A. Babic,¹ N. Khalaf,⁶ A. Aguirre,¹ K. Ng,¹ R. Miksad,⁷ A. Bullock,⁷ D. Chang,⁵ J. Tseng,⁸ T. Clancy,⁹ D. Linehan,¹⁰ J. Findeis-Hosey,¹¹ L. Doyle,¹² A. Thorner,¹ M. Ducar,¹² B. Wollison,¹³ A. Laing,¹³ W. Hahn,¹ M. Meyerson,¹ C.S. Fuchs,¹ S. Ogino,² J. Hornick,¹² A. Hezel,⁴ A. Koong,⁵ B.M. Wolpin.¹¹Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA; ²Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA; ³Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; ⁴Department of Medicine, Division of Hematology and Oncology, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; ⁵Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA; ⁶Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; ⁷Department of Hematology and Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; ⁸Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; ⁹Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; ¹⁰Department of Surgery, University of Rochester Medical Center, Rochester, NY; ¹¹Department of Pathology, University of Rochester Medical Center, Rochester, NY; ¹²Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; ¹³Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, MA.

Aim: To determine whether alterations in the four main driver genes for pancreatic adenocarcinoma (PDAC) are associated with patient outcomes after cancer resection.

Methods: We evaluated 356 patients with resected PDAC from three U.S. centers. Using immunohistochemistry and next-generation sequencing, we assessed protein expression and DNA alterations for KRAS, CDKN2A, TP53, and SMAD4 in formalin-fixed, paraffin-embedded tumors. We analyzed the associations of gene alterations with disease-free survival (DFS) and pattern of disease recurrence after adjusting for age, sex, tumor characteristics, institution, and peri-operative treatment.

Results: Patients with KRAS mutant tumors had worse DFS than those with KRAS wild-type (median 12.3 vs. 16.2 months; adjusted hazard ratio [HR], 1.72; 95% CI, 1.04-2.84; P = 0.03). We observed particularly poor DFS in patients whose tumors had KRAS G12D mutations relative to those with mutations in other KRAS codons (median 9.5 vs. 14.3 months; HR, 1.68, 95% CI, 1.24-2.28; P < 0.01). Patients whose tumors lacked CDKN2A expression had worse DFS compared to patients with intact CDKN2A expression (median 11.5 vs. 14.8 months; HR, 1.62; 95% CI; 1.19-2.20; P < 0.01). Alterations in TP53 were also associated with worse DFS compared to wild-type TP53 (median 10.8 vs. 14.8 months; HR, 1.33; 95% CI, 1.02-1.75, P = 0.04). SMAD4 loss was not significantly associated with DFS. A greater number of driver gene alterations was also associated with poor outcomes: compared to patients with 0-2 alterations, those with four alterations had a HR for DFS of 1.79 (95% CI, 1.24-2.59; P < 0.01). Alterations in the four driver genes were not associated with local recurrence as first site of failure.

Conclusion: Alterations in the four main driver genes for PDAC are associated with higher hazards for disease recurrence and death following cancer resection in a large, multi-institutional population of patients.

The Role of Bedside Ultrasonography in Monitoring Postoperative Course After Pancreaticoduodenectomy

E. Morandi,^1,2 C. Corbellini,² M. Castoldi,^1,2 M.N. Giudici.^1,31Fondazione Eugenio Morandi Onlus, Milan, Italy; ²General Surgery Department, Ospedale di Rho, Milan, Italy; ³Obstetrics and Gynecology Department; Ospedale di Rho - ASST Rhodense, Milan, Italy.

Background and Aim: Ultrasonography of the postoperative abdomen is commonly considered to be a challenging exam, especially in the immediate period after surgery. However, routinely use of ultrasound should be useful for monitoring postoperative patients to early detect complications, as is already the case for liver transplants. The advantage should be grater when the ultrasonography is done directly by the surgeon. The purpose of this study is to determine the feasibility and efficacy of this exam in this particular setting.

Methods: A total of 16 patients who underwent pancreatoduodenectomy for pancreatic cancer from May 2015 to May 2017 were included. These patients underwent two utrasonographies performed by a single surgeon, on the third and sixth postoperative days. Data and pictures were archived. Data recorded included patients' characteristics, surgical procedure details, postoperative complications and ultrasound results.

Results: Median age was 65 years (range, 42-78). A pancreatoduodenectomy with Double Jejunal Loop Reconstruction (bile and pancreatic juice were diverted from gastro-jejunostomy) was performed in all cases. Complications occurred in 8 patients (50%). In 5 of them (62%), a pancreatic fistula was diagnosed (2 Grade A; 3 Grade B). One patient developed biliary fistula and was reoperated. The average time to perform ultrasound examinations was 7.5 ± 2.7 minutes. A high quality ultrasound exploration was reached in 87% of the exams performed. Pain and BMI affected ultrasonography feasibility. Detection rate for fistula was 75% in grade B.

Conclusion: Ultrasonography has been found to be useful for monitoring, early detection and management of post-surgical complications. Surgeon performing the ultrasound examination had to be adequately trained.

The Way From Abdominal Pain to Pediatric Pancreatitis: the PINEAPPLE Study

D. Mosztbacher,^1,2 A. Párniczky,³ A. Toth,⁴ A. Demcsak,⁴ V. Ila,⁵ M. Abu- El-Haija,⁶ F.K. Szabo,⁷ I. Tokodi,⁸ B. Feher,⁹ K. Bako,⁹ O. Kadenczki,⁹ I. Guthy,¹⁰ I. Cazacu,¹¹ G. Veres,¹ K. Kaan,¹ M.F. Juhasz,¹ E. Horvath,¹ N. Lasztity,³ T. Decsi,¹² B. Mosdosi,¹² A. Nagy,¹² A. Szentesi,¹³ M. Sahin-Tóth,² P. Hegyi.¹³¹1st Department of Pediatrics, Semmelweis University, Budaptest, Hungary; ²Department of Molecular & Cell Biology, Boston University, Boston, MA; ³Heim Pál Children’s Hospital, Budapest, Hungary; ⁴Department of Pediatrics and Pediatric Health Center, University of Szeged, Szeged, Hungary; ⁵Department of Pediatrics, Dr. Kenessey Albert Hospital, Balassagyarmat, Hungary; ⁶Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; ⁷Children’s Hospital of Richmond, Virginia Commonwealth University, Richmond, VA; ⁸Department of Pediatrics, Szent György Teaching Hospital of County Fejér, Székesfehérvár, Hungary; ⁹Department of Pediatrics, University of Debrecen, Debrecen, Hungary; ¹⁰Department of Pediatrics, Jósa András Teaching Hospital of County Szabolcs-Szatmár-Bereg, Nyíregyháza, Hungary; ¹¹University of Medicine and Pharmacy Craiova, Craiova, Romania; ¹²Department of Pediatrics, University of Pécs, Pécs, Hungary; ¹³Institute for Translational Medicine & 1st Department of Medicine, University of Pécs, Pécs, Hungary.

Introduction: There is a rising incidence in the field of pediatric pancreatitis (PP), however the documented incidence of PP is very low and the PEM (pancreas enzyme measurement) correlates with the incidence of the disease.

Aims: The aim of the PINEAPPLE study is to estimate a current incidence of PP worldwide in concideration of the PEM. Furthermore we would like to develop EBM guidelines which would help to evaluate the necessity of PEM and abdominal ultrasonography when a child has abdominal pain.

Methods: PINEAPPLE is a registered (ISRCTN35618458), observational, multinational clinical trial and the prestudy protocol is already published (http://www.ncbi.nlm.nih.gov/pubmed/26641250). The PINEAPPLE-R is a retrospective review on children records appearing at ER units, whereas the PINEAPPLE-P is a prospective data collecting, PEM and abdominal imaging are performed in pediatric patients with abdominal pain. Until now we enrolled 27,170 pediatric patient records into the PINEAPPLE-R and 316 patients into the PINEAPPLE-P from 12 pediatric centres from 3 countries.

Results: PINEAPPLE-R: 9.5% (2598/27,170) of the children appeared at ER unit with abdominal pain. In case of abdominal pain 14% of patients had PEM and 32% of the patients had transabdominal ultrasonography. In our cohort the number of PEM decreases from the USA to Eastern Europe and clearly correlates with the incidence of PP. PINEAPPLE-P: 7 pancreatitis from 316 patients with abdominal pain were diagnosed. The positive family history and upper abdominal pain was characteristic for PP.

Conclusion: The PINEAPPLE-R clearly shows that the number of PEM performed at ER units are unacceptably low in children, which correlates with the incidence of PP. More patients are crucially needed for PINEAPPLE-P to develop EBM guidelines.

Epidemiology, Tumor Characteristics and Survival in Patients With Primary Pancreatic Lymphoma: A Population-Based Study Using the SEER Database

D. Mukhija,¹ S.J. Nagpal,^1,2 D. Sohal.³¹Department of Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; ³Cleveland Clinic, Cleveland, OH.

Introduction and Aims: Primary pancreatic lymphoma (PPL) is a rare manifestation of non-Hodgkin’s Lymphoma (NHL) and accounts for only 0.5% of pancreatic masses. Due to its rarity, there is paucity of information on its epidemiology and outcomes. Using the Surveillance, Epidemiology and End Results (SEER) database, we compiled the largest series of patients with PPL, and aimed to identify patient and tumor factors associated with survival in these patients.

Methods: Cases of PPL diagnosed from1973 to 2014 were identified using appropriate codes on the SEER Stat software. Data on patient and tumor characteristics were abstracted. Multivariable analyses were performed using Cox proportional hazards model; disease-specific survival was the primary outcome of the analyses.

Results: A total of 835 patients with PPL were identified, out of which 637 had no other malignancies and were included in subsequent analyses; 387 (59.7%) were male, and 84.6% were Caucasian. The median age of the study population was 66 years (interquartile range, 54–76). Surgery was performed in 57 (8.9%) patients; 454 (71.2%) patients received chemotherapy and 81 (12.7%) received radiation (non-exclusive). The median disease-specific survival was 5 months (IQR, 1–13 months). On multivariable analyses, age <65 years (HR, 0.50; P < 0.0001), married status (HR, 0.58; P = 0.0005), regional (vs distant) disease (HR, 0.68; P = 0.0074) and receiving radiation (HR, 0.58; P = 0.0360), chemotherapy (HR, 0.45; P < 0.0001) or surgery (HR, 0.47; P = 0.0162) were independently associated with improved disease-specific survival. ​​​​​​​

Conclusion: To our knowledge, this is the largest population-based study focusing on PPL using the SEER database. Younger age, being married, localized disease, and receiving chemotherapy, radiation or surgery were associated with improved disease-specific survival in patients with PPL.

*Simply imply that the P value is significant (i.e <0.05).

Understanding Pancreatic Cancer: National Pancreas Foundation’s (NPF) Animated Pancreas Patient (APP): Informing Patients for Better Health Outcomes

S. Munigala,¹ E. O’Reilly,² M. Alsante,³ J. Holt,³ A. Gelrud.⁴¹Saint Louis University, St. Louis, MO; ²Memorial Sloan-Kettering Cancer Center, New York, NY; ³National Pancreas Foundation, Bethesda, MD; ⁴University of Chicago, Chicago, IL.

Background: Pancreatic cancer (PC) accounts for substantial morbidity, mortality and cost. However, knowledge on patient education and barriers to health literacy are limited. We evaluated APP as a patient education resource to help address patient gaps in understanding and to reduce learning barriers to make informed decisions and to attain optimal health outcomes.

Methods: Using visual formats of learning for patient education related to PC (animations, expert videos, slide shows), we monitored website (WS) and YouTube (YT) audience metrics and data from September 2013 to November 2016 (38 months). We evaluated the number of learners, visits, and duration on the APP website in the US and globally. We calculated total views for APP, top views among PC animations and PC expert videos, and PC expert videos with the highest retention on WS and YT.

Results: Total: 213,115 views (US 141,037; other 72,078) were viewed by over 100 countries on the APP WS. (63,973 visits; average 4.8 min/visit) and 774,616 views (US 301,501; other 473,115) in over 100 countries on YT during the study period. 52.6% were patients, 17.6% were family/other; 14.6% were health care providers. 64.3% were US views. Audiences seeking information were interested in “Pancreatic Cancer: Signs, Symptoms and Risk Factors", "Pancreatic Cancer: Treatment and Outcomes", "Pancreatic Cancer: Pathophysiology, Diagnosis and Staging", and "Understanding Clinical Trials" with 7408, 5546, 4546, and 178 views respectively on YT and 4040, 3054, 1912, and 272 views on the WS respectively.

Conclusion: Education related to PC, based on visual formats of learning has vast potential to provide effective learning for patients and caregivers. Continued efforts should be made to provide patient resources that address patient learning barriers, particularly those of health literacy which educate and inform patients, in order to attain best possible health outcomes in PC.

Comparison of Insulin Resistance and Beta Cell Function in Patients With Chronic Pancreatitis, Pancreatic Cancer and Type 2 Diabetes Mellitus Using Homeostatic Model Assessment (HOMA)

S.J.S. Nagpal,¹ R. Basu,² W.R. Bamlet,³ S.T. Chari.¹Divisions of ¹Gastroenterology and Hepatology, ²Endocrinology, Diabetes, Metabolism, and Nutrition, and ³Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Background and Aims: The relative contribution of insulin resistance (IR) and decreased beta cell function (BCF) to glucose tolerance in patients with Chronic Pancreatitis (CP) and Pancreatic Cancer (PDAC) has not been well described. Homeostatic Model Assessment (HOMA) estimates IR and BCF using fasting serum glucose and insulin values. Using HOMA, we aimed to evaluate BCF and IR with varying degrees of glucose tolerance, i.e. normal fasting glucose (NFG) impaired fasting glucose (IFG) and diabetes mellitus (DM) among patients with CP and PDAC.

Methods: A total of 265 patients with PDAC, 112 with CP and 118 controls seen at our center between 1996 and 2011 had fasting levels of glucose, insulin and c-peptide measured. Patients with unknown glycemic status and those on insulin for treatment for DM were excluded. Overall, 194 patients with PDAC (90 DM, 67 IFG, and 37 NFG), 58 with CP (24 DM and 34 NFG) and 118 controls (46 DM, 14 IFG, and 58 NFG) were included in the final analysis. IR and BCF were measured using standard formulae for HOMA and adjusted for age and BMI.

Results: Mean age of CP patients (53.35 years) was lower than that of PDAC (66.22 years) and T2DM (66.10 years) (P < 0.0001*). Patients with T2DM had higher BMI (29.24 kg/m²) than CP (24.52 kg/m²) and PDAC (26.28 kg/m²); P < 0.0001*. Patients with PDAC had no significant difference in IR between those with NFG, IFG and DM (1.99, 3.10, and 4.47 respectively; P = 0.086) but showed a progressive decline in BCF (108.86%, 79.68%, 46.51% respectively; P = 0.0003*). Among patients with CP, those with DM had similar unadjusted HOMA-IR (2.22 vs 1.80; P = 0.324) but lower HOMA-BCF than those with NFG (39.79% vs 74.99; P = 0.0107*). Among patients with NFG, HOMA-IR was significantly higher in patients with CP and PDAC as compared to controls (1.80 vs 1.99 vs 1.35 respectively; P = 0.0053*).

Conclusion: Worsening glycemia in patients with CP and PDAC is likely secondary to a decrease in BCF but not worsening IR. Normoglycemic patients with CP and PDAC have higher IR than controls. Further studies are needed to distinguish DM associated with PDAC and CP from T2DM.

*Simply imply that the P value is significant (i.e <0.05).

Pathological Markers Which Predict Malignancy of Intraductal Papillary Mucinous Neoplasm (IPMN) of the Pancreas

J. Nakahodo,¹ Y. Fukumura,¹ Y. Yanai,¹ S. Tsuyama,¹ O. Mamat,¹ H. Mitomi,¹ H. Isayama,² S. Kawasaki,³ T. Yao.¹Departments of ¹Human Pathology, ²Gastroenterology, and ³Hepatobiliary Pancreatic Surgery, Juntendo University, Tokyo, Japan.

Background and Aims: The current management guidelines of Intraductal papillary mucinous neoplasms (IPMNs) are relatively fair, but need improvement. We tested the components used in the present guidelines and some other markers for possible predictors of malignant IPMN. Methods: 69 surgically-resected IPMN cases, including 32 benign and 37 malignant IPMNs, were used in this study. The cases with the possibility of IPMN and concomitant invasive ductal carcinoma were excluded. Duct-type, MPD/Branch duct size in maximum, height of papilla, histologic subtypes, mucin profiles, fibrotic density, and the atrophy of distal pancreas were evaluated. We investigated immunohistochemical profile of p53, p16, and βcatenin, mutational state of GNAS/KRAS, and the expression level of miR21 in IPMN tissues. Then, the relationship of each aspect of data to IPMN-malignancy was evaluated with univariate and multivariate analyses.

Results: With univariate analyses, (1) non-Branch duct types (P < 0.05), (2) MPD size in maximum (P = 0.01), (3) height of papilla in maximum (P < 0.01), (4) non-gastric subtypes (P < 0.01), and (5) the existence of dense fibrosis at tumor septum (P < 0.01) were related to IPMN malignancy with statistical significance. Severe atrophy at distal site (P = 0.16) was a suggestive factor of malignant IPMN, but did not reach statistical significance. The upregulation of miR21 was related to IPMN-invasiveness, but it did not discriminate benign/malignant IPMN. With multivariate analysis, histological subtype (non-gastric type) was the strongest predictor. Conclusion: Histological subtype (non-gastric type) is the strongest predictor to detect malignant IPMN. The miR-21 can be considered a useful marker to detect invasive IPMN.

A Novel Mechanism in Lymphatic Metastasis of Pancreatic Cancer

H. Nakayama,¹ K. Ohuchida,² S. Takesue,¹ S. Kibe,¹ Y. Ando,³ T. Abe,¹ S. Endo,² K. Koikawa,¹ T. Okumura,² T. Moriyama,² K. Nakata,² Y. Miyasaka,² K. Shirahane,² Y. Tominaga,¹ T. Ohtsuka,² K. Mizumoto,² M. Nakamura.²¹Department of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University, Fukuoka, Japan; ²Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan.

Background and Aim: Lymph node metastasis is an independent prognostic factor in pancreatic cancer. However, the mechanisms of lymph node colonization are unknown. As a mechanism of new lymphatic metastasis in other cancer, it has been reported that spheroid from cancer cells caused circular defects in lymphatic endothelial monolayers. In pancreatic cancer, similar mechanisms of metastasis have not been elucidated. We evaluate this new metastasis mechanism in pancreatic cancer and investigate the key factors related to this mechanism.

Methods: We used an in vitro co-culture system to analyze the mechanisms of tumor cell–mediated disruption of lymphatic vessels. We observed that spheroid from pancreatic cancer cells caused circular defects in lymphatic endothelial monolayers. In addition, using each cell line, we examined the changes in invasion pattern after addition of the supernatant of cancer cell cultures or VEGFC. To elucidate factors related to this phenomenon, aggregation of spheroid and adhesion to lymphatic endothelial cells were investigated using each cell line.

Results: The time-lapse microscopic images revealed that spheroid from pancreatic cancer cells caused circular defects in lymphatic endothelial monolayers. The formation ability of this invasive morphology was different depending on the cell lines, and was increased after adding the supernatant of cancer cell cultures or VEGFC. Neither aggregation of spheroid nor adhesion to lymphatic endothelial cells showed a significant correlation with this phenomenon. Conclusion: In vitro experiments demonstrated that spheroid from cancer cells caused circular defects in lymphatic endothelial monolayers. VEGF-C contained in the cancer supernatant is one of the promising factors controlling this phenomenon.

Novel c.49C>a (p.P17T) Mutation in the Activation Peptide of Human Cationic Trypsinogen (PRSS1) in a Case of Chronic Pancreatitis

B.C. Nemeth,¹ A. Szucs,² P. Hegyi,³ M. Sahin-Tóth.⁴¹First Department of Medicine, University of Szeged, Szeged, Hungary; ²First Department of Surgery, Semmelweis University, Budapest, Hungary; ³Department of Translational Medicine, University of Pécs, Pécs, Hungary; ⁴Department of Molecular & Cell Biology, Boston University, Boston, MA.

Introduction: Mutations in the activation peptide of human cationic trypsinogen (PRSS1) cause chronic pancreatitis by promoting premature, intrapancreatic trypsinogen activation. Chymotrypsin C (CTRC) can process the activation peptide to a shorter form which results in accelerated autoactivation of trypsinogen. PRSS1 mutation p.A16V stimulates autoactivation by increasing the rate of N-terminal processing by CTRC. The Hungarian Pancreatic Study Group (HPSG) performs genetic testing of young patients with idiopathic chronic pancreatitis. In this cohort we identified a novel de novo variant c.49C>A (p.P17T) in the activation peptide of human cationic trypsinogen.

Aims: Our aim was to investigate the biochemical characteristics and potential pathogenic effect of the novel p.P17T variant.

Methods: The index patient and family members were recruited by HPSG. Sanger sequencing of all exons in PRSS1, CTRC, SPINK1, CPA1 genes was performed in the index patient. Exon 2 of the PRSS1 gene was sequenced in the index patient’s parents. Trypsinogen was expressed recombinantly and its activation and N-terminal processing by CTRC were studied using enzymatic assays and SDS-PAGE.

Results: We identified a de novo c.49C>A (p.P17T) heterozygous mutation in exon 2 of the PRSS1 gene in a patient with childhood-onset chronic pancreatitis. This patient also carried a heterozygous p.N34S mutation of the SPINK1 gene. Compared to wild type trypsinogen, the p.P17T mutant showed accelerated N-terminal cleavage by CTRC and autoactivated markedly faster in the presence of CTRC. However, relative to the p.A16V mutation, these effects of the p.P17T mutation were slightly smaller.

Conclusion: The novel trypsinogen activation peptide mutation p.P17T showed similar biochemical characteristics as the pathogenic mutation p.A16V. Our results strengthen earlier findings that accelerated N-terminal processing of the trypsinogen activation peptide by CTRC is a relevant mechanism in the development of chronic pancreatitis.

Are Patients Cured After Pancreatic Resection? Definitions and Statistical Modeling

A. Nevler,¹ S.W. Keith,² H. Lavu,¹ T. Yeo,¹ C.J. Yeo,¹ J.R. Brody,¹ J. Winter.¹¹Department of Surgery and ²Division of Biostatistics, Thomas Jefferson University, Philadelphia, PA.

Background: Survival after pancreatic cancer (PC) resection is often presented in terms of 5-year survival. However, cancer recurrence is frequent beyond this point. The actual cure rate has never been defined and assessed methodically.

Methods: First, PC Patients, family members and clinicians were surveyed to understand perceptions of “cure” and to formulate a relevant and practical definition. PC survival reported in the SEER Database was then compared to age-stratified estimates from U.S Social Security Life-Tables to calculate cure rate, defined as the percentage of PC patients expected to achieve a normal life expectancy (age-adjusted). Time to cure (TTC) was defined as the survival interval required before a normal life expectancy could be expected. Since the dataset includes all PC patients, the cohort was enriched with patients who most likely underwent resection, by limiting the overall survival analysis to 5-year survivors (n = 5487, 3% of 183,898), and then adjusting survival by correcting for historical 5-year survival rates after resection (17%).

Results: PC stakeholders (n = 199) in all groups agreed that A) renormalization of life expectancy is the preferred metric of cure, compared to B) no evidence of disease, or C) 5-year survival (P < 0.001). In the SEER cohort, less than 5% of patients <75 years old achieved a normal life expectancy (cure), compared to 12% of patients over 80 years old. The median TTC was over 12 years in patients younger than 75 years old, but just 5 years in octogenarians.

Conclusion: Using this model, renormalization of life expectancy after PC resection is exceedingly rare for most patients, and surveillance should generally continue well beyond 5 years. Despite these findings, some patients are cured by resection. The likelihood of “cure”, using this practical definition, increases with age. Greater understanding of practical cure rates may inform surveillance strategies, management, and discussions with patients.

Cigarette Smoke Augments Pancreatic Cancer Stem Cells by Activating Paf1/PD2-mediated Stem Cell Signatures

R.K. Nimmakayala, P. Seshacharyulu, I. Lakshmanan, S. Rachagani, S. Chugh, S.K. Batra, M. Ponnusamy. Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE.

Background: Cigarette smoking (CS) is a major risk factor for pancreatic cancer (PC). It promotes cancer stem cells (CSCs) in various cancers; however, the role of CS in inducing pancreatic CSCs and the mechanism involved in this process are not yet delineated. It was shown that Paf1 (Paf1 complex protein) interacts with PHF5A (a Paf1 complex stabilizing protein) and this complex regulates pluripotency in embryonic stem cells. FRA1, an AP1 transcription factor has been shown to be upregulated in response to CS and to be involved in stem-ness maintenance. In addition, promoter analysis showed ten FRA1 binding sites on Paf1 promoter. Hypothesis: Based on these studies, we hypothesized that cigarette smoking increases FRA1, which activates a master stem-ness regulator Paf1/PD2, leading to the enrichment of pancreatic CSCs.

Methods: Cigarette smoke extract (CSE) treated (~10 weeks) HPNE (pancreatic normal ductal cells) and Capan-1 (PC) cells, and 20 weeks CS-exposed LSL-KasG12D and KRasG12D; Pdx-1cre mice pancreatic tissues were used.

Results: Our in vitro and in vivo findings showed that CS exposure increases expression of CSC markers along with FRA1 and Paf1/PD2. Knockdown of FRA1 reduced the expression of CS-induced Paf1/PD2 expression. Further study with CS ingredients (nicotine, NNK, and NNN) showed activation of nAChRα7-ERK-FRA1-Paf1 axis. CS also increased Paf1-PHF5A interaction, required for the activation of stem-ness genes.

Conclusion: Our results indicate that CS and its ingredients (Nicotine, NNN, and NNK) induces pancreatic CSCs by activation of nAChRα7-ERK-FRA1-Paf1 axis. It also increases Paf1/PD2-PHF5A interaction, crucial for the induction of stem-ness genes. These findings pave the way for the development of CSC-targeted therapies for PC patients with smoking history.

Gemcitabine Enhances Kras-MEK-induced Matrix Metalloproteinase-10 Expression in Gemcitabine-resistant Pancreatic Tumor-initiating Cells

A. Nishimura,¹ K. Shimizu,^1,2 Y. Kadoi,¹ Y. Takegaki,¹ M. Miyoshi,¹ Y. Hori.¹¹Department of Biophysics, Kobe University Graduate School of Health Sciences, Kobe, Japan; ²Department of Internal Medicine, Kobe Medical Center, Kobe, Japan.

Background and Aim: Advanced pancreatic ductal adenocarcinoma (PDAC) is often acquires resistance to systemic chemotherapy with poor prognosis. To understand mechanism underlying Gemcitabine (GEM) resistance might provide the second line treatment. We previously isolated a human pancreatic tumor-initiating cell line, KMC07, derived from a patient who acquired resistance to GEM. In this study, we examined the molecular mechanism of KMC07 resistance to GEM.

Methods: KMC07 cells were treated with GEM, then subjected to microarray analysis. Further functional analyses were performed using the quantitative polymerase chain reaction, immunoblotting, immunohistochemistry, chromatin immunoprecipitation, and cell transplantation into nude mice.

Results: KMC07 cell line was derived from a PDAC patient whose GEM treatment showed complete response for the first two years, but thereafter, acquired resistance to GEM. Microarray analysis showed that GEM enhanced matrix metalloproteinase-10 (MMP10) gene expression, the MMP-10 expression was in a GEM-dose dependent manner. KMC07 cells expressed KrasG12V constitutive active mutant and a MEK inhibitor (U0126) suppressed MMP-10 mRNA expression. GEM enhanced histone H3 acetylation at a MMP-10 promoter and a histone acetyltransferase inhibitor (C646) reduced GEM-enhanced MMP-10 mRNA expression. GEM induced MMP-10 protein in KMC07-derived pancreatic tumors in vivo.

Conclusion: We proved that KMC07 cells activated the KrasG12V -MEK- MMP-10 signaling pathway that was enhanced by GEM through histone acetylation, which might give novel impact to the GEM-based treatment for GEM-resistant PDAC.

Neoadjuvant Therapy Offers Longer Survival Than Upfront Surgery for Poorly Differentiated and Higher Stage Pancreatic Cancer

A. Nurmi,¹ H. Mustonen,¹ H. Parviainen,² K. Peltola,³ C. Haglund,^1,4 H. Seppänen.¹¹Department of Surgery, ²HUS Medical Imaging Centre, and ³Comprehensive Cancer Centre, Helsinki University Hospital, Helsinki, Finland; ⁴Translational Cancer Biology, University of Helsinki, Research Programs Unit, Helsinki, Finland.

Background: Neoadjuvant therapy for pancreatic cancer remains controversial. Our aim was to compare neoadjuvant therapy to upfront surgery in terms of survival and disease recurrence. Methods: Out of 399 consecutive pancreatic ductal adenocarcinoma (PDAC) patients operated at Helsinki University Hospital in 2000 to 2015, 75 borderline resectable patients received neoadjuvant therapy. Resectable propensity scored patients (n = 150) underwent upfront surgery. Neoadjuvant therapy consisted of folfirinox, single gemcitabine or combined with cisplatin, nab-paclitaxel or capecitabine with or without radiation. Survival was calculated with Kaplan-Meier and compared with the Breslow test. Survival was determined from the first day of treatment for patients receiving neoadjuvant therapy and the day of surgery for others, to death due to pancreatic cancer in disease-specific survival (DSS) and disease progression first recorded in disease-free survival (DFS).

Results: Between 2000 and 2015 DSS [34 (95% CI, 29–39) vs. 26 (20–32) months; P = 0.016] and DFS [22 (17–27) vs. 13 (9–17) months, P = 0.001] were longer in patients treated with neoadjuvant therapy than in those undergoing upfront surgery. Survival differences were not significant in the 2000s but were, in turn, among patients treated in the 2010s with better survival for patients treated with neoadjuvant therapy [DSS 35 (25–44) vs. 26 (20–31) months, P = 0.008 and DFS 25 (13–36) vs. 13 (6–21) months; P = 0.001]. Neoadjuvant therapy offered longer survival especially for patients with poorly differentiated G3 tumors [DSS 30 (17–42) vs. 11 (8–15) months; P = 0.004 and DFS 21 (11–31) vs. 7 (5–8) months; P = 0.001] and higher stage IIB-III [DSS 34 (29–40) vs. 20 (14–26) months; P = 0.006 and DFS 21 (12–29) vs. 10 (7–13) months, P = 0.001].

Conclusion: Neoadjuvant therapy offers PDAC patients longer DSS and DFS than upfront surgery. Neoadjuvant therapy benefits especially borderline resectable patients with higher stage and poorly differentiated G3 tumors.

Outcomes of Pancreatic Cysts Managed According to AGA Guidelines

A. Oakes,¹ B. Glessing,¹ A. Faulx,¹ A. Chak,¹ J. Dumot,¹ G. Parizher,² A. Richardson,² M. Hillam.³¹Department of Internal Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, OH; ²Case Western Reserve University School of Medicine, Cleveland, OH; ³University Hospitals St. John Medical Center, Westlake, OH.

Background: Incidental pancreatic cysts (PCs) are diagnosed with increasing frequency. While the majority are benign, some have malignant potential making accurate, safe diagnosis and effective surveillance critical. The most recent AGA guidelines have prompted controversy due to their departure from previous recommendations for endoscopic ultrasound (EUS) and surveillance duration. We report the outcomes of PCs referred for EUS at our tertiary referral hospital.

Methods: Retrospective review of all patients referred for EUS of PCs between 2011 and 2015, identified by ICD-9/10 codes.

Results: 208 patients underwent EUS to evaluate PCs (mean age 63, 56% F, 44% M). 55% of patients had management dictated by gastroenterologists (GI), 30% by surgeons and the rest by radiologists and primary care physicians (PCP). 33% of PCs were not managed in accordance with recent AGA guidelines, 85% of which would not have met criteria for EUS referral. In total, only 7 patients were found to have cyst progression to adenocarcinoma or dysplasia over the 4-year follow-up period. Four of these cases were not managed per guidelines and were followed by GI (2), surgery (1), and PCP (1). The 3 patients managed per guidelines were followed by GI (1) and surgery (2).

Discussion: The increase in detection and clinical variability of pancreatic cysts presents diagnostic challenges to physicians, made more confusing by the changing landscape of guidelines. The limitations in our study highlight the difficulty with managing PCs: progression can be missed despite following guidelines; variable referral data including radiology descriptions, cyst history, expectation for intervention; and lack of consensus to whom the responsibility for managing these pancreatic cysts should be designated.

Comparable Responses in Male and Female Mice to Cerulein-Induced Chronic Pancreatic Injury and Recovery

T. Obafemi, K. Liu, B. Cheng, P. Yu, J. Li, M. Younes, T. Ko, Y. Cao. UTHSC-Houston, Houston, TX.

Introduction: A higher incidence of chronic pancreatitis (CP) in males has been reported in human studies. Whether CP is reversible and whether sex factor influences CP recovery remain unclear. We hypothesized that sex-dependent differences exist during CP recovery, and designed following studies to test this hypothesis.

Methods: Adult C57BL/6 mice were administered cerulein (n = 3-6/sex/group, 50μg/kg, 5x hourly/day, 3 days/week, ip) for 4 weeks. Normal saline was injected as control. Pancreata were harvested either 4 days (injury group) or 4 weeks (recovery group) after the last injection. Acinar injury was scored on H&E sections. Fibrosis was assessed by Sirius Red staining. Macrophage infiltration was evaluated by CD68 immunohistochemistry.

Results: Four days after CP induction, pancreatic injury was shown (respective to males, females) by acinar injury score (3, 3), fibrosis (15, 11 % of area), and macrophage infiltration (8, 23 cells/field). Both males and females displayed similar responses on acinar injury and fibrosis, while females exhibited a 3-fold greater macrophage infiltration than males (P < 0.05). Four weeks after CP induction, pancreatic recovery occurred (respective to males, females) with a reversal of acinar injury (95, 100 %) and fibrosis (61, 45 %). Similar recovery responses were observed in both males and females. A reversal of macrophage infiltration (70 %) was observed in females, but not in males.

Conclusion: Cerulein-induced acinar injury is reversible, while fibrosis is partly reversed. Both male and female mice demonstrate comparable responses in CP injury and recovery, except for macrophage infiltration. Ultimately, understanding of CP recovery may provide insight and guidance for patient care.

The 2012 International Consensus Guidelines of Intraductal Papillary Mucinous Neoplasms of the Pancreas (Fukuoka Criteria) Predict Malignant Potential, Even in Actual Clinical Situations

Y. Okamura,¹ S. Sano,¹ T. Sugiura,¹ T. Ito,¹ Y. Yamamoto,¹ R. Ashida,¹ K. Sasaki,² K. Uesaka.¹Divisions of ¹Hepato-Biliary-Pancreatic Surgery and ²Pathology, Shizuoka Cancer Center, Sunto-Nagaizumi, Shizuoka, Japan.

Objectives: Although the diagnostic modalities for intraductal papillary mucinous neoplasm (IPMN) have been improved, it is often difficult to differentiate malignant from benign cases in IPMN patients without definite findings for surgical indications. The aim of the present study was to validate the utility of the 2012 International Consensus Guidelines of IPMN (Fukuoka criteria) in patients without findings of obstructive jaundice and/or an enhanced solid component.

Methods: This retrospective study included patients who underwent pancreatectomy for IPMN between October 2002 and September 2016. A pathological examination was performed in accordance with the 2010 World Health Organization criteria. The sensitivity, specificity, and positive and negative predictive values for malignancy were calculated for each feature of high-risk stigmata.

Results: Of the 135 patients who underwent surgery for IPMN, 50 (37.0%) had low/intermediate-grade dysplasia, 25 (18.5%) had high-grade dysplasia, and the remaining 60 (44.5%) had invasive carcinoma. A malignant potential was thus present in 63% of all resected cases. Considering an actual clinical situation, the predictors for malignant potential were assessed in 62 patients without findings of obstructive jaundice and/or an enhanced solid component. A multivariate analysis revealed that the Fukuoka criteria were the only independent factor for predicting the malignant potential (odds ratio, 5.69; 95% confidence interval, 1.12-28.9; P = 0.036) in an actual clinical situation.

Conclusion: The present study revealed that a high rate of malignant potential could be achieved by faithfully keeping the Fukuoka criteria. Using these criteria enables us to identify patients with malignant potential, even in the actual clinical situations.

Adipose Tissue Derived Stromal Cells Accelerate Tumor Progression and Desmoplasia of Pancreatic Cancer

T. Okumura, K. Ohuchida, T. Moriyama, K. Nakata, Y. Miyasaka, T. Ohtsuka, K. Mizumoto, M. Nakamura. Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan.

Background: Although the formation of desmoplasia in peripancreatic fat is one of the important histological changes during extra-pancreatic invasion of cancer cells, underlying mechanism and contribution of adipose tissue derived stromal cells (ASCs) remain unclear.

Aim: To investigate the role of ASCs in tumor progression and desmoplasia at extrapancreatic invasion site by in vitro and in vivo experiments.

Methods: We used organotypic fat invasion model in vitro, and visceral fat transplantation model in vivo, and performed Immunohistochemistry, Sirius red staining, and Fluorescent immunohistochemistry.

Results: To analyze the recruitment of ASCs in vitro, we established organotypic fat invasion model using visceral fat of CAG-EGFP mice. In both vertical and horizontal organotypic fat invasion models, GFP positive ASCs infiltrated toward cancer cells, though few cells were observed in the control model (P < 0.001). Next, we transplanted visceral fat of CAG-EGFP mice into the subcutaneous space of nude mice and pancreatic cancer cells were inoculated into the visceral fat pad. We also injected cancer cells subcutaneously and orthotopically without fat pad as control models. The weight of tumor with visceral fat was significantly heavier than other groups (P < 0.001), with increased αSMA positive cells and collagen fibers (P < 0.001). In addition, GFP positive ASCs were located around cancer cells and co-localization of αSMA and GFP was confirmed by fluorescent immunohistochemistry.

Conclusion: ASCs infiltrate toward extrapancreatic invasion site and accelerate tumor progression with dense collagen matrices. Inhibiting recruitment and activation of ACSs might lead to a novel anti-stromal therapy of pancreatic cancer.

Detecting Pancreatic Cancer Earlier: Identifying Type 3c Diabetes in Individuals Newly Diagnosed With Type 2 Diabetes

L. Oldfield,¹ R. Rao,¹ T. Purewal,² J.P. Neoptolemos,¹ C.M. Halloran,¹ W. Greenhalf,¹ E. Costello.¹¹Department of Molecular and Clinical Cancer Medicine, The University of Liverpool, Liverpool, United Kingdom; ²Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, United Kingdom.

Introduction: Over 40% of pancreatic cancer patients have diabetes mellitus (DM); up to 80% have glucose intolerance. Pancreatic cancer-associated DM (PDAC-DM) can precede cancer diagnosis by up to 3 years. Approximately 1% of individuals with new-onset DM have PDAC, it is therefore necessary to differentiate PDAC-DM (type 3c) from the more common type 2 DM for screening to be feasible in this high-risk group.

Aim: To develop a protein panel capable of identifying type 3c DM in individuals newly diagnosed with type 2 DM.

Methods: A comprehensive mass spectrometry-based discovery program, comprising >500 pre-diagnostic, diagnostic and control samples, identified 25 differentially regulated markers which were significantly enriched for an association with diabetes. Candidate markers were assessed using immunoassays in independent training (n = 140) and validation (n = 220) sets, which included a group of individuals newly diagnosed (< two years) with type 2 DM. Performance characteristics were obtained by ROC analysis.

Results: Of 19 candidate markers evaluated, significant differences in the levels of seven were observed between PDAC and DM or healthy subjects (P ≤ 0.05). The three most promising markers were selected for validation as future components of a diagnostic panel for the identification of type 3c DM.

Conclusion: The validated panel including CA 19–9 could enrich those individuals with new-onset DM at the highest risk of a subsequent diagnosis of PDAC, enabling them to be selected for clinical evaluation for PDAC.

Circulating Pancreatic Stellate Cells (Cpscs) and Tumor Cells (Ctcs) in Metastatic Pancreatic Cancer

T. Pang,^1,2 Z. Xu,^1,2 S. Pothula,^1,2 T. Becker,³ D. Goldstein,^1,2 R. Pirola,^1,2 J. Wilson,^1,2 M. Apte.^1,21Pancreatic Research Group, Ingham Institute for Applied Medical Research, Liverpool, Australia; ²South West Sydney Clinical School, University of New South Wales, Liverpool, Australia; ³Centre for Circulating Tumor Cell Diagnostics and Research, Ingham Institute for Applied Medical Research, Liverpool, Australia.

Background: Using an orthotopic model of pancreatic cancer (PC) produced by implantation of human cancer cells (AsPC-1) + human PSCs into pancreas of nude mice, we have previously shown that i) PSCs from primary tumors travel to distant metastatic sites; and ii) gemcitabine (Gem) treatment alone does not prevent metastasis, but Gem + inhibition of the hepatocyte growth factor (HGF)/c-MET pathway virtually eliminates metastasis. To determine whether the observed effects are secondary to modulations in CTC and cPSC numbers, we examined portal vein blood for these cells in our orthotopic model.

Methods: Mice bearing pancreatic tumors were randomised into 4 groups (n = 6 mice/group): 1) *IgG (controls); 2) Gem (75mg/kg IP twice weekly); 3) dual therapy - HGF antibody AMG102 (300microg IP twice weekly) + small molecule c-MET inhibitor (60 mg/kg daily gavage); 4) triple therapy - HGF antibody + c-MET inhibitor + Gem. Six weeks after treatment, pancreatic tumor size and metastatic burden were assessed. Portal vein blood was processed via a filtration device and CTCs and cPSCs identified by immunostaining for cytokeratin and alpha smooth muscle actin respectively.

Results: Data expressed as percent of IgG control (Mean ± SEM). Tumor burden was lowest in mice receiving triple therapy (primary tumor size 48.2% ± 5.7%; P < 0.002; metastasis score 15.5% ± 9.8%; P < 0.002). Gem treatment alone resulted in increased CTC numbers (vs IgG), but triple therapy reduced this back to control levels. Notably, circulating PSC counts were significantly reduced with dual therapy (17.4% ± 0.08%; P < 0.001).

Conclusion: Our study is the first* to demonstrate that i) PSCs are present in the circulation of pancreatic tumor bearing mice and ii) circulating PSC numbers are significantly reduced by inhibition of the HGF/c-MET pathway, which we have previously shown to be a major player in stromal-tumor interactions in PC.

Most Chronic Pancreatitis Patients Continue Smoking After Their Diagnosis

M. Parhiala,¹ J. Laukkarinen,² J. Sand.²¹Tampere University, Tampere, Finland; ²Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

Background/Aims: Progression of chronic pancreatitis (CP) may be slowed down by cessation of smoking and prevention of acute attacks. Our aim was to investigate the epidemiologic and behavioural data of CP patients in Finland.

Methods: Medical records of all patients with a CP diagnosis in Tampere University Hospital 2014–2015 were reviewed, and true CP patients included in the study database Information about CP ethiology, time after diagnosis, pancreatic function, treatment, complications, lifestyle. Quality of life (QoL) (QLQ C30, PAN26) and alcohol consumption (AUDIT) were gathered. Results: 235 CP-patients (57 (25–94) years, 65% men) were included. Time after diagnosis was 5.5 (1–41) years. Ethiology was alcohol in 67%, and smoking was contributing in 54%. 78% continued smoking and 56% alcohol consumption even after CP diagnosis. 65% had developed exocrine insufficiency, 55% endocrine insufficiency and 37% both. Pancreatic calcification occurred in 65% and enlarged pancreatic duct in 50%. CP related complications were common (pseudocysts 57%, pancreatic duct stenosis 10%, pseudoaneurysms 5%, pancreatic fistulas and porta thrombosis 5%). Pseudocysts were more common in alcohol related CP than in non-alcohol related CP (60% vs 38%; P < 0.05). Endoscopic procedures were done in 31% of the patients, consisting of bile duct stenting 19%, pancreatic duct stenting 61% and endoscopic draining 19%. Surgical interventions were done to 9%. Reported overall QoL and pancreatic pain were worse compared to healthy controls. 17% (n = 40) of the patients died during the follow-up, median 7 years after the CP diagnosis.

Conclusion: CP creates a great burden to the health care system and for the patients. The patients develop complications and symptoms frequently and the QoL is lower compared to others. According to the current knowledge, the most important step to halt the progression of CP would be to prevent acute phases and quit smoking. As this does not actualize in CP patients, it would be crucial to increase this awareness among CP patients and medical staff.

Examining the Potential Oncogenic Function of Septins and Their Interaction With Chmp1A Tumor Suppressor in Pancreatic Cancer Cells

M. Park,¹ V. Eversole,² Z. Slattery,² D. Upton,³ C. Roberts,² J. Kidd,³ T. Bentley.³¹Physiology, KYCOM-UPIKE, Pikeville, KY; ²KYCOM-UPIKE, Pikeville, KY; ³UPIKE, Pikeville, KY.

Introduction: Chmp1A functions as tumor suppressor by the activation of ATM and p53 in pancreatic cancer cells. The nuclear localization signal (NLS) of Chmp1A is required for cell growth inhibition and activation of ATM and p53. Proteomic analysis has identified Septins as NLS-deleted Chmp1A associated proteins. Since NLS-deleted Chmp1A promotes cancer cell growth, we hypothesized that Septins may function as oncogenes and that Chmp1A functions as tumor suppressor by inhibiting the oncogenic action of Septin proteins.

Objective: To examine whether Septins exhibit oncogenic activity and to investigate whether Chmp1A inhibits the oncogenic function of Septins.

Methods: Using pancreatic normal and cancer cells, we will compare Septin transcripts using PCR assays, Septin protein expression using Western blot, and Septin cellular expression using immunocytochemistry. We will perform immunohistochemical analysis to examine whether Septin expression is increased in pancreatic cancer tissues compared to corresponding normal tissues. We will utilize silencing technology and test whether Septin expression is regulated by Chmp1A.

Results and Future Direction: Our preliminary data indicates that the transcript and protein of Septins are increased in various pancreatic cancer cell lines compared to normal. Septin protein expression is increased or altered in human pancreatic ductal adenocarcinoma tissues compared to corresponding normal tissues. Additionally, our data implies that Chmp1A negatively regulates Septin expression since Septin transcripts and proteins are increased when Chmp1A protein is silenced. We are in the process of determining the function of Septins via overexpression or short-hair RNA mediated silencing approaches in combination with cell viability assays.

Factors Affecting Opioid Use in Hospitalized Patients With Acute Pancreatitis

N. Parsa,¹ M. Faghih,¹ F. Garcia Gonzalez,¹ A. Kamal,¹ N. Yahyapourjalaly,¹ R. Moran,¹ H. Al-Grain,² M. Makary,³ M. Khashab,¹ A. Kalloo,¹ V.K. Singh.¹¹Division of Gastroenterology and Hepatology/Internal Medicne, ²Department of Anesthesiology and Critical Care Medicine, and ³Department of Surgery, Johns Hopkins Hospitals, Baltimore, MD.

Introduction: Opioid analgesics are commonly used to treat abdominal pain in hospitalized patients with acute pancreatitis (AP). It is unknown whether the quantity of administered opioid is related to disease specific or patient specific characteristics. The aim of this study was to quantify the amount of opioids administered, and to determine factors associated with increased opioid use in hospitalized patients with AP.

Methods: The records of adult patients with the diagnosis of AP from 2006–2016 were reviewed. The revised Atlanta classification (RAC) was used to define AP. Exclusion criteria included outside hospital transfers, incomplete data, readmission for AP within 2 weeks, underlying chronic pancreatitis (CP) as defined by the presence of calcification(s) and/or a dilated main pancreatic duct (≥5 mm) on past or current abdominal imaging, psychiatric comorbidities, mechanical ventilation, chronic opioid use, and illicit drug use. Co-morbidities were quantified using the Charlson Co-morbidity Index (CCI). The BISAP ≥3 defined to predict severity. The medication administration record was examined to determine the total quantity of opioids administered in the first 7 days of hospitalization and was converted to oral morphine equivalents (OME), using the CDC opioid conversion chart. The total OME was divided by the total number of days of opioid administration to obtain a mean OME per day(s) of treatment. Results: There were 879 patients with AP, of whom 267 were included, with 56.2% males, the mean age of 47(±14) years, alcoholic etiology in 55.5 % and 39.9% with the first episode of AP. The mean OME/day was 59 mg. When OME/day was assumed as an indirect index of pain severity, it was found that age (β = −1.4; P = 0.008), black race (β = −21; P = 0.004), first episode of AP (β = −1.09; P = 0.049) and Hematocrit >44% (β = 25; P < 0.001) were significant predictors in multivariable analysis.

Conclusion: Advanced age, black race, and first episode of AP are independently associated with less, but hemoconcentration is associated with increased opioid use in patients hospitalized with AP.

E2F-1 Induced MCAK Overexpression Promotes the Proliferation and Gemcitabine Resistance of Pancreatic Cancer Cells

Y. Peng, Y. Zhu, Z. Lu, L. Yin, J. Wei, C. Xi, Y. Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Introduction: Some kinesin-like proteins was reported to play key roles in the progression of pancreatic cancer (PC) by promoting mitotic chromosome segregation. However, the roles of MCAK (a member of kinesin family) in PC is still unclear.

Aims: The purpose of this study was to investigate the expression and functions of MCAK in PC, as well as the potential mechanisms.

Methods: The TAGC and IHC data were both applied to assess the MCAK expression and prognostic roles in PC. MCAK knockdown and overexpression cells were used to perform a series of in vivo and in vitro assays to investigate the function and related mechanisms.

Results: The TCGA and IHC data suggested that MCAK was widely expressed in PC samples, and higher MCAK expression was positively associated with aggressive progression, and poor prognosis. Furthermore, functional assays suggested that MCAK could promote PC cell proliferation by accelerating S cell cycle. And MCAK knockdown or overexpression cloud respectively decrease or increase the gemcitabine resistance of PC cells by affecting RRM1 expression. Moreover, MCAK expression was positively correlated with CDK1, CCNB1, and RRM1expression in samples. Further CHIP and dual luciferase reporter gene assays demonstrated that E2F-1 could directly enhance the MCAK expression by binding to the promoter region of MCAK, and E2F-1 expression was also positively associated with MCAK expression in samples.

Conclusion: In conclusion, MCAK could act as a potential therapeutic target to inhibit PC growth and improve gemcitabine efficacy.

Intracellular Signaling Profiles of Blood Leukocytes in Sepsis Complicated by Organ Dysfunction and in Acute Pancreatitis in Relation to Disease Severity

A.K. Penttilä,¹ K. Kuuliala,² K.M. Kaukonen,³ H. Mustonen,¹ A. Kuuliala,² J. Oiva,⁴ M. Hämäläinen,⁵ E. Moilanen,⁵ V. Pettilä,³ P. Puolakkainen,¹ L. Kylänpää,¹ H. Repo.²Departments of ¹GI Surgery, ²Bacteriology and Immunology, and ³Anesthesiology, Intensive Care, and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsikni, Finland; ⁴Department of Surgery, Kuopio University Hospital, Kuopio, Finland; ⁵The Immunopharmacology Research Group, Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, Tampere, Finland.

Aim: To study if blood leukocytes’ signaling aberrations (i) in sepsis mimic those in acute pancreatitis (AP) and (ii) associate with outcome of AP.

Background: We have previously characterized changes in blood leukocyte signaling pathways in AP complicated by organ dysfunction (OD), yet, it remains unknown whether the changes (i) also occur in sepsis complicated by OD and (ii) associate with severity of inflammation in AP. Methods: The study comprises 14 patients with sepsis (11 with shock, 3 without shock) complicated by OD, 18 patients with AP (mild, n = 9; moderately severe, n = 6; severe, n = 3), and 28 healthy adults. Within 48 hours after admission to hospital, phosphorylation levels of nuclear factor ĸB (NF-ĸB), signal transducers and activators of transcription (STAT) 1 and 3, and extracellular signal-regulated kinases (ERK) 1/2 were measured, using whole blood flow cytometry, from stimulated or unstimulated monocytes, neutrophils, and lymphocytes.

Results: Proportions of stimulated pNF-ĸB-positive monocytes and their pNF-ĸB fluorescence intensities were lower in sepsis and AP than in healthy adults (P < 0.001 for all), while not associating with the severity of AP. Proportions of stimulated pSTAT1-positive monocytes and lymphocytes were depressed in AP (P < 0.001 for both), and associated with severity of AP (P = 0.002 and 0.003, respectively). Neutrophil STAT3 was constitutively phosphorylated in sepsis and AP, and proportions of pSTAT3-positive cells associated with severity of AP (P = 0.024).

Conclusions: Signaling aberrations in blood leukocytes in sepsis patients with OD mimic those in AP patients with OD. The aberrations in STAT1 and STAT3 pathways may provide novel severity markers predicting the evolution of OD in patients with early AP.

Effects of Unsaturated Free Fatty Acid (uFFA) Release in Severe Acute Pancreatitis (SAP)

A.E. Phillips,¹ A.S. Wilson,¹ G. Papachristou,^1,2 D.C. Whitcomb.¹¹Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; ²VA Pittsburgh Health Care and University of Pittsburgh, Pittsburgh, PA.

Background: Hypertriglyceridemic acute pancreatitis can be severe, with up to 30% mortality. Release of pancreatic lipase during systemic lipolysis in AP facilitates hydrolysis of triglycerides to free fatty acids (FFA), with studies showing acinar cell toxicity. In humans, endothelial injury results in a vascular leak syndrome (VLS), linking SAP with multi-organ dysfunction. Hypothesis: We hypothesize that FFA release in SAP causes toxicity to human intestinal microvascular endothelial cells (HiMECs), resulting in in vitro cell death and correlating with more severe clinical disease.

Methods: HiMECs were treated with long-chain FFAs Stearic Acid (SA), Oleic Acid (OA), Linoleic Acid (LA) for 24h. MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide) and Lactate Dehydrogenase (LDH) were tested. 85 serum samples were obtained from subjects enrolled in the Pancreatitis Associated Risk of Organ Failure (PROOF) study and stored at -80F. Pancreatitis was measured as mild, moderate, or severe by the 2012 Revised Atlanta Criteria. Serum fatty acid levels were tested through gas chromatography.

Results: HiMECs treated with increasing concentrations of SA, OA, and LA showed corresponding increases in cell toxicity, with LDH being lower in controls compared to cells treated with 0.6mM and 1.2 mM SA, OA, and LA (P < 0.05). In vivo, subjects grouped by pancreatitis severity (Control, Mild, Moderate Severe) had the following levels of FFAs (μM): Stearic Acid (μM) (41.1 ± 15.2, 79.1 ± 45.2, 93.9 ± 50.9, 99.9 ± 60.5; P = 0.0004); Oleic Acid (61.6 ± 39.0, 174.9 ± 66.5, 265.2 ± 137, 260.6 ± 130.4; P = 0.000); Linoleic Acid (41.9 ± 28.0,102.8 ± 63.2, 175.8 ± 123.6,144.4 ± 77.7; P = 0.00). Mean levels of unsaturated fatty acid levels (OA and LA) were higher than saturated (SA).

Conclusion: Long-chain FFAs cause direct cell toxicity in HiMECs, with uFFAs being more toxic than their saturated counterparts. Clinical studies in humans are needed to correlate uFFA levels and evidence of VLS and lipotoxicity.

Prior History of Pancreatitis Accelerates the Development of Pancreatic Adenocarcinoma

A.E. Phillips,¹ N. Shah,¹ D. Yadav,¹ R.E. Brand.²¹Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Shadyside Hospital, Pittsburgh, PA.

Background: Association of chronic pancreatitis (CP) and pancreatic adenocarcinoma (PC), and presentation of PC as acute pancreatitis (AP) is well recognized. Studies have shown the important role of inflammation in PC carcinogenesis. If inflammation from these conditions does promote tumorigenesis, we hypothesized that inflammatory changes associated with a remote history of AP or CP, defined as ≥2 yrs prior to PC diagnosis (dx), would result in an earlier age of PC dx.

Methods: Histologically confirmed PC patients enrolled in our PAGER study were reviewed for history of CP or AP. Date of dx relative to dx of PC was determined by reviewing questionnaires and medical records. Univariate analysis comparing patients with remote pancreatitis to those without a history of pancreatitis was calculated. Multivariate analysis was conducted through a linear regression model to control for gender, smoking, alcohol, diabetes, BMI, and BMI at age 18.

Results: From 790 eligible PC patients, a history of any pancreatitis was noted in 114 (14.4%): 65(8.2%) <2 years PC dx; 27(3.4%) ≥2 years PC dx; 22 were excluded due to unknown age pancreatitis dx. Univariate analysis revealed a significant difference in age at PC dx in patients with remote pancreatitis (62.5±10.8) compared to those with no history of pancreatitis (n = 676; 67.6 ± 10.8) (P = 0.016). Multivariate analysis revealed that remote pancreatitis patients presented 3.8 years earlier than patients without pancreatitis (P = 0.11).

Conclusion: A remote history of any pancreatitis appears to accelerate carcinogenesis with PC diagnosed 3.8 years earlier than patients without a history of pancreatitis. Future work focused on obtaining a larger cohort with remote pancreatitis is planned to allow validation of the findings by multivariate analysis.

Let-7b and SHH Inhibitor Combination Therapy for Pancreatic Cancer

R. Pothuraju,¹ V. Kumar,² R.I. Mahato,² M. Kalaga,¹ W. Junker,³ S.K. Batra,¹ S. Rachagani.¹Departments of ¹Biochemistry and Molecular Biology and ²Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE; ³Sanguine Diagnostics and Therapeutics, Omaha, NE.

Background: Pancreatic cancer (PC) is characterized by extensive desmoplasia, which is primarily driven by sonic hedgehog (SHH) signaling that plays an important role in tumor growth and metastasis, and limits the delivery/efficacy of chemotherapy. Let-7b is significantly down-regulated in PC and targets several important genes including KRAS and MUC4, which are known to play an important role in PC pathogenesis. To restore Let-7b and target desmoplasia in PC, we encapsulated Let-7b alone or in combination with the Vismodegib.

Methods: Let-7b expression was examined in human PC tissues, cell lines and in the KrasG12D;Pdx-1-Cre (KC) mouse PC progression model by TaqMan assay. Over-expression of Let-7b in PC cell lines was performed by lentivirus transfection and validated by TaqMan assay. Microarray and immunoblot analysis was carried out in the Let-7b transfected and vector PC cell lines. Finally, a self-assembling nanopolymer was used to encapsulate Let-7b alone or in combination with Vismodegib to treat PC.

Results: Let-7b expression was down-regulated significantly in human PC tissues, cell lines, as well as in the KC progression model. Microarray analysis of Let-7b over-expressing CD18/HPAF cell line showed down-regulation of KRAS, XIAP, PTEN, SMAD4, TERT, HMGA2, MMP9, MMP7, MMP2, NCOA3, ZEB1 and MUC4, which were validated by immunoblot. Ectopic expression of Let-7b led to inhibition of motility and EMT markers. Further, administration of encapsulated Let-7b/Vismodegib to mice carrying xenograft tumors resulted in less tumor weight and decreased metastasis to distant organs.

Conclusion: Over-expression of Let-7b resulted in down-regulation of tumor promoting genes and reduced tumor growth. Encapsulated Let-7b/Vismodegib is a potential therapeutic approach for PC.

Chronic Consumption of Ethanol Decreases Trimethylation at Lys9 and Phosphorylation at Ser10 of Histone H3 in Rat Pancreas

A. Pruitt,¹ C. Hernandez,² T. Patton,³ M.E. Sabbatini.¹Departments of ¹Biological Sciences, ²Pharmacology and Toxicology, and ³Psychological Sciences, Augusta University, Augusta, GA.

Introduction and Aim: Alcoholism can cause chronic pancreatitis, which can increase the predisposition to pancreatic cancer. Because combinations of histone modifications have been implicated in pancreatic tumorigenesis, our goal is to find histone modifications in pancreatic acinar cell nuclei following by chronic consumption of ethanol.

Methods: As an animal model of alcoholism, alcohol-preferring (P) rats were used. Alcohol non-preferring (NP) rats were used as a control.The rats were given access to one bottle of 20% ethanol and one bottle of water for a month. The phenotypic characterization of P rats was performed by amylase secretion and trypsin activation assays, as well as histology. Histones were extracted from rat pancreatic nuclear fractions using 0.4 N sulfuric acid and dialysis. Histone modifications were studied by Western-blotting analysis using the following antibodies: anti-trimethyl-histone H3 at Lys9 (H3K9me3), anti-dimethyl-histone H3 at Lys9, anti-phospho-histone H3 at Ser10, anti-acetyl-histone H3 at Lys14, anti-histone H3, anti-acetyl-histone H4, anti-histone H4.

Results: P rats consumed between 8 and 10 g of ethanol/kg BW/day, whereas NP rats consumed between 2 and 4g of ethanol/kg BW/day. The pancreas from either NP rats or P rats showed no developmental, gross morphologic or pancreatic histologic abnormalities. Cholecystokinin-stimulated amylase secretion and the levels of active trypsin were slightly increased in P rats compared with NP rats. Both histone H3 phosphorylation at Ser10 and trimethylation at Lys9 were attenuated in pancreas from P rats.

Conclusion: Chronic consumption of ethanol caused decreased levels of both trimethylation at Lys9 and phosphorylation at Ser10 of histone H3 in rat pancreatic tissues.

Overexpression of DCLK1 in Pancreatic Cancer Cells Increases Chemo-resistance via Activating KRAS/PI3K/MTOR Signaling Pathway

D. Qu,^1,2,3 N. Weygant,¹ J. Yao,¹ W.L. Berry,⁴ P. Chandrakesan,^1,2,3 R. May,^1,3 S.M. Sureban,^1,3 C.W. Houchen.^1,2,31Division of Digestive Diseases, and Nutrition, Department of Medicine, ²OU Cancer Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK; ³Department of Veterans Affairs Medical Center, Oklahoma City, OK; ⁴Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.

Aim: To determine whether overexpressing DCLK1 promotes pancreatic cancer cell chemo-resistance.

Background: Cells with cancer stem cell-like (CSC) properties have been identified in pancreatic ductal adenocarcinoma (PDAC). These cells are often resistant to conventional chemotherapy and radiation therapy, and as such may explain why current treatments do not cure PDAC or prevent recurrences. Doublecortin-like kinase 1 (DCLK1) is overexpressed and marks a population of tumor-initiating cells in PDAC. In this study, we evaluate the role of DCLK1 in PDAC responding to chemotherapy treatment.

Methods: Human pancreatic cancer cells were infected with Lentivirus containing DCLK1 cDNA to overexpress DCLK1 or red fluorescent protein (RFP) cDNA as control. These cells were treated with Gemcitabine, mTOR inhibitor (Everolimus), PI3K inhibitor (LY-294002), or BCL-2 inhibitor (ABT-199), and the effects were determined using cell toxicity assay. Expression of proteins of interest was detected by Western blotting. Analysis of gene expression in human PDAC was performed using the TCGA PAAD dataset.

Results: Overexpression of DCLK1 in pancreatic cancer cells resulted in significant resistance to Gemcitabine (P < 0.0001 at 200 nM), Everolimus (P < 0.005 at 37.5 μM), LY294002 (P < 0.05 at 27.5 μM), and ABT-199 (P < 0.05 at 5 μM). Knockdown DCLK1 expression re-sensitizes the cells for these inhibitors. Evidence from TCGA PAAD demonstrated that pancreatic tumors expressing high levels of DCLK1 had activated PI3K/AKT/MTOR-pathway signaling.

Conclusion: These findings demonstrate that overexpressing DCLK1 increases chemo-resistance maybe by activating KRAS/PI3K/MTOR pathway. Targeting DCLK1 in PDAC with therapeutics may overcome these pathways and increase the currently dismal PDAC patient survival.

Pancreaticoduodenectomy for Presumed Malignancy: Is a Preoperative Biopsy a Must?

H. Ramesh, J. Mathew. Surgical Gastroenterology, VPS Lakeshore Hospital, Cochin, India.

Background: Despite ISGPF and NCCN recommendations, there is a widespread tendency to attempt to achieve preoperative tissue histopathology of malignancy before pancreaticoduodenectomy (PD).

Aim: Analyze retrospectively the data of patients who underwent PD to determine the frequency of PD for benign diseases, and better determine which patients would benefit from preoperative tissue confirmation.

Methods: Out of 411 consecutive PDs in this center, 19 patients were excluded due to incomplete data. 392 patients were divided into three groups: group 1 (typical; painless obstructive jaundice with a demonstrable mass and double duct obstruction); n = 204 (52%), group 2 (atypical; anicteric, cystic lesion, ill-defined pancreatic mass, lymph node mass larger than primary, single duct obstruction or no ductal obstruction); n = 137 (35%), and group 3 (chronic pancreatitis with superimposed mass lesion); n = 51 (13%).

Results: Benign pathology occurred in 4 (1.96%), 12 (7.8%), and 14 (27.5%) among groups 1, 2 and 3. In group 1 and 2, there was no difference in the incidence of benign patholog whether preoperative biopsy was performed or not. There was a statistically higher incidence of benign pathology among patients in Group 3 who did not undergo preoperative biopsy.

Conclusion: Patients with typical presentation do not need preoperative biopsy before PD. Atypical presentation warrant preoperative biopsy. However, patients with chronic pancreatitis and mass lesions must undergo mandatory preoperative biopsy.

Assessment of Plasma Interleukin-6 as a Biomarker of Pancreatic Cancer-Induced Cachexia

M.L. Ramsey,¹ E. Talbert,¹ D.L. Conwell,¹ D. Ahn,² M.R. Farren,³ A. Hinton,¹ M. Dillhoff,¹ S.G. Krishna,¹ G.B. Lesinski,³ A. Manilchuk,¹ T.M. Pawlik,¹ P. Rajasekera,¹ C. Schmidt,¹ T. Bekaii-Saab,² D.C. Guttridge,¹ P.A. Hart.¹¹The Ohio State University, Columbus, OH; ²Mayo Clinic, Phoenix, AZ; ³Emory University, Atlanta, GA.

Background: Cachexia is common in patients with pancreatic ductal adenocarcinoma (PDAC), primarily due to local and systemic inflammation. Interleukin-6 (IL-6) is considered a key mediator of cancer cachexia. We sought to evaluate the role of IL-6 as a biomarker of PDAC-induced cachexia across all cancer stages.

Methods: We retrospectively studied 136 subjects diagnosed with biopsy-proven PDAC from 2010 to 2015. Subjects from all stages were included and were most commonly either stage IV (47%) or stage IIB (36%). Clinical data were abstracted and plasma IL-6 levels measured using both Multiplex Immunoassay (eBioscience, San Diego, Calif) and ELISA. Data were evaluated with univariate and multivariate comparisons.

Results: Seventy (56.9%) subjects had cachexia (i.e., a relative weight loss ≥ 5% at diagnosis). Neither detectable plasma IL-6 (Multiplex) nor plasma IL-6 above the median (ELISA) were associated with cachexia on univariate comparison (P = 0.47 and 0.37, respectively). Factors independently associated with detectable plasma IL-6 values (Multiplex) included Stage IV disease (OR, 8.23; P < 0.01), increased BMI at diagnosis (OR, 1.09; P = 0.05), and increased absolute neutrophil count (OR, 1.23; P = 0.04). In multivariate survival models high plasma IL-6 (detected by Multiplex or ELISA) and advanced cancer stage were independently associated with shorter median survival, whereas cachexia was not.

Conclusion: When considering all stages of PDAC, increased plasma IL-6 levels are not independently associated with cachexia. Rather, elevated plasma IL-6 is most strongly associated with an advanced cancer stage. IL-6 is not an accurate marker of PDAC-induced cachexia, but appears to reflect disease progression, and further study is needed to clarify its role in worsened survival.

Is Obesity Associated With Main-duct or Mixed-type Intraductal Papillary Mucinous Neoplasm?

A.C. Rodriguez,¹ L.K. Mejia,² P. Kandel,¹ M. Wallace,¹ T. Woodward,¹ V. Gomez,¹ J. Stauffer,³ H. Asbun,³ M. Raimondo.¹¹Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL; ²Department of Internal Medicine, Cleveland Clinic, Cleveland, OH; ³Section of General Surgery, Mayo Clinic Florida, Jacksonville, FL.

Background: Intraductal papillary mucinous neoplasms (IPMN) are mucin-producing exocrine neoplasms. Main duct (MD-IPMN) and mixed-type have been associated with a higher rate of pancreatic ductal adenocarcinoma (PDAC). Obesity is a risk factor of PDAC but interestingly a correlation with MD-IPMN has not been established. The aim of this study was to determine if obesity is associated with MD-IPMN and mixed-type.

Methods: This was a retrospective study of 98 patients evaluated at our Institution from October 1997 to April 2017. Diagnosis of IPMN was based on imaging and histology. MD-IPMN and mixed-type were grouped together given their high risk of progression to PDAC. Sociodemographic, anthropometric, co-morbidities, histology, imaging, and surgical reports were recorded. Obesity was classified according to the world health organization. Malignancy was defined as high-grade dysplasia or invasive carcinoma. Continuous variables were reported as mean and SD. Logistic regression was used to assess for an association between obesity and MD-IPMN. P values <0.05 indicated statistically significant differences.

Results: 98 patients with IPMN were included, 49 had surgical resection and 49 were observed. The mean age was 74, majority females (63%). History of chronic pancreatitis, ethanol, tobacco, & family history did not statistically differ between the groups. Patients with obesity did not have a higher risk of MD-IPMN OR, 1.083 (95% CI, 0.389-3.012; P = 0.878). Of those in the surgical group, 20 (41%) had a diagnosis of malignancy, 29 (59%) had a benign pathology. Of those with surgically confirmed malignancy, 3 (15%) were obese with MD-IPMN and 9 (45%) were non-obese with MD-IPMN.

Conclusion: The majority of patients with IPMN had a benign pathology. This study did not demonstrate an association between obesity and MD-IPMN which could be potentially be explained by the small sample size. Studying a larger cohort should be considered, recognition of modifiable risk factors may result in earlier diagnosis of MD-IPMN which could potentially lower the incidence of PDAC.

Nox1-Derived Reactive Oxygen Species Deteriorates the Pancreatic Exocrine Function in Middle-Aged Mice

J. Rommohan,¹ A. Pruitt,¹ K. Bhagat,¹ L. Miller,² M.E. Sabbatini.¹Departments of ¹Biological Sciences and ²Psychological Sciences, Augusta University, Augusta, GA.

Introduction: Reactive oxygen species (ROS) have been proposed as a pathogenic mechanism underlying the aging-induced pancreatic exocrine insufficiency. However, the source and functional significance of ROS in the deterioration of pancreatic function remain poorly defined. One of the major intracellular sources of ROS includes the NADPH oxidase (Nox). The mouse genome encodes four Nox enzymes: Nox1-4.

Aim: Study the extent to which Nox-derived ROS influences aging-induced impairment of pancreatic function.

Methods: Three groups of mice of different ages (4 weeks, 12 weeks and 40 weeks, which are equivalent to a human age of about 14, 26, and 50 years old, respectively) were used. Isolated pancreatic acini were prepared by collagenase digestion. Trypsin activation was determined using a colorimetric assay. Hydrogen peroxide formation was determined using OxiRed Probe and Horse Radish Peroxide. The expression of Nox enzymes in isolated pancreatic acini was studied by RT-PCR.

Results: CCK-dose response curve for amylase secretion from the three groups of mice displayed a biphasic pattern. However, the fold stimulation was lower at 40 week of age. Because oxidative stress associated with alcohol abuse plays an important role in the deterioration of pancreatic function in middle-aged patients, we studied the impact of the interaction between alcohol and CCK. We found that aging decreased CCK and ethanol-induced trypsin activation while increased CCK and ethanol-induced hydrogen peroxide formation. We also found that only Nox1 is expressed in isolated mouse pancreatic acini. To study the functional role of Nox1, the flavoprotein inhibitor, diphenyleneiodonium (DPI), was used. DPI reduced the effect of CCK, but not ethanol, on hydrogen peroxide formation and this effect was age-dependent.

Conclusion: Nox1-induced hydrogen peroxide impairs CCK-induced amylase secretion and trypsin activation in middle-aged mice.

GLI1 Complex With BRM to Control Gene Expression in Pancreatic Cancer

S.L. Safgren,¹ R.L. Olsen,² M.E. Fernandez-Zapico,² A.L. Vrabel,² N. Hernandez-Alvarado.²¹Mayo Clinic Graduate School of Biomedical Sciences and ²Oncology Research, Mayo Clinic, Rochester, MN.

Pancreatic ductal adenocarcinoma (PDAC) is a devastating cancer prognosis with limited effective therapies available to treat PDAC. It is essential to understand the molecular basis controlling PDAC pathobiology to develop new therapies. Our group and others have identified the transcription factor GLI1 as driver for PDAC initiation. Thus, understanding the mechanisms of GLI1-mediated gene regulation is a foundation for the development of new chemopreventive therapies targeting PDAC initiation and promotion. We have identified the ATPase BRM as a co-activator of GLI1’s transcriptional activity. GLI1 and BRM complex in pancreatic cancer cells and cooperate to regulate gene transcription. RNA-seq analysis following siRNA knockdown of BRM and GLI1 identified 527 genes coregulated by these proteins. The genes BMP3 and LEFTY1 involved in TGF-beta signaling were confirmed to be downregulated along with the ITGB3 integrin receptor and the PAD2 citrullination enzyme. Co-occupancy of GLI1 and BRM at the gene promoters of BMP3, LEFTY1 and ITGB3 was determined by ChIP-PCR. Interestingly, GLI1’s binding at the target gene promoters was impaired by BRM, but BRM occupancy was not affected by GLI1 knockdown. Using domain mutations, we observed the bromodomain of BRM has a greater influence on GLI1-mediated transcriptional activity than the ATPase domain. This suggests BRM may play a dual role as a coregulator and chromatin remodeler to promote the binding of transcription factors such as GLI1. Future experiments are aimed at evaluating both roles by assessing the chromatin changes and protein recruitment associated with the GLI1-BRM complex. Knowledge from these studies expands the understanding of epigenetic regulation of PDAC initiation and provides a foundation for chemopreventive therapies for this disease.

Time-Dependent Effects of Nerve Growth Factor on Pancreatic Cancer

J.L. Saloman, K.M. Albers, B.M. Davis. Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA.

In patients with pancreatic ductal adenocarcinoma (PDAC) and in genetic mouse models, up regulation of growth factors is correlated with a poorer prognosis, greatest neural invasion, and in the case of nerve growth factor, the most severe pain. Based on these observations, we hypothesized that NGF sequestration reduces neural inflammation and impedes PDAC development. Using the genetically engineered PKC(T) mice, we assessed the effects of bi-weekly injections of α-NGF (200 μg/kg) beginning at either 4wks of age (healthy) or 8 wks of age (PanIN stage). Mice receiving α-NGF beginning at 4wks of age had no detectable differences compared to vehicle treated mice in a number of measures including, peri-neural invasion, severity and spread of disease, and spinal GFAP expression (a marker of astrocyte activity). However, western blot analyses did show that mice receiving α-NGF beginning at 4wks of age had significantly higher levels of spinal p-ERK, a marker of cellular activation and inflammation. Interestingly, mice that received α-NGF beginning at 8 wks of age exhibited a significant reduction in spinal inflammation (GFAP-immunoreactivity), single pancreas-cell migration into the spinal cord, and grossly detectable metastases. Indeed, only 60% of these mice exhibited histopathology while 100% of vehicle treated mice exhibited some level of pancreas disease. In summary, later intervention (presumably after the onset of pancreatic disease), α-NGF treatment reduces spinal glial activation, neural invasion, and the severity of disease.

Changes in Body Composition During Neoadjuvant Treatment for Pancreatic Cancer

M. Sandini,¹ M. Patino,² C.A. Alvarez-Pérez,³ K.C. Honselmann,¹ C.R. Ferrone,¹ S. Paiella,⁴ M. Catania,⁵ L. Riva,⁶ G. Tedesco,⁵ R. Casolino,⁷ A. Auriemma,⁷ M.C. Salandini,⁸ G. Carrara,⁸ G. Cristel,⁹ A. Damascelli,⁹ D. Ippolito,⁶ M. D’Onofrio,⁵ K.D. Lillemoe,¹ C. Bassi,⁴ M. Braga,⁸ L. Gianotti,¹⁰ D. Sahani,² C. Fernández-Del Castillo. ¹ Departments of ¹Surgery and ²Radiology, Massachusetts General Hospital, Boston, MA; ³Department of Radiology, Hospital Universitario Dr. José Eleuterio González, Monterrey, Mexico; ⁴Unit of General and Pancreatic Surgery, Pancreas Institute, Verona, Italy; ⁵Radiology, Pancreas Institute, Italy; ⁶Department of Radiology, School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy; ⁷Oncology, General and Pancreatic Surgery Department, Pancreas Institute, Italy; Departments of ⁸Surgery and ⁹Radiology, Vita-Salute San Raffaele University, Milan, Italy; ¹⁰Department of Surgery, School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.

Aim: To evaluate whether neoadjuvant chemotherapy (NCT) affects muscle mass and adipose tissue in borderline resectable (BR) and locally advanced (LA) pancreatic cancer (PC) patients

Background: Sarcopenia and sarcopenic obesity have been associated with poor oncologic and long-term outcomes in unresectable PC. Neoadjuvant treatment is increasingly used to improve resectability. Its effects on fat and muscle body composition have not been characterized.

Methods: Patients undergoing surgical exploration after receiving NCT were analyzed. Measurement of body compartments was computed by abdominal CT-scan, prior and after NCT. Surface areas of skeletal muscle (SM), total (TAT) and visceral adipose tissue (VAT) were assessed at the third lumbar vertebra, using dedicated software and a standardized protocol to estimate body compounds.

Results: Radiologic imaging was available for 193 patients from 4 institutions. Most of them received FOLFIRINOX (65.8%). The median interval between pre- and post-NCT imaging was 6 months (IQR 4–7). All body compartments significantly changed. The adipose compound decreased (median TAT area from 284.0 cm² to 250.0 cm²; P < 0.001; median VAT area from 115.2cm² to 97.7cm²; P < 0.001), whereas the lean mass compartment slightly improved (median SM from 122.1 cm² to 123 cm²; P = 0.001). Surgical resection was achievable in 70.5% of patients. Resected patients experienced a 5.9% SM area increase with respect to baseline versus a 1.7% decrease in unresected patients (P < 0.001).

Conclusion: Pancreatic cancer patients experience a significant loss of adipose tissue during neoadjuvant chemotherapy, but no lean mass wasting. A lack of muscle tissue gain during NCT in unresected patients may represent a marker of tumor chemo-resistance.

Effect of Major Morbidity on Long-Term Survival Following Resection for Pancreatic Ductal Adenocarcinoma

M. Sandini,¹ K.J. Ruscic,² C.R. Ferrone,¹ K.D. Lillemoe,¹ M. Qadan,¹ M. Eikermann,² A.L. Warshaw,¹ C. Fernández-Del Castillo.¹¹Departments of Surgery and ²Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA.

Aim: To analyze whether long-term survival in pancreatic cancer (PC) is affected by the occurrence of major surgical complications.

Background: Postoperative major morbidity has been associated with worse survival in most gastrointestinal tumors. This association remains controversial in pancreatic cancer.

Methods: Records of all PC patients resected from 2007 to 2015 were included. Major morbidity was defined as any 30-day complication with grade 3-severity or higher (Clavien-Dindo Classification).

Results: Of 616 patients, 81.7% underwent pancreatoduodenectomy (PD) and 18.3% distal pancreatectomy (DP). Major complications occurred in 18.5%; 19.1% after PD and 15.9% after DP (P = 0.50). By univariate analysis, besides the conventional prognostic determinants related to pathology and receipt of adjuvant treatment, major complications worsened long-term survival in proximal resections (median OS 26 months vs. 15, P = 0.008). A difference was also seen at after distal pancreatectomy, but it did not reach statistical significance, likely related to small sample size (median OS 33 months vs. 18; P = 0.189). In the multivariate model for pancreatoduodenectomy, major postoperative complications remained independently associated with worse survival [HR, 1.38; 95% CI, (1.01-1.87); P = 0.041], together with nodal involvement [HR, 1.82; 95% CI, (1.35-2.47); P < 0.001], positive margins [HR, 1.39; 95% CI (1.08-1.80); P = 0.012], tumor size >3 cm [HR, 1.43, 95% CI (1.11-1.85); P = 0.006] and lack of adjuvant treatment [HR, 1.85; 95% CI (1.42-2.42); P < 0.001].

Conclusion: In pancreatic cancer, major surgical complications after pancreatic resection are associated with worse long-term survival. This effect is independent of the receipt of adjuvant treatment.

The CT Value of the Future Remnant Pancreas Predicts Pathological Fibrosis and the Risk of Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

S. Sano,¹ Y. Okamura,¹ K. Ohgi,¹ T. Sugiura,¹ T. Ito,¹ Y. Yamamoto,¹ R. Ashida,¹ K. Sasaki,² K. Uesaka.¹Divisions of ¹Hepato-Biliary-Pancreatic Surgery and ²Pathology, Shizuoka Cancer Center, Sunto-Nagaizumi, Shizuoka, Japan.

Aim: This study aimed to investigate whether the computed tomography (CT) values of the future remnant pancreas reflect pathological pancreatic fibrosis and predict pancreatic fistula (PF) after pancreaticoduodenectomy (PD).

Methods: Between January 2010 and December 2013, 237 consecutive patients who underwent PD were studied. The CT values of the pancreatic body and tail were measured on unenhanced CT. The degree of pathological pancreatic fibrosis of samples close to the pancreatic stump were scored to 7 grades. Correlations between the CT value of the future remnant pancreas and the degree of pathological pancreatic fibrosis and the incidence of PF were analyzed.

Results: The CT value of the future remnant pancreas was negatively correlated with pathological fibrosis (Spearman’s rank correlation coefficient [ρ]=−0.609). PF (International Study Group of Pancreatic Fistula Grade B/C) occurred in 81 patients (34%); its incidence was significantly higher in patients with CT value ≥35 HU than in those with CT value < 35 HU (75% vs. 25%, P < 0.001). A multivariate analysis revealed that a BMI ≥25 (odds ratio [OR], 4.63; P < 0.001), a main pancreatic duct diameter of <3 mm (OR, 2.63; P = 0.007), and a CT value of ≤35 HU (OR, 2.30; P = 0.027) independent predictors of PF.

Conclusion: The CT value of the remnant pancreas was correlated with pathological fibrosis. The preoperative CT values may be useful as a predicting factor for clinically significant PF after PD.

Sequential Gene Profiling of Metachronous Liver and Lung Metastasis After Pancreatectomy for Pancreatic Ductal Adenocarcinoma: A Case Report

H. Sato,¹ J. Sasajima,^1,2 Y. Ono,² T. Goto,¹ K. Koizumi,³ T. Okada,^1,2 S. Fujibayashi,¹ A. Hayashi,¹ H. Kawabata,¹ S. Takauji,¹ Y. Mizukami,^1,2 T. Okumura.¹¹Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University, Asahikawa, Japan; ²Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan; ³Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, Japan.

Introduction: Somatic mutations in KRAS, Tp53, SMAD4, and CDKN2A are frequently found in pancreatic ductal adenocarcinoma (PDA). Recent study demonstrated the number of the mutated driver genes is significantly correlated with post-operative survival; however, genetic landscape in patient with PDA who achieved long-term survival is still unclear. Here we performed sequential tumor genotyping of the PDA patient who has survived over 5 years with liver and lung metastasis after surgical intervention.

Methods: Genomic DNA was isolated from formalin-fixed paraffin embedded tissue of primary PDA and liver/lung metastases. Mutation profiles were determined by target amplicon sequencing covering 18 commonly mutated genes in PDA on Ion PGM system.

Results: A 42-years old female was hospitalized with a 3 cm mass in the body of the pancreas. The patient underwent distal pancreatectomy, and the pathological examination revealed moderately differentiated tubular adenocarcinoma. Six months later, a metachronous solitary liver metastasis was found. The metastasis slowly increased without any signs of another distant metastasis. Thus, the patient underwent hepatic segmentectomy. Twenty-five months later, another metastatic lesion was detected in the right pulmonary lobe. The patient underwent surgical resection again and is still alive with chemotherapy over 5 years later. Target-amplicon sequencing covering major PDA associated mutations demonstrated that all 3 tumor possessed identical KRAS mutation at codon 12 (p.G12V), and mutations in tumor suppressors Tp53, CDKN2A and SMAD4 were not identified. Additionally, sequential accumulation of mutations in other critical genes was not evident in the metastatic sites.

Conclusion: Surgical intervention for solitary metastasis can be considered in selected PDA patients. Clinical sequencing of tumor specimens provides a useful information for the patient selection and proper decision making.

Efficient Systemic Treatment With Fiber-redesigned Oncolytic Adenovirus in Pancreatic Cancer In Vivo Model

M. Sato-Dahlman,¹ Y. Miura,¹ J.L. Huang,¹ P. Hajeri,¹ H. Yoshida,¹ K. Jacobsen,² J. Davydova,¹ M. Yamamoto.¹¹Department of Surgery, University of Minnesota, Minneapolis, MN; ²Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN.

Pancreatic cancer is an aggressive malignant disease. Despite extensive efforts, systemic therapies have provided only limited efficacy for patients with this disease. Oncolytic Adenovirus (OAd) is a promising therapeutics, and it is also known for its efficient in vivo gene delivery. However, when adenovirus vectors are injected intravenously into mice, most of the virus goes to the liver and can in high dosage lead to liver toxicity. One of the reason for liver tropism is that hepatocytes express high levels of the primary adenovirus receptor, and non-parenchymal liver cells, such as Kupffer cell and epithelial cell, also capture the viral particle. As a consequence of large sequestration of adenovirus by liver, the tumor transduction rate is low and the in vivo efficacy is limited. Therefore, the improvement of cancer selective transduction and vector distribution to avoid liver sequestration would overcome the obstacles for systemic delivery and enable efficient systemic treatment of spread and/or metastatic lesions of pancreatic cancer with OAd. To improve the tumor transduction, we have generated the pancreatic cancer-targeted OAd (AdML-VTIN) by Ad library screening. AdML-VTIN targets the mesothelin protein, which is overexpressed on the surface of pancreatic cancer. AdML-VTIN showed selective and powerful anti-tumor effect against PANC-1 xenograft tumor model in both intratumoral (i.t.) and intravenous (i.v.) injection. Interestingly, when we assessed viral distribution after i.v. injection, the liver sequestration of AdML-VTIN was lower than AdML-5WT (Ad5 WT fiber) at 48 hrs after injection. By day 7, the viral copy number of AdML-VTIN in the tumor was significantly higher than WT. These results suggest that systemic injection of the tumor targeted-OAd showed significantly lower liver sequestration and better tumor accumulation. Both systemic and intratumoral injections resulted in remarkable anti-tumor effect at low dose. Mesothelin-targeted OAd may embody efficient treatment for pancreatic cancers which are mostly found with spread or metastatic lesions.

E47 Governs a p27/RB/C-MYC Regulatory Network Independent of p16 and Wild-Type p53 in Pancreatic Ductal Adenocarcinoma Cells

K.M. Scully,¹ R. Sasik,² R. Lahmy,¹ L. Signaevskaia,¹ A. Lowy,³ P. Itkin-Ansari.¹¹Development, Aging and Regeneration Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA; ²Center for Computational Biology and Bioinformatics, UCSD School of Medicine, La Jolla, CA; ³Division of Surgical Oncology, UCSD Moores Cancer Center, La Jolla, CA.

We have previously shown that overexpression of the basic helix-loop-helix (bHLH) transcription factor, E47, induced stable p21-dependent growth arrest in highly aggressive PDA cells in vitro and in vivo. Here, to integrate these findings into the broader system of genes that control the cell cycle, we profiled the entire E47-dependent transcriptome in five genetically diverse, low passage number patient-derived primary and established pancreatic cancer cell lines. The data revealed that E47 uniformly inhibited expression of cyclin-dependent kinases (CDKs) that disable RB through phosphorylation. Consistent with reactivation of RB, E2F target genes that license the G1/S cell cycle transition were downregulated. Conversely, E47 increased transcripts encoding the CDK inhibitor, p27, and importantly, blocked degradation of p27 protein. Moreover, both p27 and RB were required for growth arrest. In addition, c-MYC transcripts were decreased while proteosomal degradation of c-MYC protein was profoundly enhanced. At the cellular level, E47 elicited a senescence-like phenotype marked by increased SA-bgal activity and altered expression of C/EBP-a, LAMIN B1, and CENP-A. Together, the data establish that E47 governs a highly conserved network of cell cycle control genes, including RB and c-MYC, which can induce a senescence-like program in aggressive PDA cells that lack p16 and wild-type p53.

Nationwide Trends in Acute and Chronic Pancreatitis for Children and Adults in the United States From 2007–2014

Z.M. Sellers,¹ D. Macisaac,² H. Yu,¹ K.Y. Zhang,³ R. Bensen,¹ J.J. Wong,⁴ A. Gupta,¹ C. Kin,² K.T. Park.¹¹Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA; ²Department of Surgery, Stanford University, Stanford, CA; ³Department of Pediatrics, Stanford University, Stanford, CA; ⁴Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA.

Background: Acute pancreatitis (AP) is reported to affect ~10/100,000 children and 40/100,000 adults annually in the U.S. with increasing incidence. Chronic pancreatitis (CP) incidence is estimated to be ~8/100,000 adults and 0.5/100,000 children. Prior population health studies have only analyzed inpatient AP encounters and no study has used the same database to examine incidence in children and adults.

Aims: Determine the most up-to-date and comprehensive incidence of AP and CP in children and adults using a nationwide insurance claims database containing inpatient and outpatient encounters.

Methods: We utilized the Truven MarketScan Database consisting of insurance claims from inpatient and outpatient visits from 2007–2014. AP and CP patients were identified by their ICD-9 codes. The pediatrics cohort was <19 years old and adults were ≥19 years old. Incidence results are expressed per 100,000 people.

Results: There were a total of 102,295,088 pediatric and 288,662,274 adult patients from all 50 U.S. states, ranging from 0 to 64 years old. 14,589 pediatric and 410,274 adult patients had AP or CP. Pediatric AP incidence was steady from 2007–2014 with an incidence of 11.7 in 2014. There was a slight downtrend in adult AP with an incidence of 122.2 in 2007 and 110.4 in 2014. During this time, the percentage of adult admissions with AP increased. Pediatric and adult CP incidences decreased from 2.1-1.8 and 30.5-24.2 from 2007–2014, respectively. AP and CP incidences increased with advancing age.

Conclusion: We present the most up-to-date and comprehensive epidemiological trends on U.S. pediatric and adult AP and CP incidences. These trends will be presented in the context of recent trends in risk factors associated with AP and CP. Accurate epidemiological trends in pediatric and adult AP and CP will help to appropriately allocate health care resources to improve the care for individuals of all ages with pancreatitis.

Systemic Inflammation During Acute Pancreatitis is Regulated by NLRP3 Inflammasome Activation in Pancreatic Macrophages

M. Sendler,¹ C. Van Den Brandt,¹ F.U. Weiss,¹ J. Golchert,² G. Homuth,² M.M. Lerch,¹ J. Mayerle.³¹Department of Medicine A, University Medicine Greifswald, Greifswald, Germany; ²Interfaculty Institutes for Genetics and Functional Genomics, University Medicine Greifswald, Greifswald, Germany; ³Department of Medicine II, University Hospital München-Grosshadern of the LMU, München, Germany.

Introduction: Systemic inflammation in acute pancreatitis determines disease severity and mortality. Macrophages are the dominant infiltrating immune cell population during acute pancreatitis and play a crucial role in immune regulation. We investigated the role of the NLRP3-inflammasome-IL1β/IL18 signaling for the systemic immune response and the disease severity in acute pancreatitis.

Methods: Bone marrow derived macrophages were isolated from C57BL6 mice and co-incubated with freshly prepared acinar cells. Transcriptome analysis of macrophages was performed by affymetrix chip array. Severe acute pancreatitis was induced by partial duct ligation and additional cerulein stimulation (50μg/kg/bodyweight). MCC950 a small molecule inhibitor was used to prevent inflammasome activation in vivo as well as in vitro. Disease severity was determined by serum amylase, lipase and histology. Systemic inflammation was measured by MPO in the lungs and FACS analysis of splenic leukocyte populations.

Results: Macrophage activation by acinar cells leads to a massive pro-inflammatory immune response and the release of pro-inflammatory cytokines. Activation of the NLRP3 inflammasome complex results in caspase 1 activation and the release of IL1β and IL18. Absence of inflammasome activation by genetic deletion or inhibition via MCC950 results in decreased disease severity and reduced local and systemic inflammation. The pro-inflammatory immune response was triggered not only by innate immunitybut activation of the adaptive immune system as splenicCD4+ T-cells were also decreased. Affymetrix chip data from macrophages and acini in co-culture suggest that IL18 is the link to T-cell activation and SIRS.

Conclusion: Inflammasome activation within infiltrating macrophages induces systemic hyperinflammation by activation of the innate and adaptive immune system. Treatment with MCC950 prevents systemic hyperinflammation and decreases pancreatic damage. Inhibition of the inflammasomeappears a promising therapeutic option for the treatment of severe acute pancreatitis.

Gut Microbiome Depletion Decreases Tumor Burden in Murine Models of Pancreatic Cancer

V. Sethi, B. Giri, B. Garg, M. Tarique, S. Lavania, L. Hellmund, Z. Malchiodi, S. Banerjee, S. Roy, S. Ramakrishnan, A.K. Saluja, V. Dudeja. Department of Surgery, University of Miami, Miami, FL.

Background: Gut bacteria significantly outnumber human cells and constitute a distinct metagenome in the body. The relationship between gut microbiome and its host has only started to being unraveled in diabetes, asthma, colitis, etc. But, little is known on its role in pancreatic cancer. We aimed to investigate this relationship through various murine models of pancreatic ductal adenocarcinoma (PDAC).

Methods: C57BL/6J mice were either depleted of their gut microbiome by oral administration of a cocktail of broad-spectrum, non-absorbable antibiotics or were given vehicle only and had an intact gut microbiome. Both groups were used to model PDAC. This included subcutaneous implantation of pancreatic cancer cells derived from Kras LSL.G12D/+; p53 R172H/+ ;Pdx::Cre (KPC) mouse or orthotopic implantation of PDAC cells derived from Ptf1acre/+; KrasLSL.G12D/+; Tgfbr2flox/flox (PKT) mouse. To investigate the role of immunity, similar experiments were repeated in immunodeficient mice carrying a Rag1tm1Mom mutation (RAG1 knockout mice).

Results: Gut microbiome depletion significantly decreased tumor burden in both models of pancreatic cancer. Tumors derived from antibiotics-gavaged mice showed lower Ki-67 staining and their splenocytes showed higher in-vitro cancer cell cytotoxicity. Flowcytometry revealed increased Th1 cytokines-secreting leucocytes in antibiotics-gavaged group. Depleting gut microbiome in RAG1 knockout mice did not have any effect on tumor burden, thus implicating a role of immune system in mediating this phenomenon.

Conclusion: Gut microbiome depletion reduces pancreatic cancer burden through a possible immune system-mediated mechanism.

Ionizing Radiation Potentiates the Effect of Minnelide on Pancreatic Cancer

V. Sethi,¹ A. Da Silva Benaduce,² B. Giri,¹ B. Garg,¹ M. Tarique,¹ Z. Malchiodi,¹ S. Lavania,¹ L. Hellmund,¹ S. Ramakrishnan,¹ A. Ishkanian,² V. Dudeja,¹ A.K. Saluja.¹¹Department of Surgery, University of Miami, Miami, FL; ²Department of Radiation Oncology, University of Miami, Miami, FL.

Background: The annual incidence of pancreatic cancer (PC) approximates the annual mortality due to it. By 2020, it is predicted to become the 2nd leading cause of cancer-related deaths in the US. A search for an effective and rational treatment regimen still continues. Minnelide, a prodrug of an immunomodulatory botanical, Triptolide, has been shown by our group to be highly efficacious against PC in preclinical models and it acts at various levels: cancer stem cell, tumor angiogenesis and stroma. Ionizing radiation (IR) mainly acts by irreparably damaging the cancer cell at DNA level. We aimed to do a preclinical study of Minnelide combined with hypofractionated radiotherapy as a potential therapy for PC.

Methods: Effects of Triptolide (0–75 nM), IR (0–12 Gy) and their combination were studied on highly metastatic S2VP10 cells and on PC cells derived from Kras LSL.G12D/+; p53 R172H/+;Pdx::Cre (KPC) mouse. Cell viability, apoptosis and cell cycle were studied by appropriate assays. In vivo, C57BL/6J mice were implanted with KPC cells and effect of IR alone or in combination with Minnelide was studied. IR involved giving X-Rays to the tumor site at a dose of 2 Gy for 21 days. Minnelide was given at a clinically tolerable dose of 0.21 mg/kg/day.

Results: Low dose IR significantly potentiated the effect of Triptolide in decreasing cancer cell viability, increasing apoptosis and causing cell cycle arrest. IR + Minnelide was more effective in reducing PC burden than IR alone and the tumors, so treated, had the highest level of apoptosis among all groups.

Conclusion: Minnelide is soon going to begin its Phase II trial against advanced GI malignancies. Its combination with IR holds important promise for an effective therapeutic regimen against pancreatic cancer.

Pancreatic Cancer Following Incident Diabetes in African-Americans and Latinos: The Multiethnic Cohort

V.W. Setiawan,¹ D. Stram,¹ J. Porcel,² S.J. Pandol,³ C. Haiman,¹ K. Monroe.¹¹Preventive Medicine, ²University of Southern California; ³Cedars Sinai Medical Center, Los Angeles, CA.

Background and Aims: Diabetes mellitus has been proposed to be both a risk factor and a consequence of pancreatic cancer. The relationship between new-onset diabetes and subsequent pancreatic cancer incidence is not well understood, and epidemiological data in African Americans and Latinos are sparse. To address this gap, we examined the relationships between new-onset diabetes and incidence of pancreatic cancer in a prospective study of African Americans and Latinos in the Multiethnic Cohort (MEC).

Methods: We included African-American and Latino MEC California participants without prior diabetes and pancreatic cancer at baseline (1993–1996) in the analyses. We used a combination of questionnaires, Medicare inpatient and outpatient claims, and California hospital discharge files to identify new diabetes diagnoses in participants ≥ age 50. Subsequent pancreatic cancers in diabetic and non-diabetic subjects were identified via SEER registry linkages. Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for pancreatic cancer associated with diabetes adjusting for age, race, sex, body mass index, and smoking status.

Results: Among 65,654 African Americans and Latinos, we identified 20,401 (31%) with new-onset diabetes between baseline and 2013; 155 subsequently developed pancreatic cancer (age-adjusted incidence rate = 86.2/100,000). Compared to non-diabetics, new-onset diabetes was significantly associated with higher pancreatic cancer incidence (HR, 1.98; 95% CI, 1.61- 2.42). The association was evident in Latinos (HR, 2.38; 95% CI, 1.79-3.17) and African-Americans (HR, 1.63; 95% CI, 1.22-2.19). The association was particularly strong during the first 3 years after diabetes diagnosis (HR, 3.25; 95% CI, 2.54-4.16). The race-specific association was 3.61 (95% CI, 2.53-5.15) in Latinos and 2.97 (95% CI, 2.10-4.20) in African-Americans.

Conclusion: New-onset diabetes is associated with pancreatic cancer incidence in African Americans and Latinos, with a strong association observed within 3 years of a diabetes diagnosis.

Increasing Hyperglycemia and Diabetes With Increasing Tumor Size in Pancreatic Cancer Provides Insights Into Timeline of Growth of Pancreatic Cancer

A. Sharma, S.T. Chari. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.

Background: We have previously reported that in the 3 years prior to pancreatic cancer (PC) diagnosis fasting blood glucose (FBG) values progressively increase (mean FBG (mg/dl): 107 at −3 to −2 y vs. 114 at −2 to −1 y vs 123 at diagnosis) and diabetes (DM) prevalence increases in the same timeframe (24% at −3 to −2 y vs. 30% at −2 to −1 y vs 40% at diagnosis). We hypothesize that this correlate with increasing tumor size and the mean FBG and DM prevalence at different tumor sizes reflect the timeline of PC growth.

Methods: From the Mayo Clinic Tumor registry we identified subjects with resected PC categorized by size into Group I (≤15mm; n = 47), group II (16–29 mm; n = 280) and group III (≥30 mm; n = 134). We manually reviewed their medical records to verify PC diagnosis and tumor size, and abstract clinical data, FBG and DM status.

Results: The age (y) of subjects in Group I vs II or III was lower (62 vs 65 vs 65) (P = 0.07, 0.09, respectively). The mean BMI of the 3 groups was similar (P = 0.41). With increasing tumor size, there were increases in mean FBG (mg/dl) (108 Group I vs 128 Group II vs 140 Group III; P < .001), DM prevalence (25% group I vs 35% group II vs 46% group III; P = 0.01) and the proportion of subjects with CA 19–9 >50 IU/mL (37% Group I vs. 62% Group II vs 82% Group III; P < 0.001). A downward trend was observed for 5-year survival with increasing tumor size (50% Group I vs. 30% Group II vs. 11% Group III; P < 0.001).

Conclusion: In PC, rising FBG and DM prevalence in the 3 years prior to diagnosis mirror the increasing age, FBG levels and DM prevalence with increasing tumor size. Based on these data we propose that PC increases from 15 mm to 30 mm in size over 2 to 3 years. This has significant implications for early detection of pancreatic cancer.

Screening for Pancreatic Cancer in New-Onset Diabetes May Identify 20% of Incident Cases: A Population Based Study

A. Sharma,¹ K.G. Chaffee,² W.R. Bamlet,² B. Broderick,² A.L. Oberg,² G.M. Petersen,² S.T. Chari.¹¹Division of Gastroenterology and Hepatology and ²Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Background: Subjects aged *>* 50 years with new-onset diabetes mellitus (NOD) are a high-risk group for pancreatic cancer (PC). The aim of this study was to determine the incidence of NOD in the population and the incidence of PC in NOD while varying the interval between the 1st abnormal blood glucose (BG) at the time of meeting NOD criteria and the most recent prior non-elevated BG (left window [LW]).

Methods: Using Rochester Epidemiology Project (REP) data, we identified all BG values measured on subjects aged >50 years in Olmsted County (OC), MN. We assembled a cohort of all NOD subjects between 2000 and 2013. We also identified all PC subjects (n = 220) within the OC population diagnosed in the years 2000–2015, verifying histologic and clinical diagnosis by medical record review.

Results: Between 2000 and 2013 the incidence of NOD using an 18-month LW was 4.2/1000 subjects/year (n = 2047) of whom 24 (1.2%) were diagnosed with PC within 3 years and 16 (67%) were diagnosed within 1 year of meeting NOD criteria. Extending the LW to 36 months, the incidence of NOD was 4.9/1000 subjects/year (n = 2394) of whom 30 (1.3%) were diagnosed with PC within 3 years and 20 (67%) within 1 year of first meeting NOD criteria. Ignoring the LW, the incidence of NOD increased to 10.2/1000 subjects/year (n = 4978) of whom 46 (0.9%) were diagnosed with PC within 3 years and 19 (41%) within 1 year of meeting NOD criteria. Of the total of 220 PC patients in OC, 11% were included (n = 24) using an 18-month LW, 14% (n = 30) using a 36-month LW, and 21% (n = 46) when ignoring the LW.

Conclusion: Incidence of PC in NOD ranges from 0.9% to 1.3% depending on the length of time between prior non-elevated glucose and PC diagnosis. Screening for PC in NOD can potentially capture up to 21% of PC subjects.

O GlcNAc Modification of SOX2 Mediates Invasion and Self-Renewal in Pancreatic Cancer

N.S. Sharma,¹ V.K. Gupta,¹ P. Dauer,² K.K. Kesh,¹ A.K. Saluja,¹ V. Dudeja,¹ S. Banerjee.¹¹Division of Surgical Oncology, University of Miami, Miami, FL; ²Department of Pharmacology, University of Minnesota, Minneapolis, MN.

Pancreatic cancer remains an extremely aggressive, treatment resistant malignancy and the third leading cause of cancer related death in the United States. An increase in invasion and metastasis along with increased expression of self-renewal genes makes pancreatic cancer an extremely aggressive disease. O GlcNAcylation is a dynamic post translational modification in the serine and threonine residues of nuclear and cytoplasmic proteins mediated by the enzyme O-linked N-acetylglucosamine (GlcNAc) transferase (OGT). SOX2 is a transcription factor that regulates self-renewal along with OCT4. In the current study we show that O GlcNAcylation of SOX2 regulates its stability and function which can regulate the self-renewal and invasion of pancreatic cancer cells.

Methods: S2-VP10 and L3.6pL cell lines were used for all the experiments. Cells were silenced with 20nM of siRNA. OSMI was used as a pharmacological inhibitor of OGT at a concentration of 50 μM and DON was used at a concentration of 100μM. Female athymic nude mice, 4–6 weeks of age were used for the in vivo experiment. OSMI was given at a dose of 10mg/kg/day and DON was given at a dose of 1mg/kg/5days a week for 4 weeks.

Results: OGT was overexpressed in pancreatic cancer cell lines and in human pancreatic cancer tissues. The overexpression of OGT was found to correlate with an increase in invasion and self-renewal in pancreatic cancer cell lines. Among the self-renewal genes, SOX2 was found to be post translationally modified by OGT. SOX2 gets O GlcNAcylated in pancreatic cancer cell lines S2-VP10 and L3.6pL. Reduction in O GlcNAcylation of SOX2 results in a decrease in its reporter activity along with a decrease in the colony forming ability. Reduction in this post translational modification was found to reduce its ability to interact with its transcriptional partner OCT4. In addition to this in vivo inhibition of OGT and GFAT lead to a reduction in tumor volume in mice. Thus our data suggests that the O GlcNAcylation of SOX2 is responsible for its effect on invasion and self-renewal in pancreatic cancer.

Improved Outcomes for Severe Acute Pancreatitis in High Volume Hospitals

R. Sharma, H. In, P. Friedmann, J.C. McAuliffe, P. Muscarella. Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

Background: Studies have demonstrated better outcomes for patients with acute pancreatitis (AP) who are treated at high volume (HV) centers, but most of these include both mild and severe cases. Since almost all cases of mild AP are self-limiting, we hypothesized that these associations are attributable to cases of severe AP. The aim of the study was to investigate the relationship between hospital volume and in-hospital mortality for patients with severe AP

Methods: All adult patients in the Nationwide Inpatient Sample (NIS) database with a primary diagnosis of acute pancreatitis during the years 2007–2011 were examined. Severe acute pancreatitis was defined as acute pancreatitis with organ failure. Demographics, in-hospital mortality, and complications were compared across different hospital volume groups using descriptive statistical methods. Multivariate logistic regression analysis was used to examine factors predicting in-hospital mortality.

Results: We identified 30,211 patients with severe AP treated in 5109 hospitals. Hospitals were divided into three categories; low volume (<7 cases/year), moderate volume (≥7 - ≤21) and high volume (>21 patients). These hospital treated 10,429 (34.52%), 12,372 (40.96%), and 7410 (24.53%) patients. Overall in-hospital mortality rates were similar for each hospital group (5.93% vs 6.31% vs 5.99%), while surgical complication rates, bleeding, wound complications, and pulmonary infections were higher in the HV hospitals. Comorbidities, non-private insurance, and non-white race increased incrementally as hospital volume increased. On multivariable logistic regression analysis, we found that the HV hospitals were less likely to have in-hospital death as compared to the lowest volume hospitals (OR, 0.788; 95% CI, 0.668-0.930).

Conclusion: There appear to be some disparities in care for patients with severe AP with HV centers tending to treat more disadvantaged patients. After controlling for these factors, HV hospitals demonstrated improved outcomes. These data suggest that HV hospitals are better equipped to manage severe AP.

The Significance of Conversion Surgery for Unresectable Pancreatic Cancer

R. Shimazaki, S. Takano, H. Yoshitomi, K. Furukawa, T. Takayashiki, S. Kuboki, D. Suzuki, N. Sakai, S. Kagawa, H. Nojima, M. Ohtsuka. Department of General Surgery, Chiba University, Chiba City, Japan.

Background: About 20% of all pancreatic ductal adenocarcinoma (PDAC) cases have distant metastasis (metastatic unresectable PDAC: UR-M) at the time of diagnosis, and including locally advanced unresectable PDAC (UR-LA), more than 50% of PDAC patients are not initially subject to surgery. In recent years, multidisciplinary treatment with chemoradiotherapy has been performed for UR PDAC, some of cases can be converted from medical to surgical treatment, so called conversion surgery. In this study, we analyzed the clinical impact and significance of conversion surgery for UR PDAC.

Methods: A total of 42 (UR-LA group: 33 UR-M group: 9) PDAC patients undergoing conversion surgery in Chiba University hospital between 2006 and 2015 were analyzed retrospectively. We compared the clinicopathological factors, the period of preoperative treatment and the clinical outcomes between these two groups.

Results: The preoperative chemotherapy was administrated in 32 patients and chemoradiotherapy in 10 patients. In UR-M group, 6 patients (67%) had liver metastasis, 2 patients (22%) had lung metastasis, and 1 patient (11%) had peritoneal metastasis at the time of initial treatment. In all 42 patients, portal vein resection were underwent in 29 patients (69%) and arterial resection in 20 patients (48%). Median time of period from initial treatment to operation was 3.9 months in UR-LA group and 13.1 months in UR-M group. These results implicated that careful observation for more than 1 year was necessary for control of metastatic lesion in UR-M group. Median overall survival time (MST) in UR-LA group was 27 months and not reached yet in UR-M group.

Conclusion: We have achieved conversion surgery for 42 UR PDAC and it would contribute to improvement of prognosis. There is a possibility that conversion surgery is meaningful and a promising option, however, it is necessary to decide indication for determining the optimal condition.

Chronic Pancreatitis is a Devastating Disease Across All Ages

A. Uc,¹ S.J. Schwarzenberg,² M.E. Lowe,³ J.N. Abberbock,⁴ M.B. Zimmerman,⁵ D.C. Whitcomb,⁶ D. Yadav.⁶¹Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA; ²Department of Pediatrics, University of Minnesota, Minneapolis, MN; ³Department of Pediatrics, Washington University, St. Louis, MO; ⁴Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA; ⁵Department of Biostatistics, University of Iowa, Iowa City, IA; ⁶Division of Gastroenterology, Hepatology, and Nutrtion, University of Pittsburgh/UPMC, Pittsburgh, PA. Submitted on behalf of INSPPIRE & NAPS2 Consortium.

Background: Chronic pancreatitis (CP), well-characterized in adults, is increasingly recognized in children. No study has compared CP patients who presented in childhood with those who presented as adults to identify unique differences between the groups.

Objective: We compared demographics, clinical presentation, risk factors and disease burden of childhood and adult CP using two large multicenter cohorts.

Methods: We performed a cross-sectional study of data from INSPPIRE (pediatric) and NAPS2 (adult) cohorts. Values were reported as mean ± SD. We compared between-group differences using Pearson Chi-Square test, pain patterns with Wilcoxon rank sum test.

Results: Age of CP diagnosis was 9.8±4.1 for children (n = 189); 47.3±15.3 for adults (n = 1195). The majority were Caucasian (82% of children vs 76% of adults; P = 0.13); female sex was predominant in children (57% vs 46%; P = 0.004). Alcohol and smoking were reported exclusively in adults (51% vs 1% and 49% vs 8% respectively; P < 0.0001); genetic mutations (77% vs 25%; P < 0.0001), autoimmune pancreatitis and obstructive risk factors were more common in children (7% vs 2% and 30% vs 19% respectively; P < 0.001). Pancreatic calcifications were more common in adults (57% vs 16%; P < 0.0001), pancreatic duct stricture in children (38% vs 27%; P = 0.006). Pancreatic sphincterotomy and stone removal were more commonly performed in children (48% vs 31% and 25% vs 13% respectively; P < 0.0001). Adults with CP were more likely to suffer from exocrine pancreatic insufficiency (EPI) and diabetes (37% vs 25% ; P = 0.004 and 32% vs 5% respectively; P < 0.0001). Eighty-seven percent reported abdominal pain, with constant pain observed more often in adults (56 vs. 43%; P = 0.05). Pain medication and narcotic use were more common in adults (70% vs 57% and 63% vs 41% respectively; P < 0.001).

Conclusion: Pediatric and adult CP have distinct characteristics with advancing organ failure and significant burden at all ages. The high rate of EPI in adults may suggest earlier onset. Children may be undertreated for pain.

Preoperative Serum Elastase-1 Level is an Independent Risk Factor for Pancreatic Fistula After Pancreaticoduodenectomy

Y. Ueda. Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.

Aim: This study was designed to determine whether preoperative serum elastase-1 level can predict the risk of pancreatic fistula (PF) in the patients after pancreaticoduodenectomy (PD).

Methods: Medical records of 248 consecutive patients who underwent PD at our hospital from January 2007 to December 2013 were retrospectively reviewed. Correlation between preoperative serum elastase-1 level and incidence of PF was analyzed.

Results: The study cohort consisted of 162 men and 86 women with a median age of 67 years (range, 37–88 years). PD was performed for pancreatic adenocarcinoma (n = 121, 49%), biliary tract cancer (n = 83, 33%), the others (n = 44, 18%). Seventy (28%) patients had grades B and C PF. Preoperative serum elastase-1 level was significantly lower in the patients with PF than in the patient without PF (203±52 ng/ml vs 620±170 ng/ml; P = 0.02). The optimal cut-off value to predict high risk patients of PF was determined as 427 ng/dL using the receiver operating characteristic curve. On multivariate analysis, preoperative serum elastase-1 level ≤427 ng/dL was identified to be an independent risk factor for PF (P = 0.03) in addition to main pancreatic duct diameter ≤3 mm (P = 0.001), operative time ≥509 minutes (P = 0.004), and body mass index ≥25 (P = 0.03).

Conclusion: Preoperative serum elastase-1 level can predict the risk of PF in the patients after PD.

Expression of Sirtuin-3 and Tumor Heterogeneity in Pancreatic Ductal Adenocarcinoma

S. Urayama,¹ A. Habib.²¹Division of Gastroenterology and Hepatology, Department of Interal Medicine, University of California, Davis Medical Center, Sacremento, CA; ²Department of Internal Medicine, University of California, Davis Health, Sacramento, CA.

Background: Tumor heterogeneity is thought to contribute to chemotherapeutic resistance in pancreatic ductal adenocarcinoma (PDAC). SIRT3, as a mitochondrial sirtuin, has been implicated in regulating cellular metabolism and cancer growth. We investigated the role of tumor microenvironment characteristics which may play in remodeling the PDAC phenotype via changes in expression of SIRT3.

Methods: Gemcitabine treatment of PDAC cells were performed under hypoxic condition. SIRT3 overexpression vector was transduced into MiaPaCa-2. For cytotoxicity assay using WST-1 assay was performed. T-scratch test was completed with TScratch software [version 1.0, 18 May 2010 release, CSElab] for cellular invasion. Data was analyzed using t-test, with P < 0.05 significance. MitoSOX assay was used to detect intracellular superoxide levels.

Results: Both hypoxia and gemcitabine treatment (assimilating local tumor environment) resulted in increased Sirt3 expression. Sirt3 overexpression correlated with a 23% increase in cell viability following treatment with Gemcitabine (300nM, 48 hours, n = 6; P < 0.001). Sirt3 overexpression correlated with a 25% greater average open wound area relative to control (48 hours, n = 6; P < 0.001). Sirt3 overexpression negatively correlated with intracellular superoxide levels.

Conclusion: Tumor microenvironmental factors affected the expressions of Sirt3, and overexpression of Sirt3 positively correlated with increased cell viability following chemotherapeutic treatment, while negatively correlating with cellular invasiveness. Changes in superoxide levels as a result of overexpression suggest that Sirt3 may contribute to the anaerobic metabolic pathways. Further studies are in progress to elucidate the effects of such interactions.

A Systematic Review and Meta-Analyses of Genetic Risk Factor for Acute Pancreatitis

F.F. Van Den Berg,¹ R. Kempeneers,¹ M. Boermeester,¹ M.G.H. Besselink,¹ H.C. Van Santvoort,² Y. Issa.¹¹Department of Surgery, Academic Medical Center, Amsterdam, Netherlands; ²Department of Surgery, St. Antonius, Nieuwegein, Netherlands.

Introduction: Genetic risk factors are thought to enhance susceptibility in complex traits like acute pancreatitis. Researchers often face the difficulty of interpreting results from genetic association studies, due to failure of replication and methodological limitations. We systematically reviewed the literature on all genetic variants associated with the susceptibility to acute pancreatitis.

Methods: MEDLINE, Embase, BIOSIS, Web of Science and Cochrane were searched for eligible studies in duplicate. Meta-analyses was performed when multiple studies reported on the same mutation and odds ratios and confidence intervals were calculated. The Venice criteria and Bayesian False Discovery probability were applied to assess the credibility of the associations.

Results: 98 studies studies were identified, reporting on 230 polymorphisms in 80 genes. Meta-analysis of 30 variants resulted in the identification of one two highly credible association in SPINK1 rs17107315 (n = 9; OR, 2.70; 95% CI, 1.82-4.01) and IL-1b rs16944 (n = 4; OR, 1.28; 95% CI, 1.06-1.54). An association of moderate credibility was found in ALDH2 rs671 (n = 3; OR, 0.48; 95% CI, 0.36-0.64). Subgroup analyses according disease severity could not establish credible associations. Meta-analysis for AP susceptibility was not previously performed in 21 variants.

Conclusion: This is the first effort to systematically pool and grade genetic evidence in acute pancreatitis. Despite methodological flaws of the studies, our meta-analyses indicate a potential role for genetics in the pathogenesis of acute pancreatitis. Next-Generation Sequencing techniques and international collaboration is needed to determine the influence of genetic polymorphisms on AP susceptibility and severity.

Assessment of CFTR, SPINK1 and PRSS1 Mutations, Smoking, and Alcohol Abuse in Adult Chronic Pancreatitis Patients From Barcelona

E.C. Vaquero,¹ H. De Leon,¹ J. Velasquez,² C. Badenas,³ E. Varela,² X. Molero.²¹Gastroenterology Department, Hospital Clínic, Barcelona, Spain; ²Exocrine Pancreatic Diseases Research Group, Hospital Universitari Vall d'Hebron d'Hebron, Barcelona, Spain; ³Biochemistry and Molecular Genetics Unit, Hospital Clínic, Barcelona, Spain.

Genetic susceptibility for chronic pancreatitis (CrP) and impact of smoking/alcohol abuse show geographical variations. Non cystic fibrosis (CF)-causing CFTR mutations may have population, age and toxic dependent pathogenicity.

Aim: To examine CFTR, SPINK1 and PRSS1 mutations, smoking/alcohol abuse in adult CrP patients.

Methods: All coding regions (exons 2-3 for SPINK1 and PRSS1) in unselected 156 CrP patients (definite/probable) from two community centres in Barcelona and 82 controls were sequenced. 96 patients and 71 controls completed a 8-year follow-up.

Results: Smoking and alcohol abuse were more prevalent in patients. No relevant PRSS1 mutations were found. CFTR or SPINK1 mutations were present in 41% patients (7.3% controls; P < 0.001). 31% had CFTR mutations, most being non CF-causing variants (73%). Sweat chloride was higher in patients than controls (42.6±2.1 vs 30.3±1.7 nM; P < 0.001) irrespective of smoking, age or mutational status. 15% patients (n = 22) had SPINK1 mutations (0 controls; P < 0.001). Patients with specific mutation types had lesser rates of smoking or alcohol intake. Smoking (but not alcohol) correlated with the predicted basal CFTR function (r2=0.95; P = 0.02). CFTR/SPINK1 mutations were associated with early onset disease (37.6±1.7 vs 45.9±1.6 years; P = 0.001). On follow-up, 22% patients had 25 malignancies (9.8% controls) that developed earlier in patients carrying CFTR/SPINK1 mutations (P = 0.02). Mortality was higher (33.3% vs 11.2%) and occurred earlier (58.9±2.1 vs 70.2±7.1 years; P = 0.04) in patients than in controls due to cancer (lung, pancreas, other GI), cardiovascular or lung disease.

Conclusion: SPINK1 and CFTR mutations (most non CF-causing) are frequent in adult CrP patients from Barcelona. Smoking/alcohol abuse may contribute to gene mutation pathogenicity. CrP is associated with significant comorbidities and high mortality.

Dynamic, Serum-Dependent Clustering and Attachment-Independent Growth of Cultured Circulating Tumor Cells From Pancreatic Ductal Adenocarcinoma

R.T. Waldron,^1,2 R. Wang,¹ C.Y. Chu,¹ A. Nayebosadri,^1,2 A.E. Hendifar,¹ A. Lugea,^1,2 L.W.K. Chung,¹ S.J. Pandol.^1,21Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ²Department of Medicine, University of California, Los Angeles, Los Angeles, CA.

Pancreatic ductal adenocarcinoma is highly lethal due to aggressive malignancy/late diagnosis that often preclude surgical therapy. Circulating tumor cells (CTC), explored as diagnostic and treatment markers, have been isolated from patient blood both as single cells and as clusters. Biologic and behavioral studies are now enabled by recently advanced methods to culture CTC from PDAC patient-derived blood. We cultured rbc-depleted blood cells from nine patients, and in one case obtained proliferative cells, which we serially cultured over several months, cryopreserved and thawed, reconstituting viable cultures. KRas mutation status (wild-type at exons 1 and 2) was obtained by Sanger DNA sequencing. Dynamic cell clustering was monitored in real time using an Incucyte S3 Live-Cell Analysis System. Proliferating cells remaining after several weeks were designated “cultured CTC”. Undisturbed cultured CTC form free-floating, macroscopic clusters. Turbulence (brief shaking of culture flask) reversed clusters into cell suspensions; clusters rapidly reform in a serum-dependent manner. Without FBS, cells rapidly (within 10 min) adhere to dishes, change in morphology and shed cellular material. Adherent CTC become “inactive”, but re-cluster in days upon re-exposure to FBS. Microscopic images of forming clusters were recorded every six h in vivo for 48 h. FBS concentration-dependently promoted rapid increases in the number and size of CTC clusters. This clustering was attenuated at early times by 250 nM Latrunculin B. These data demonstrate serum-dependent, active CTC clustering mediated, at least in part by actin-based motility. Novel dynamic behavior and phenotypic shifts documented here have important implications for the biological role, behavior and responses of CTCs in PDAC.

Short-Term Outcomes and Risk Factors for Pancreatic Fistula After Pancreatic Enucleation: A Single-Center Experience of 142 Patients

X. Wang, C.L. Tan, X. Liu. Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China.

Background: Enucleation is increasingly used for benign or low-grade pancreatic neoplasms. Enucleation preserves the pancreatic parenchyma as well as decreases the risk of long-term endocrine and exocrine dysfunction, but may be associated with a higher rate of postoperative pancreatic fistula (POPF). The aim of this study was to assess short-term outcomes, in particular, POPF.

Methods: Data were collected retrospectively from all 142 patients who underwent pancreatic enucleation between 2009 and 2014 in our institution were analyzed.

Results: Lesions were most frequently located in the head and uncinate process of the pancreas (60.6%), and the most common types were neuroendocrine neoplasms (52.1%), followed by pancreatic cystic neoplasms (29.6%, including serous cystic neoplasms, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms). Overall morbidity was 66%, mainly due to POPF (53.5%), and severe morbidity (Clavien -Dindo grade III and above) was only 8.4%, including one death (0.7%). Clinical POPF (Grade B or C) occurred in 22 patients (15.5%). Independent risk factors for clinical POPF were age ≥ 60 years, an episode of acute pancreatitis, and cystic morphology. Tumor size, coverage (with Roux-Y loop), histological differentiation and prolonged operative time were not associated with the risk of POPF. Conclusion: Enucleation is a safe and feasible procedure for benign or low-grade pancreatic neoplasms. The rate of clinical POPF is acceptable, and clinical POPF occurs more frequently in elderly patients (≥60 years of age), patients with cystic neoplasms, or patients with an episode of acute pancreatitis.

Lin28B Facilitates the Progression and Metastasis of Pancreatic Ductal Adenocarcinoma (PDAC) by Downregulating Let-7 Expression

Y. Wang, H. Wang. Institute of Hepatopancreatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China.

Background: Lin28B is considered a potential therapeutic target for various human malignancies. We investigated the associations between Lin28B and the clinical features and outcomes of patients with PDAC, and whether Lin28B regulates cell proliferation, cell cycle transition, migration, EMT and the expression of c-MYC, HMGA2 and KRAS genes, which are targeted by the cancer-suppressor miRNA Let-7.

Methods: Lin28B expression in normal pancreatic tissue and PDAC tissue was detected by immunohistochemistry. The lentiviruses were transduced into PDAC cell lines, Lin28B-silenced and Lin28B-overexpreseed cells impacted on cell proliferation, cell cycle transition, migration and EMT were observed. Let-7 expression in normal pancreatic tissue and PDAC tissue was detected by RT-PCR. The correlation of Let-7a and Let-7b with Lin28B in cells was analyzed. GSEA was performed to obtain further insights into the Lin28B-mediated biological pathways involved in the pathogenesis of pancreatic cancer.

Results: The Lin28B protein was markedly overexpressed in the PDAC cell lines and the 185 archived, paraffin-embedded PDAC tissues. Its expression was strongly correlated with clinical stage, lymph node status, distant metastasis and vascular invasion in patients with PDAC. Lin28B knockdown significantly inhibits pancreatic cancer cell migration and the EMT, Its overexpression promotes the aggressive phenotype of pancreatic cancer cells. Lin28B decreases Let-7 levels and activates the following oncogenic pathways: c-MYC, HMGA2 and KRAS.

Conclusion: Lin28B facilitates the progression and metastasis of PDAC by downregulating Let-7 expression. It may serve as an important mediator of PDAC progression and an independent prognostic predictor in patients with PDAC.

The Impact of Metformin in Overall Survival in Diabetic Patients Diagnosed With Pancreatic Adenocarcinoma: A Meta-analysis

D. Wang,¹ J. Satiya,¹ J.S. Barkin,^2,3 E. Donath.¹¹University of Miami Miller School of Medicine Palm Beach Regional Campus, Atlantis, FL; ²Department of Gastroenterology, University of Miami Leonard Miller School of Medicine, Miami, FL; ³University of Miami Pancreas Center, Miami, FL.

Introduction: Pancreatic adenocarcinoma (PAC) accounts for the fourth leading cause of all cancer related deaths in the United States. Several studies have evaluated the use of metformin as potential adjunctive therapy through its inhibition of pancreatic adenocarcinoma (PAC) cell growth and proliferation by lowering IGF-1 levels and activating AMP-activated protein kinase. The aim of this meta-analysis was to examine if the use of metformin when compared to no exposure to metformin therapy leads to an increase in overall survival in patients with pre-existing diabetes diagnosed with PAC.

Methods: A total of 1256 studies were initially identified, of which seven were ultimately included in the meta-analysis. The primary endpoint of interest was overall survival assessed by hazard ratio. The pooled hazard ratio (HR) and 95% confidence intervals (CI) were calculated from the original study data by using the Mantel-Haenszel method (fixed effects model). Statistical heterogeneity was assessed using the forest plot and inconsistency statistic (I-squared). If any heterogeneity existed (I-squared > 50%), it was to be explored by subgroup analyses, meta-regression and sensitivity analyses.

Results: A total of seven retrospective cohort studies, involving 3807 pre-existing diabetic patients with PAC were included. Across studies, mean age was 75 years old and 49% of the patients were men. Sixty-one % had BMI <25 and 86% of patients had ECOG score of 0-1. Among the studies, 35% had either resectable or locally advanced disease and the remaining 65% had either unresectable or metastatic disease. Administration of metformin to pre-existing diabetic patients with PAC reduced the risk of overall mortality by 19% (OR, 0.81; 95% Cl, 0.75-0.86) when compared to those not taking metformin. I-square of the study was 48.8%, which was below 50% indicting statistical homogeneity among the studies.

Conclusion: Metformin exposure when compared to non-exposure is associated with an increase in overall survival in pre-existing diabetic patients diagnosed with PAC.

Significance of Baseline Neutrophil-to-Lymphocyte Ratio in Predicting Prognosis in Pancreatic Cancer Treated With Carbon-Ion Radiotherapy

M. Shinoto, H. Suefuji, K. Terashima, S. Toyama, Y. Shioyama. SAGA HIMAT Foundation, Ion Beam Therapy Center, Tosu, Japan.

Background: Neutrophil-to-lymphocyte ratio (NLR) is one of the systemic inflammation markers, which has prognostic values in many types of tumor. The aim of this study was to explore the prognostic factors including NLR for pancreatic cancer treated with carbon-ion radiotherapy (C-ion RT).

Methods: We retrospectively reviewed 41 pancreatic cancer patients treated with definitive C-ion RT in our institution between April 2014 and June 2015. The total dose of C-ion RT was 55.2 Gy (RBE) in 12 fractions. NLR was assessed before the treatment and the prognostic relevance as well as that of clinical variables were evaluated for overall survival (OS). Univariate analysis on OS was generated using Kaplan-Meiere method and compared using the log-rank test. Multivariate Cox proportional hazards analysis were applied to investigate independent prognostic factors.

Results: Among these 41 patients, 33 (80%) patients underwent induction chemotherapy and the median duration time was 3 (1-14) months. Basically, concurrent and maintenance chemotherapy were performed as much as possible. In all patients, the median survival time and 2-year survival rate calculated from the initiation of C-ion RT were 30 months and 61%, respectively. A high level of baseline NLR ≥ 2.19 was a significant poor prognostic factor (P = 0.0196). On multivariate analysis revealed that the NLR [hazard ratio (HR), 2.72; P = 0.0472] and performance status 1 (HR, 2.72; P = 0.0496), and tumor size < 3.5 mm (HR, 2.92; P = 0.0236) were independent negative prognostic factors.

Conclusion: Our study demonstrates that high baseline NLR was associated with worse survival.

Vasoactive Intestinal Peptide-secreting Tumors: 24 Year Experience From a Tertiary Center

P. Siddappa,¹ S.T. Chari,¹ M. Topazian,¹ M.J. Levy,¹ F. Gleeson,¹ R.K. Pearson,¹ B.T. Petersen,¹ M.B. Farnell,² M.L. Kendrick,² G. Thompson,² D. Farley,² S.S. Vege.¹¹Division of Gastroenterology and Hepatology and ²Department of Surgery, Mayo Clinic, Rochester, MN.

Introduction: Vasoactive intestinal peptide-secreting tumors (VIPoma) are rare hormonally active neuroendocrine tumors, manifesting with refractory watery diarrhea, hypokalemia and achlorhydria. Due to the rarity of the lesion, there are limited published data from single centers. Our Aim was to review the clinical spectrum, management and outcomes of patients with VIPoma at our high volume pancreas center.

Methods: All consecutive patients with diagnosis of VIPoma evaluated at our center from 1992-2016 were identified retrospectively and their clinical details recorded. Nominal data was described as percentages and continuous data was described as mean with range.

Results: We identified 20 patients with VIPoma during this period with a median age of 60 yrs (40–87) and 9 (45%) were male. Primary tumor was identified in the pancreas in 18 (90%) and 13 (72%) of them were in the tail region. Liver metastases were noted in 10 (50%) at diagnosis and in 2 of these no primary was identified. Diarrhea occurred in 19 (95%) and more than half of these patients had documented dehydration (68%) with hypokalemia (79%). Median serum VIP level was 281 pg/ml. Surgery was performed in 12 patients. The intent was curative in only 4 (30%). Ablation of liver metastasis by various techniques was done in 12 (60%) patients. Median follow-up period was 90 months (1–240). 11 patients were followed up for more than 5 yrs and 6 were followed up for more than 10 yrs. Six (32%) patients died with a median survival of 120 months (48–168). Among these, 5-year survival was seen in 5 (83%) and 10- year survival in 3 (50%).

Conclusion: Largest single center case series on VIPomas. Despite the high rate of metastasis, patients have good prognosis and long survival with aggressive multimodality treatment.

Indications and Clinical Outcomes for Pancreatectomy and Islet Autotransplantation (IAT) in a High Volume Pancreas Center

P.K. Siddappa,¹ Y.C. Kudva,² S.T. Chari,¹ M. Topazian,¹ M.J. Levy,¹ F. Gleeson,¹ P.K. Randall,¹ B.T. Petersen,¹ M.B. Farnell,³ M.L. Kendrick,³ S.S. Vege.¹Divisions of ¹Gastroenterology and Hepatology and ² Endocrinology, Mayo Clinic, Rochester, MN.

Introduction: Pancreatectomy and IAT is becoming an increasingly popular procedure most commonly for painful chronic pancreatitis (CP) and recurrent acute pancreatitis (RAP). Multiple concerns have been raised regarding the high narcotics and insulin dependence rates following this procedure. Proponents have advanced the indications to include even controversial entity of ‘minimal change pancreatitis’. With this background, we reviewed our experience with TPIAT over 6 years at our high volume pancreas center.

Methods: All patients who were considered for pancreatectomy and IAT from 2006 to 2012 at the Mayo Clinic, Rochester were retrospectively analyzed clinical and procedural details.

Results: Thirty-four patients were considered for pancreatectomy and IAT. Abdomen pain requiring narcotics was present in 26 patients. CP was seen in 22 and RAP was seen in 26 patients. Pancreatectomy and IAT was performed in 18 patients, and 16 patients underwent pancreatectomy without islets transfusion. Inadequate harvest of islet cells in 10 (62.5%), was the commonest reason for not transplanting. Total pancreatectomy was performed in 16 and partial pancreatectomy in rest. After pancreatectomy 12 (46%) still required narcotic medications at a median follow-up of 48 months. Insulin independence was seen in 43% of patients after IAT, compared to none in patients without IAT after 4 years.

Conclusion: Narcotic requirement was seen in almost half the population and insulin independence was seen in 43% at a median of 4 years. We urge strict selection criteria for this novel procedure to bring down the rates of narcotic and insulin dependence. Future may lie in the development of novel diabetes control regimens after TP like newer insulin delivery systems.

Dual Specificity Phosphatases (DUSPs) Role in Metabolic Reprogramming and Chemoresistance in Pancreatic Adenocarcinoma Cells

V. Silveira, P. Andrade, G. Vieira. Department of Genetics, Ribeirao Preto Medical School, Ribeirao Preto, Brazil.

Background: The highly malignant potential and aggressiveness of pancreatic ductal adenocarcinoma (PDAC) cells is mainly promoted by oncogenic KRAS activation, which triggers specific metabolic reprogramming pathways essential for PDAC progression mediated by MAPK activities. DUSP family constitute one of the major classes of phosphatases involved in MAPK regulation and their role in PDAC cells still remains to be elucidated. Here we investigated the DUSPs activity on MAPK signaling regulation and their impact on PDAC metabolic reprogramming and tumor chemoresistance.

Methods: PDAC cell lines (PANC-1 and Mia-PaCa2) stably expressing the Cas9 endonuclease were submitted to CRISPR screening using an Edit-R library (GE Dharmacon) of crRNAs targeting all DUSP genes with 3 crRNAs per gene. Phenotypic analysis was conducted to address metabolic reprogramming based on glucose uptake colorimetric assay and cytotoxic assay for gemcitabine response performed in a 4-day MTT assay. Furthermore, DUSPs RNAseq data from human PDAC samples (data generated by the TCGA Research Network:) was analyzed using the cBioPortal (Sci. Signal. 6, pl1 (2013)).

Results: CRISPR screening revealed several DUSPs involved in both phenotypic analysis. Interestingly, DUSP6, DUSP19, and DUSP26 knockout significantly reduced glucose uptake and increased gemcitabine responsiveness in both cell lines (P < 0.05). Gene expression profile analysis showed that DUSP6 is highly expressed (a 10-fold log scale upregulation) in PDAC samples and shows relevant correlation with glucose transporter genes.

Conclusion: These data suggest that specific DUSPs may play an important role in PDAC metabolic reprogramming and they could be a potential target for PDAC adjuvant treatment.

Comprehensive Genomic Profiling of 3426 Pancreatic Ductal Adenocarcinomas Identifies a Subset of Patients With Potentially Targetable Alterations

A.D. Singhi,¹ J. Greenbowe,² J. Chung,² M. Bailey,² N. Bahary,³ H.J. Zeh,⁴ R.E. Brand,⁵ P. Stephens,² J. Ross,² V. Miller,² S. Ali,² B. George.⁶¹Department of Pathology, University of Pittsburgh, Pittsburgh, PA; ²Foundation Medicine, Inc., Cambridge, MA; Divisions of ³Hematology and Oncology, ⁴Gastrointestinal Surgical Oncology, and ⁵Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁶Medical College of Wisconsin, Milwaukee, WI.

Background: Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal cancer with a 5-year survival of 9%. While surgical resection offers a chance of cure, >85% of patients are inoperable. Further, current chemotherapeutic options show limited efficacy. Recent genomic sequencing studies have reported recurrent mutations in KRAS, TP53, CDKN2A and SMAD4, and otherwise a low prevalence of targetable alterations. However, these studies are largely biased to surgical specimens or relatively small in size to adequately assess for infrequent mutations. In order to evaluate the breadth of targetable alterations in PDAC, we prospectively performed comprehensive genomic profiling (CGP) of 3426 PDACs in the context of clinical care.

Methods: Hybrid-capture based CGP was performed for up to 315 cancer-related genes and intronic regions of up to 28 genes rearranged in cancer. Tumor mutational burden (TMB) and microsatellite instability (MSI) status were also assessed. TMB was calculated by counting mutations across a 1.25 Mb region with TMB-high (TMB-H) defined as >20 mut/Mb. MSI-high (MSI-H) status was assigned by examining 114 intronic homopolymer loci.

Results: In addition to KRAS (89%), TP53 (70%), CDKN2A/B (43%) and SMAD4 (21%), commonly altered genes in PDAC were ARID1A (8%), MYC (6%), GATA6 (6%), BRCA2 (4%), GNAS (4%), ATM (4%), AKT2 (3%), PIK3CA (3%), KDM6A (3%) and ERBB2 (3%). Defects in the BRCA pathway was seen in 12% of PDACs. A similar spectrum of alterations was present in KRAS-wildtype PDACs, but 10% harbored oncogenic mutations/deletions in BRAF. Further, ERBB2 amplifications/mutations and ALK fusions were identified in 6% and 1% of KRAS-wildtype PDACs, respectively. Among PDACs evaluated for MSI (n = 2563) and TMB (n = 1021), an MSI-H and TMB-H phenotype were each detected in 0.5% of PDACs.

Conclusion: Genomic alterations in PDAC were present in the BRCA pathway, ERBB2, BRAF and ALK. Although the incidence was low, MSI-H and TMB-H were also found in subset of patients. Overall, CGP identified 15% of patients with PDAC that may be candidates for targeted agents and immunotherapy.

Preoperative Next-Generation Sequencing of Pancreatic Cyst Fluid is Highly Accurate in Cyst Classification and Detection of Advanced Neoplasia

A.D. Singhi,¹ K. McGrath,² R.E. Brand,² A. Khalid,² H.J. Zeh,² J.S. Chennat,² K.E. Fasanella,² G. Papachristou,² A. Slivka,² D.L. Bartlett,² A.K. Dasyam,² M. Hogg,² K.K. Lee,² J.W. Marsh,² S.E. Monaco,² N.P. Ohori,² J.F. Pingpank,² A. Tsung,² A.H. Zureikat,² A.I. Wald,² M. Nikiforova.²¹Department of Pathology, University of Pittsburgh, Pittsburgh, PA; ²University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: DNA-based testing of pancreatic cyst fluid (PCF) is a useful adjunct to the evaluation of pancreatic cysts (PCs). However, previous reports have been retrospective, lack adequate follow-up and/or used insensitive detection strategies. A prospective study was performed to evaluate the accuracy of DNA testing in PC classification and identification of advanced neoplasia.

Methods: Within 31-months, 462 PCFs from 440 patients were obtained by endoscopic ultrasound (EUS)-fine needle aspiration and were prospectively assessed by targeted next-generation sequencing (NGS) for KRAS, GNAS, HRAS, NRAS, BRAF, CTNNB1, TP53, PIK3CA, PTEN and AKT1. NGS was performed with a minimum coverage of 500x for each genomic region. In addition, VHL was assessed by Sanger sequencing. Molecular results were correlated with EUS findings, ancillary studies and follow-up. In comparison, a separate cohort of 159 PCFs was prospectively evaluated for KRAS/GNAS mutations by Sanger sequencing.

Results: KRAS/GNAS mutations were detected in 220 (48%) PCs, while alterations in TP53/PIK3CA/PTEN were present in 27 (6%) cases. Follow-up information was available for 423 (96%) patients with surgical follow-up for 83 (18%) PCs. The sensitivity and specificity of KRAS/GNAS mutations by NGS for a mucinous PC was 86% and 100%, respectively. In comparison, KRAS/GNAS mutations detected by Sanger sequencing was associated with 65% sensitivity and 100% specificity for a mucinous PC. By NGS, the combination of KRAS/GNAS mutations and alterations in TP53/PIK3CA/PTEN had 88% sensitivity and 100% specificity for advanced neoplasia. Main duct dilatation, the presence of a mural nodule and malignant cytopathology were associated with lower sensitivities (38%, 38% and 31%, respectively) and specificities (75%, 93%, 97%, respectively).

Conclusion: Preoperative NGS of PCF for KRAS/GNAS mutations and TP53/PIK3CA/PTEN alterations was highly sensitive and specific for mucinous PC and PCs with advanced neoplasia. These results support the application of NGS testing to the assessment of PCs in clinical practice.

Portal vs. Systemic Venous Drainage in Pancreas Transplantation: An Update of the UNOS Database

E. Siskind,¹ C. Liu,¹ R. Wali,¹ J. Piper,¹ J. Jonsson,¹ J. Ortiz.²¹Department of Transplant Surgery, Inova Fairfax Medical Center, Fairfax, VA; ²Department of Transplantation, University of Toledo, Toledo, OH.

Background: The decision to utilize portal or systemic venous drainage in pancreas transplantation is surgeon and center dependent. Information regarding the superiority of either method is based on single center reports and animal models.

Methods: Data from the UNOS database on all adult (≥18 years old) patients who received pancreas and kidney-pancreas transplants between 1987 and 2016 were analyzed (n = 29, 078). Patients were divided into two groups: systemic venous pancreas graft drainage (n = 24,512), or portal venous pancreas graft drainage (n = 4566) based on the method of venous outflow utilized for the transplant.

Results: There was no statistically significant difference between the two groups in patient survival and allograft survival at 1, 3, 5, 10, or 15 years post transplant. A multivariate subgroup analysis for pancreas after kidney transplant (PAK) found that PVD reduced the risk of death by 22% compared to SVD. Insufficient data was present to adequately comment on short term rejection rates. Median length of stay was longer by one day in the portal drainage group.

Conclusion: Based on this analysis, there is no significant clinical difference in patient or allograft survival between portal venous drainage and systemic venous drainage in pancreas transplantation for the majority of cases. For the subgroup of PAK, PVD was associated with decreased mortality.

The Utility of Endoscopic Ultrasound in Patients With Isolated Serum Elevations in Amylase and/or Lipase: A Single Center Experience

L. Sitaraman, A. Sachdev, T.A. Gonda, A. Sethi, J. Poneros, F.G. Gress. Department of Medicine, Columbia University Medical Center, New York, NY.

Background: The diagnostic yield of endoscopic ultrasound (EUS) in patients with isolated mildly elevated levels of amylase and/or lipase, symptomatic or asymptomatic, is not well described.

Methods: A retrospective chart review was conducted at a large tertiary academic medical center from 2000 to 2016. Patients were selected based on having elevated amylase, lipase, or both, but without a diagnosis of acute pancreatitis or known pancreatobiliary disease. Patients were excluded if they had abnormal serum liver function tests, amylase/lipase greater than 3 times the upper limit of normal, or abnormal imaging of the pancreas.

Results: Out of 299 EUS performed with the indication of elevated amylase and/or lipase, 38 patients met inclusion criteria. Patients were predominantly female (74%), mean age 50.3. Symptoms were present in 31 patients, most frequently abdominal pain (87%). Both amylase and lipase were elevated in 9 patients, with isolated high lipase in 20 patients and isolated high amylase in 9 patients. In 20 patients (53%), initial EUS was diagnostic; most common findings were chronic pancreatitis (n = 7; 18%), sludge (5; 13%), and new diagnosis of pancreas divisum (3; 8%). In the asymptomatic patients (7), diagnoses were found in 3 patients, most significant for sludge (2), stone (1), and pancreas divisum (1). No patients were diagnosed with a mass or cyst. Follow-up was available in 27 patients, median 3 years. There were 7 patients (26%) who had cholecystectomy during the follow-up period.

Discussion: In our study cohort of patients with isolated elevations in amylase and/or lipase without acute pancreatitis who underwent EUS, approximately 50% were found to have a pancreatobiliary etiology; most common findings were chronic pancreatitis or biliary/gallbladder sludge.

Islet Graft Function is Preserved After Pregnancy in Patients With Previous Total Pancreatectomy With Islet Autotransplant

M.E. Skube,¹ P. Mills,² J. Hodges,³ G.J. Beilman,¹ M.D. Bellin.⁴Departments of ¹Surgery, ²Obstetrics, Gynecology, and Women's Health, ³Division of Biostatistics, and ⁴Department of Pediatrics, University of Minnesota, Minneapolis, MN.

Introduction: The effect of pregnancy on islet graft function after total pancreatectomy with islet autotransplantation (TPIAT) is unknown. We hypothesized that although pregnancy would temporarily stress graft function, there would not be a sustained impact on islet graft function.

Methods: Women who underwent TPIAT at our institution and then successfully completed a pregnancy were eligible for inclusion. Data on graft function as well as pregnancy course were collected from medical records and the institutional database. A control group was selected from our female TPIAT patients without pregnancies who were of childbearing age at the time of transplant, matched on year of transplant, age and body mass index at transplant, and islet yield. Case-control comparisons used Mantel-Haenszel tests and mixed linear models.

Results: Five patients representing 7 pregnancies were enrolled. The pregnancies spanned the years 2006 to 2016. The median time from TPIAT to conception was 21 months (IQR, 8-163). During pregnancy, the median increase from baseline insulin use was 2.0 units (IQR, 2.0-10.0). Five of the 7 pregnancies were complicated by preterm labor, and the caesarean section rate was 57.1% (4/7). Median gestational age at birth was 36 weeks (IQR, 35.5-38.0) with median birth weight of 2800 grams (IQR, 2325-3254). No significant differences were found between the cases (post-partum) and controls in the primary outcomes of glycosylated hemoglobin (mean [SE], 6.8 [0.87] vs. 6.4 [0.62], P = 0.68), insulin use (16.6 units [9.6] vs. 12.6 units [7.6], P = 0.64), and graft function categorized as failed, partial, or full function (P = 0.82).

Conclusion: Long-term graft function was comparable between these cases and their matched controls. Pregnancy did not have a negative impact on long-term graft function in women with a history of TPIAT.

Idiopathic (IRF) and IgG4 Associated Retroperitoneal Fibrosis: Clinical and Imaging Characteristics - Treatment Response to Steroids Monotherapy vs Tamoxifen + Steroids

A. Soriano, M. Pelaez Luna, J. Hernandez Calleros, L. Uscanga Dominguez. Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.

Background: Retroperitoneal Fibrosis (RF) is a rare entity. It is characterized by the presence of fibrosclerotic tissue in retroperitoneum and other abdominal structures. Approximately 50% of IRF result from immunoglobulin-G4 related disease (IgG4RD). Steroid treatment (St) is highly effective, although relapse rate upon discontinuation is high (>50%). Tamoxifen (Tmx) has been considered as an alternative or adjuvant therapy at the initial, maintenance or recurrent forms. Objective: To describe clinical and imaging characteristics and evaluate response to treatment. (St vs.Tmx + St).

Methods: Charts from patients diagnosed with RF between 2007-2016 were reviewed. Diagnosis was suspected on imaging and confirmed in pathology specimens in all cases. Demographic, clinical, imaging and treatment data at diagnosis and last follow-up (FU) were noted. Improvement, (complete or partial) was considered, when symptoms and image abnormalities disappeared or decreased at last FU.

Results: We included 9 patients (5 male); mean age 49.7 years. Mean age at diagnosis 46.7 years; mean FU 30 months (interval 6-84). Four patients were associated to IgG4-RD; At diagnosis patients presented with abdominal pain (n = 5), weight loss (n = 4), recurrent acute pancreatitis (n = 1), jaundice (n = 2) urinary symptoms (n = 2), and intestinal suboclussion (n = 1). The most frequent imaging locations were, peripancreatic (n = 4) and periureteral (n = 5). All patients were initially treated with St; those with Ig4 RD (n = 4) had a complete clinical and imaging response. Four did not responded to ST monotherapy; Tmx was added (1 presented clinical and imaging response, 1 clinical, 1 imaging and 1 stable disease). The remaining patient still without FU.

Conclusion: St monotherapy in RF associate to IgG4 RD is effective in achieving clinical and imaging response: RF not associated to IgG4 RD might benefit from initial combined therapy (St + Tx).

Alcohol Activates Cyclic AMP Response Element Binding (CREB) in the Pathogenesis of Pancreatic Cancer

S. Srinivasan, T. Totiger, R. Dawra, P. Lamichhane, M. Vansaun, N. Merchant, N. Nagathihalli. Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL.

Aim: To investigate the role of cyclic AMP response element binding (CREB) in alcohol-related pathogenesis and progression of pancreatic ductal adenocarcinoma (PDAC).

Background: Results from two meta-analyses estimate a 20-22 percent increased risk of pancreatic cancer from consuming three alcoholic drinks per day. Moreover, heavy alcohol drinkers have a significantly higher risk of pancreatic cancer when compared to non-drinkers or occasional drinkers. Though alcohol consumption has been implicated in the pathogenesis of pancreatic cancer, the molecular mechanism underlying the pathogenesis of alcohol-related pancreatic cancer is poorly understood.

Methods: Human pancreatic ductal epithelial lines (H6c7, HPNE and HPNE KRAS), mouse pancreatic stellate cells (mPSCs) and cancer-associated fibroblasts (CAFs) generated from LSL-KrasG12D/+;Trp53R172H/+;Pdx1Cre/+ (KPC) mice were exposed to chronic alcohol (Ethanol, 50 mM) for up to 25 days and immunoblotted for pCREB expression. Inducible LSL-KrasG12D/+; Ptf1acreER (iKC) mice were exposed to Lieber-DeCarli alcohol diet for up to 14 weeks with cerulein injections. PanIN lesions and activation of CREB were measured by immunohistochemistry and Western blotting.

Results: The expression of pCREB was higher in ductal epithelial cells exposed to chronic alcohol suggesting that pCREB is elevated in alcohol drinkers. Moreover, exposure of iKC mice to an alcohol diet significantly elevated pCREB and increased the number of PanIN lesions. Consumption of an alcoholic diet coupled with cerulein administration resulted in synergistic induction of PanIN lesions. The effect of alcohol on CREB expression levels will be further investigated using iKCCREBKO mice.

Conclusion: Induction of pCREB levels in alcohol-associated PDAC may reveal important susceptibilities for the initiation and progression of PDAC. Blocking CREB may also serve as a therapeutic target for more effective treatment of alcohol-associated PDAC.

IL-6 and CRP are Superior in Early Severity Stratification of Acute Pancreatitis

H. Sternby, H. Hartman, D. Johansen, H. Thorlacius, S. Regnér. Department of Surgery, Institution of Clinical Sciences, Malmö, Sweden.

Background: The revised Atlanta classification (RAC) on acute pancreatitis (AP) presents distinct criteria for severity categorization. Currently all patients with AP are hospitalized and managed identically. As incidence, and subsequently financial costs, is rising the necessity of early differentiation in AP will increase. This study aimed to investigate the capacity of biomarkers to stratify AP patients early in the course of the disease.

Methods: Patients with AP were consecutively enrolled and dichotomized into mild versus moderately severe plus severe AP (non-mild) according to the RAC. Serum samples taken within 13-36 hours after onset of disease were analyzed for 20 biomarkers. Through receiver operating curves cut-offs were set for the biomarkers that differed significantly between the mild and non-mild group. Patients were additionally classified according to the harmless acute pancreatitis score (HAPS).

Results: Among the 175 patients, 70.9% had mild and 29.1% non-mild AP. CRP and IL-6 combined, with the cut-off levels 57.0 mg/L and 23.6 pg/ml respectively, demonstrated superior discriminative capacity with an area under the curve of 0.803, sensitivity 98%, specificity 54% and a positive and negative likelihood ratio of 2.1 and 0.06 for the non-mild group. Regarding the mild cases, the identification potential of the HAPS was generally inferior compared to CRP plus IL-6.

Conclusion: In this study CRP and IL-6 demonstrate a clinically relevant capacity to differentiate mild from non-mild AP early in the course of AP.

Pomalidomide Alters Pancreatic Macrophage Populations to Decrease Fibrosis and Growth of Precancerous Lesions

P. Storz,¹ L. Bastea, G.Y. Liou, B. Edenfield, H.W. Tun. Department of Cancer Biology, Mayo Clinic, Jacksonville, FL.

During development of pancreatic cancer, alternatively-activated macrophages contribute to pancreatic intraepithelial neoplasia (PanIN) lesion growth and fibrogenesis. This is mediated by macrophage released factors such as IL-1ra and CCL2. Inhibition of the occurrence of these alternatively-activated macrophages decreases fibrosis and progression of abnormal pancreatic structures. This can be achieved by blocking IL-13 signaling, and shifts macrophage populations towards an inflammatory phenotype. We here show that pomalidomide has similar effects on macrophage populations. Treatment of p48cre;LSL-KrasG12D (KC) mice with pomalidomide not only decreased the growth of pancreatic lesions, but also decreased fibrosis at these lesions. This was due to a shift from alternatively-activated macrophage populations towards inflammatory populations. Our results indicate that this compound could be used to decrease fibrogenesis in pancreatic cancer and may be ideal for combination treatment with drugs that target the cancer cells.

A Novel Mouse Model With Bigenic Targeting of Activated Pancreatic Stellate Cells

H.Y. Su,¹ R.T. Waldron,^1,2 S.J. Pandol,^1,2 A. Lugea.^1,21Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ²Department of Medicine, University of California, Los Angeles, Los Angeles, CA.

Pancreatic stellate cells (PSC) are key regulators in the stroma of chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC). Recent studies found that elimination of cells expressing α-smooth muscle actin (αSMA), such as PSC, pericytes and other cell types stimulated PDAC, suggesting that PSC may restrain rather than promote tumor progression. A limitation in these studies is the inadequacy of αSMA as a sole marker to exclusively target PSC. In a novel approach, we generated Acta2-Flp/Col1a1-FSF-tk (AC-tk) mice to selectively target activated PSC, which express both αSMA (Acta2 gene) and α 1 type-I collagen (Col1a1 gene). In these mice, flippase expressed under control of the Acta2 promoter leads to expression of herpes simplex virus thymidine kinase (HSV-tk) under control of the Col1a1 promoter. In AC-tk mice, the HSV-tk-activating drug ganciclovir (GCV) specifically targets and eliminates activated PSC, sparing other cells not co-expressing both genes. In vitro studies confirmed that co-expression of both Acta2-Flp and Col1a1-FSF-tk in mouse PSC led to HSV-tk expression. Moreover, GCV markedly sensitized PSC isolated from AC-tk mice to cell death, while wild-type PSC were unaffected by GCV. In a mouse model of cerulein-induced CP, GCV effectively reduced PSC numbers and collagen deposition in AC-tk mice compared to wild-type mice and AC-tk mice not exposed to GCV. No changes in blood vessel architecture were observed in pancreas of GCV-treated AC-tk mice. In addition, depleting PSC in AC-tk mice expressing pancreatic KrasG12D reduced PanIN formation compared to controls. In Conclusion, our mouse model allows for temporally controlled, targeted elimination of activated PSC, and provides an excellent tool for studying the role of PSC during development of CP and PDAC.

EN-RAGE is an Early Predictive Biomarker for Acute Pancreatitis

A. Sud,¹ J. Armstrong,² D. Latawiec,² R. Furze,³ N. Smithers,³ N. Galwey,³ R. Sutton.¹¹Department of Molecular and Clinical Cancer Medicine, NIHR Liverpool Pancreas Biomedical Research Unit, Liverpool, United Kingdom, ²Department of Molecular and Clinical Cancer Medicine, University of Liverpool, NIHR Liverpool Pancreas Biomedical Research Unit, Liverpool, United Kingdom, ³Immuno-Inflammation Theraputic Area, Medicines Research Centre, GSK Epinova DPU, Stevenage, Hertfordshire, United Kingdom.

Aim: Identification of an early biomarker that correlates with disease severity classification.

Background: The course of acute pancreatitis (AP) is highly variable and unpredictable. Severity scores (APACHE II, Ranson’s) are not reliable early predictors of severity. There is good evidence to support the use of CRP (C-reactive protein) to discriminate severe disease, but only on or after 48 hr from admission. The absence of reliable early prediction method contributes to treatment failures.

Methods: Plasma samples from 8 mild, 11 moderate and 11 severe AP patients on days 1,2,7,14,28 post-admission (NIHR Liverpool Pancreas Biomedical Research Unit) were compared to samples from 10 healthy volunteers (GlaxoSmithKline). 88 analytes per sample were assayed using Myriad RBM Multi-Analyte platform. Statistical comparison analysis was undertaken between the control and revised Atlanta criteria classification (RAC) group means.

Results: CRP was 2.44-fold greater on day 2 (P = 0.04) between the mild and severe groups. Levels of EN-RAGE (S100A12) generally remained low in mild patients but were elevated early in moderate and severe patients. Within 24 hrs from hospital admission the EN-RAGE ratio between mild/moderate (ratio 3.80; P = 0.0043) and mild/severe (ratio 6.86; P = 0001) was significant. The differential levels were more pronounced at 48 hrs. Discussion: This study has demonstrated RAC stratified elevations in EN-RAGE levels at ≤24 hr from admission. EN-RAGE may be a pivotal initiator in the immunopathogenic response to pancreatitis and correlate with AP inflammation.

Conclusion: EN-RAGE alone or in combination with CRP, may provide a robust earlier predictor of severity and biomarker of therapeutic response. A larger cohort study with subgroup analysis is necessary to further validate this premise.

Glucose-Responsive Oxygen Consumption Rate in Islets From Chronic Pancreatitis Patients is Size Dependent: Novel Islet Quality Assessment Through Bioenergetic Phenotyping

Z. Swanson, J. Wilhelm, M.D. Bellin, B. Hering. Department of Surgery, University of Minnesota, Minneapolis, Minneapolis, MN.

Background: Higher basal oxygen consumption rate (OCR) has been shown to be predictive of outcomes in chronic pancreatitis (CP) patients undergoing total pancreatectomy with islet autotransplantation (TPIAT). We sought to develop an assay using extracellular flux (XF) technology to measure bioenergetic changes in both OCR & ECAR (extracellular acidification rate) during a series of drug stimulations to assess mitochondrial (mito) quality parameters.

Methods: Islets were handpicked and plated separately as large, small, or embedded. OCR & ECAR were measured every 8 min, with baseline determined prior to injection of glucose (20.6 mM), oligomycin (50uM), FCCP (5uM), and rotenone/antimycin A (10uM). Each well was stained with dithizone and imaged for size measurements. Islet size index (ISI) was calculated as a ratio of IEQ:IPN. Wells with islets of similar ISI were grouped and mito quality parameters compared.

Results: With glucose stimulation, wells with the smallest islets (ISI 0-1) showed an increase in OCR of 69.27+/-69.54%, compared to wells with ISI >5 (12.27+/-18.50%; P < 0.001), as did wells with ISI 1-2 (42.84+/-50.48; P < 0.001). Acinar and embedded islets exhibited a slight decrease in OCR. Wells with an ISI of 0-1 and 1-2 showed increased spare capacity (104.16+/-72.06% and 81.34+/-41.00%, respectively) when compared to wells with ISI >5 (24.23+/-25.23%, P < 0.001).

Conclusion: We detected different bioenergetic profiles of acinar, pure and embedded islets. Small islets were especially distinct, including higher OCR response to glucose, and higher spare respiratory capacity, suggesting a possible metabolic advantage of smaller islets. Bioenergetic phenotyping holds potential to detect novel differences in islet quality that may predict metabolic outcomes during TPIAT.

Long Non-coding RNA HULC Derived From Circulating Extracellular Vesicles Would Correlate With Tumor Invasion and Metastasis in Patients With Pancreatic Cancer

K. Takahashi, Y. Ota, H. Iwamoto, K. Yamakita, Y. Kitano, Y. Makino. Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan.

Background: Epithelial-mesenchymal transition (EMT) is a trigger of invasion and metastasis in pancreatic ductal adenocarcinoma (PDAC). Although long non-coding RNAs (lncRNAs) have been implicated in disease pathogenesis, their roles to PDAC remain unclear. Recently, extracellular vesicle (EV)-encapsulated ncRNAs have been reported to modulate cancer cell behaviors and thought to serve as biomarkers for cancers. Our aims were to investigate the functional roles of lncRNAs during EMT and identify a new EV lncRNA as a biomarker for PDAC.

Methods: Human PDAC (PANC-1, etc.) cells and serum samples from 10 PDAC patients and 10 healthy individuals were used. EVs were isolated from cells or serum. Expression profiling of 90 lncRNAs was performed. Cells were treated with TGF-ß to induce EMT. siRNA was used for knockdown of lncRNA. qPCR, Western blot, cell invasion and migration assay were used.

Results: LncRNA profiling identified HULC was a highly induced lncRNA by TGF-ß in PANC-1 cells and their EVs. HULC expression was increased in PDAC cells compared to pancreatic epithelial cells. In PANC-1 cells, knockdown of HULC inhibited EMT pathway, cell invasion and migration. Moreover, HULC could be transferred from donor cells to recipient cells by EV and promoted EMT pathway, invasion and migration in recipient cells. Furthermore, HULC expression was significantly increased in serum EV from PDAC patients compared to healthy individuals, and was increased in StageIII and IV compared to StageI and II (UICC 7th).

Conclusion: These data provide mechanistic insights into invasion and metastasis in PDAC by demonstrating HULC could promote cell invasion and migration via induction of EMT pathway through transfer by EVs and identifying EV encapsulated HULC would be a new biomarker for PDAC.

The Biological Propensity Predicts Peritoneal Recurrence After Curative Operation in Locally Advanced Pancreatic Head Cancer

S. Takano, H. Yoshitomi, K. Suzuki, S. Kagawa, K. Furukawa, T. Takayashiki, S. Kuboki, D. Suzuki, N. Sakai, H. Nojima, T. Mishima, M. Ohtsuka. Department of General Surgery, Chiba University, Chiba, Japan.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive cancers, and easily invades to the adjacent tissues and occurs recurrence. In this study, we investigated the clinical impact of pancreatic head plexus (PL) invasion and the indicators for biological characteristics (epithelial and mesenchymal markers) in locally advanced head PDAC. We also examined whether we can predict the recurrence forms of patients after curative operation using these parameters.

Methods: Of consecutive 164 patients with the head PDAC, 72 locally advanced PDAC patients (Borderline resectable (BR) PDAC: 53 patients, Unresectable (UR) PDAC: 18 patients) were retrospectively analyzed by the clinico-pathological features. Furthermore, immunohistochemistry for E-cadherin and Vimentin was performed in these resected PDAC tissues.

Results: Patients who undergone R1 (histologically margin positive) resection showed a significant association with the high rate of UR-PDAC (P = 0.046) and advanced UICC stage (P = 0.027), but not with PL positive status. PL positive status was associated with portal vein invasion (P = 0.018), however, was not correlated with prognostic outcomes of patients with BR-UR PDAC. Interestingly, patients with PL positive was strongly associated with local recurrence (P = 0.0012). Additionally, patients of PDAC tissues showing mesenchymal property, low E-cadherin or high Vimentin expression, were significantly correlated with the recurrence of peritoneal dissemination. Taken together, these data implicated that the recurrence forms might be able to be predicted by the examination for PL invasion and biological characteristics of resected PDAC tissues.

Conclusion: PL positive was strongly associated with local recurrence of PDAC patients. EMT markers presenting biological propensity might predict the recurrence of peritoneal dissemination in patients with BR-UR PDAC after curative operation.

Oncogene Transduced Mouse Pancreatic Stem/Progenitor Cells Show Phenotypes Similar To Tumor-Initiating Cells

Y. Takegaki,¹ K. Shimizu,¹ Y. Kadoi,¹ A. Nishimura,¹ M. Miyoshi,¹ T. Akagi,² K. Sasai,² Y. Hori.¹¹Analytical Biomedical Sciences, Kobe University Graduate School of Health Sciences, Kobe, Japan; ²KAN Research Institute, Japan.

Background and Aim: Since cancer stem cells are assumed to be involved in metastasis, resistance to anticancer drugs, they attract attentions as a target of new drug. However, its localization and origin are still unclear. In the present study, we introduced pancreatic ductal adenocarcinoma (PDAC) specific oncogenes to mouse pancreatic stem/progenitor cells and developed novel mouse PDAC (mPDAC) cells. Then, we analyzed its phenotype.

Methods: We isolated stem/progenitor cells (CD133+ cells) from BL6 mouse fetal pancreas as described previously, then transferred a combination of four genetic alterations by retrovirus, including GFP, an activated from of K-ras, a dominant negative from of p53, and CDK4 and designated mPDAC cells. We carried out PCR, immunostaining, half maximal inhibitory concentration (IC50) for Gemcitabine (GEM) in vitro, moreover, engraft mPDAC cells into BL6 mice and performed graft analysis.

Results: mPDAC cells also expressed CD133 and Pdx1, similar to pancreatic stem/progenitor cells. mPDAC cells expressed GFP and p53 by immunostaining. IC50 for GEM was 0.08 μl, which was comparable to GEM-sensitive human PDAC cells. Tumor growth from mPDAC cells was inhibited and enhanced invasive phenotype by GEM as well as human PDAC cells derived tumor. CD133+ mPDAC cells isolated by magnetic activated cells sorting not only formed cell population consisted of CD133+ and CD133- cells in vitro, but tumor consisted of CD133+ and CD133- cells in vivo.

Conclusion: Engineered mPDAC cells formed tumor similar to human PDAC cells in several ways, such as desmoplasia formation, mucin production and response to GEM. CD133+ cells among mPDAC cells have a characteristic feature of tumor-initiating cells.

Analysis of Clinical Significance of MUC4 Isoforms in Pancreatic Cancer Patients Using TCGA RNA-Seq Dataset

C.M. Thompson,¹ S. Kumar,¹ D. Ghersi,² R. Chirravuri,² I. Thapa,² L. Smith,³ S.K. Batra.¹¹Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE; ²School of Interdisciplinary Informatics,College of Information Science and Technology, University of Nebraska Omaha, NE; ³Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE.

Background: Pancreatic cancer (PC) is one of the most lethal malignancy with the 5-year survival rate of ~8%. Overexpression of mucins like MUC1, MUC4, MUC16 and MUC5AC is the hallmark of PC. MUC4 is expressed in 70-80% of pancreatic tumors and has been associated with enhanced motility, invasiveness and metastasis of PC cells. We have previously identified multiple isoforms of MUC4 generated due to alternative splicing events; however, the clinical significance of the expression of MUC4 isoforms in PC remains completely obscure.

Methods: Using RNA-Seq and clinical data available from The Cancer Genome Atlas (TCGA) from 184 PC patient samples, we investigated the expressions of all 22 known MUC4 isoforms and correlated with overall survival and time-to-progression by stepwise multiple regressions analysis.

Results: MUC4 expression above the normalized threshold was detected in over 92% of PC patients. Eighty-seven patients met inclusion criteria for survival analysis and thirty-five for progression-free survival analysis. Two isoforms were significantly correlated with duration until clinical outcomes. Isoform uc003fvc.2 was detected in 8% of samples and exhibited a positive correlation with survival (P = 0.000014) while isoform uc003fvo.2 positively correlated with progression-free survival (P = 0.00082). Paired DNA alignment analysis revealed that isoform uc003fvc.2 had complete deletion of exon 19, which encodes the EGF-like domains, and isoform uc003fvo.2 retained a part of the 3’ UTR, and had a complete loss of exon 2 and a downstream frameshift.

Conclusion: Our analysis of expression of all 22 known MUC4 isoforms identified unique association of two MUC4 isoforms, uc003fvc.2 and uc003fvo.2, with prolonged survival time and time-to-progression, respectively. Our findings suggest the existence of functional diversity in mucin isoforms, which in turn can alter the course or kinetics of disease progression.

Polyunsaturated Fatty Acids Affect the Localization and Signaling of PIP3/PI3K/AKT in Pancreatic Ductal Adenocarcinoma

C. Torres, R. McKinney, S. Saeed, P.J. Grippo. Department of Medicine, University of Illinois, Chicago, IL.

Abstract: The death rate for pancreatic cancer (PC) continues to rise and will likely usurp colon cancer as the second cause of cancer related deaths within a decade. Thus, there is an urgent need to find new therapies and means for chemoprevention. In this regard, the influence of nutrition in health and disease has attracted much attention over the last several years, especially regarding the role of polyunsaturated fatty acids (PUFA) on inflammation and cellular signals affecting tumor growth and progression. Using two mouse models that recapitulate IPMN-like lesions (EL-Kras) and PanINs (KC), we have evaluated the effects of diets supplemented with ω-3 or ω-6 FAs on lesion development to support that ω-3 FA reduces lesion penetrance via repression of proliferation associated with reduced pAKT, whereas the ω-6 FA accelerated tumor formation. Our in vitro analyses also confirmed modulation of the AKT pathway using PC cell lines. Indeed, we demonstrate that ω-3 and ω-6 compete with each other and that the presence of ω-3 reduced proliferation even when ω-6 FA is present in equal quantity. AKT is a serine-threonine protein kinase that plays important roles in cell growth, proliferation and apoptosis. AKT can be phosphorylated and activated after binding PIP3 which itself is phosphorylated by PI3K with PIP2 as a substrate. Our data also suggest that altered proliferation rates and pAKT levels may be partially explained through metabolic pathways regulated by COX-2 but not 5-LOX. Yet some other mechanism is likely responsible for modifying levels of pAKT through PUFAs. We present data that supports a correlation between ω-3 FA stabilization of PIP2, ω-6 FA stabilization of PIP3, and the converse of each. This interaction may represent a novel mechanism of cancer prevention induced by ω-3 FA.

A Novel Natural Compound to Target PI3K/AKT/mTOR Pathway in Pancreatic Cancer

T. Totiger,¹ S. Srinivasan,¹ V. Jala,² J. Castellanos,³ P. Lamichhane,¹ X. Dai,¹ M. Vansaun,¹ N. Merchant,¹ N. Nagathihalli.¹¹Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL; ²Department of Microbiology and Immunology, University of Louisville, Louisville, KY; ³Department of Surgery, Vanderbilt University, Nashville, TN.

Aim: To elucidate the anticancer mechanism of Urolithin A in pancreatic ductal adenocarcinoma (PDAC).

Background: Cytotoxic chemotherapy including Gemcitabine (Gem), FOLFIRINOX, nab-paclitaxel offer modest improvement in survival for PDAC, albeit at the cost of increased side effects and unwanted toxicities. Therefore, developing novel chemotherapeutic agents for PDAC treatment is critical to improve survival. Ellagic acid/ellagitannins are abundantly present in the pomegranate and berries, are actively metabolized by the intestinal microflora to Urolithin A (UA). Oral administration of UA has shown to be highly bioavailable and non-toxic.

Methods: Inhibition of AKT (downstream of PI3K/PDK1) and p70 S6 Kinase (PS6K, downstream of mTOR) was quantified in human PDAC cells treated with UA. The mechanism of action was validated for UA’s specific activity on PI3K/PDK1 and PS6K activation using immunoblot analysis. To test the efficacy of UA in vivo, MiaPaCa2 cells were implanted subcutaneously in athymic nude mice. The animals received UA daily and tumor volume was measured weekly for 5 weeks. Next, we assessed tumor growth and overall survival (OS) in PKT (Ptf1acre/+;LSL-KrasG12D;Tgfbr2fl/fl) mice, in response to UA and/or Gem treatment. Tissues from the xenografts and PKT mice treated with vehicle or UA were analyzed for cell proliferation and apoptosis.

Results: UA inhibited PI3K/AKT/mTOR signaling in vitro and in vivo. UA treated MiaPaCa2 cells showed significant dose-dependent increase in apoptosis. As a single agent, UA effectively reduced in vivo PDAC tumor growth. Immunohistochemistry of UA treated tissues from tumor xenografts and PKT mice showed inhibition of Ki-67 positive tumor cells and increased cleaved caspase 3 staining. PKT mice treated with UA showed a decrease in tumor size and an increased OS when compared to vehicle or Gem treated mice alone.

Conclusion: These findings show that UA is a novel inhibitor of PI3K/AKT/mTOR signaling pathways in PDAC. These results suggest UA has potential for pre-clinical development in pancreatic cancer.

Outcomes for Interventions for Acute Necrotic Collections (ANC) Compared to Walled Off Necrosis (WON) Using an Endoscopically Based Step-Up Approach for Necrotizing Pancreatitis (NP)

G. Trikudanathan, P. Tawfik, S.K. Amateau, S. Munigala, M. Arain, R. Attam, M.L. Freeman, S.J. Mallery. Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN.

Background: Current guidelines for NP recommend delay in invasive interventions until 4 weeks after initial presentation to allow the collection to become walled off. However, ANC with clear evidence of infection, and clinical deterioration despite maximum support, often mandate earlier (<4 wks) intervention. Safety of early endoscopic step-up approach is not known.

Aim: To compare the clinical outcome of interventions for ANC and WON in a single tertiary care referral center using an endoscopy-based ‘step-up approach’ with adjunctive percutaneous drainage as indicated for collections not accessible for transluminal drainage. Surgery reserved for failures.

Methods: All NP patients who underwent interventions between 2010-2016 were grouped into either ANC or WON based on timing of intervention (< or > 4 weeks from onset). Demographic data, indications and timing for interventions, number and type of intervention, mortality and complications were compared.

Results: A total of 195 pts underwent intervention for NP; 75 ANC [median age, 55 yrs; males, 52 (69%)] and 120 WON [median age, 51 yrs; males, 90 (75%)]. Comparing ANC vs WON, indication for intervention was more often infection (91% vs. 42%; P < 0.0005), patients were sicker, with more renal failure (45% vs. 31%; P < 0.05) and respiratory failure (43% vs 23%; P = 0.004). Initial intervention was endoscopic transluminal drainage in both (64% vs. 76%, P = 0.1). However, ANC pts needed more sessions of endoscopic necrosectomy and adjuvant percutaneous drainage. Organ failure improved after intervention in both. There was no difference in need for surgical necrosectomy (5% vs. 1%; P = 0.07) or mortality (12% vs 5%; P = 0.98) or in complications between groups. ANC patients had increased median hospital (36d vs 26d; P = 0.0009) and ICU stay (2.5d vs 0d; P = 0.001).

Conclusion: An endoscopically based step up approach is safe and feasible in ANC with outcomes similar to WON, and should be considered when there is a strong indication for intervention. Improvement in organ failure with no difference in mortality or need for surgery was demonstrated.

Pediatric Normal Values for Pancreatic Exocrine Function Measured by Secretin-Stimulated MRI

A.T. Trout,¹ L. Fei,² M. Abu- El-Haija.³¹Department of Radiology, ²Division of Biostatistics and Epidemiology, and ³Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.

Background: In adults pancreatic fluid secretion measured by secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) correlates with other measures of exocrine function and normal values for total secretion exist (112 ± 50 mL). We have previously demonstrated the feasibility of S-MRCP in children but normal values for function do not exist. The purpose of this study was to define normal values for secretin-stimulated pancreatic exocrine function in children.

Methods: In this prospective study, 50 children (6-15 years old) with no history of pancreatic disease underwent S-MRCP. Following administration of secretin (0.2 mcg/kg, max 16 mcg), fat saturated coronal single-shot fast spin echo (SSFSE) images were acquired at 1, 5, 10 & 15 minutes. Secreted fluid volume was measured utilizing image segmentation (ImageJ, NIH). Pearson correlation coefficients, univariate, multivariate and quantile regression were utilized to define population data.

Results: Mean total secreted fluid volume (SV) in response to secretin was 81 mL (range, 33-162 mL). SV was significantly correlated with age, height, weight, BMI, and BSA but not sex. Correlation with age was weak (r = 0.39; P < 0.005) and the best observed correlation was with BSA (r = 0.54; P < 0.0001). The 5th/95th percentiles for SV for the population as a whole were 42/122 mL. Stratified by age, 5th/95th percentiles for SV defined by quantile regression ranged from 30/95 mL (6 yo) to 60/142 mL (15 yo). Multivariate models including age, sex and BSA were only marginally more predictive of SV than BSA alone (AICc: 429 vs. 439).

Conclusion: Secretin-stimulated pancreatic fluid secretion measured by MRI in children depends on patient size, particularly body surface area, and differs from adult norms. Secreted fluid volume less than 42 mL (5th percentile) should be considered abnormal.

Multiagent Chemotherapy and Chemoradiotherapy are Associated With Improved Overall Survival in Patients With Locally Advanced Pancreatic Cancer: A National Cancer Database Analysis

R. Tuli,¹ A. Torossian,¹ N.N. Nissen,² A.E. Hendifar,³ J. David.¹¹Department of Radiation Oncology, ²Comprehensive Transplant Center, and ³Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA.

Introduction: High rates of distant and local failure contribute to poor clinical outcomes of pancreatic cancer patients. The role of multiagent chemotherapy (MAC) has not been prospectively investigated in locally advanced patients (LAPC) and the data regarding the benefit of chemoradiotherapy (CRT) is mixed. Herein, we investigate the benefit of MAC with and without CRT in patients with LAPC.

Methods: The National Cancer Database (NCDB) was utilized to identify LAPC patients treated with chemotherapy and/or CRT. Univariate (UVA) and multivariate (MVA) Cox regression were performed to identify the impact of single agent (SAC), MAC and CRT on overall survival (OS).

Results: From 2004–2014, a total of 10,123 patients were identified. The median age was 66 years (range, 22-90) with median follow-up of 11 months (range, 0.26–139 months); 49.8% were male and 50.2% female. All patients had clinical stage 3/T4 disease irrespective of nodal metastases. Of these, 2766 (27%) received SAC, 2792 (28%) received MAC, 2705 (27%) received SAC with CRT, and 1860 (18%) received MAC with CRT. On UVA, age, race, median income, education level, comorbidities, nodal disease, and treatment type were associated with improved OS. On MVA, SAC (HR, 1.79; 95% CI, 1.68–1.92), SAC and CRT (HR, 1.35; 95% CI, 1.27–1.44), and MAC (HR, 1.22; 95% CI, 1.14–1.29) led to inferior OS relative to patients receiving MAC and CRT.

Conclusion: The use of MAC and CRT individually led to significantly improved OS rates in patients with LAPC relative to patients receiving SAC alone. Patients receiving both MAC and CRT had the most favorable survival rates. In the absence of prospective data, these treatments should be considered standard of care for patients with LAPC.

Mesenteric Lymph as a Source of Circulating Cell-Free DNA in Acute Pancreatitis

S.M. Tun,^1,2 J. Hong,³ J.A. Windsor,¹ A.R. Phillips.^1,31Department of Surgery, University of Auckland, Auckland, New Zealand; ²Department of Internal Medicine, Woodhull Medical and Mental Health Center, New York, NY; ³School of Biological Sciences, University of Auckland, Auckland, New Zealand.

Introduction: Mesenteric lymph (ML) produced during acute pancreatitis (AP) transports toxic factors from the gastrointestinal tract to the systemic circulation and promotes systemic inflammation and multiple organ dysfunction syndrome (MODS). One toxic factor may be cell-free DNA (cfDNA), a “Damage-Associated Molecular Pattern” (DAMP) which activates inflammatory pathways, is elevated in plasma during severe AP and implicated in MODS. The aim of this study was to determine whether ML transports increased cfDNA during AP and diversion of ML reduced circulating cfDNA.

Methods: Thirty-two Sprague Dawley rats were divided into 4 groups (n = 8): 1) Sham (SH) without ML drainage, 2) SH with ML drainage, 3) AP (taurocholate-induced) without ML drainage, and 4) AP with ML drainage. Plasma samples were collected before AP induction (pre-AP), then 150 and 300 min after induction. ML was collected before AP induction, between induction and 150 min, and between 150 and 300 min. The SH had matching ML collection. The cfDNA content was isolated from plasma and ML, and their concentration was measured using a Qubit dsDNA HS assay kit. Two-way ANOVA statistical test was performed after log-transformation of data.

Results: Pre-AP ML cfDNA concentration was 22-fold (P < 0.0001) higher than Pre-AP plasma. ML cfDNA collected over last 150 min of AP was ~4-fold higher (P = 0.002) than for SH and 2-fold higher than ML collected over first 150 min of AP (P = 0.007) or the Pre-AP (P = 0.006). Plasma cfDNA increased in AP compared with SH and Pre-AP whether or not there was ML drainage. A greater increase in plasma cfDNA was seen without drainage at each time point (9.5 to 17.6-fold; P < 0.001) than with drainage (6.1 to 8.2-fold; P < 0.01) when compared with comparable SH group.

Conclusion: ML is rich in cfDNA and transports significantly more cfDNA during AP. There is a less elevation of circulating cfDNA in AP with ML drainage than without drainage compared to their respective SH. Further research is required to determine whether therapeutic ML drainage will reduce circulating cfDNA, systemic inflammation and the risk of MODS.

Time Course of Monocyte STAT3 and NF-κB Phosphorylation in Severe Acute Pancreatitis

A. Turunen,¹ A.K. Penttilä,¹ J. Oiva,¹ H. Mustonen,¹ A. Kuuliala,² P. Puolakkainen,¹ H. Repo,² L. Kylänpää,¹ K. Kuuliala.²Departments of ¹Surgery and ²Bacteriology and Immunology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Background: We showed previously that signaling profiles of circulating monocytes are aberrant in patients with acute pancreatitis (AP). We now present preliminary results of the time course of monocyte STAT3 and NF-κB phosphorylation (p) in severe AP.

Methods: The study comprises 6 patients with severe AP without organ dysfunction (OD) and 3 with AP complicated by OD. For reference, 9 patients with mild AP were studied on admission to hospital. Constitutive pSTAT3 (pY705) and LPS-stimulated pNF-κB (pS529) levels of CD14+ monocytes were determined by phosphospecific whole blood flow cytometry on admission to intensive care unit and after four and seven days. The proportion of positive cells was determined by comparing patients’ samples with concurrently studied samples from healthy adult controls. The Page’s trend test was used in statistical analysis.

Results: During follow-up, mean pSTAT3 decreased from 63% to 58% to 33% (P = 0.011) in severe AP without OD, tended to follow a similar course in AP with OD (mean 57% to 56% to 34%), was 53% in mild AP, and <5% in healthy controls. Mean pNF-κB increased from 36% to 43% to 56% (P = 0.003) in severe AP without OD, remained low in patients with OD (mean 41% to 49% to 36%), being 51% in mild AP and 83% in healthy controls.

Conclusion: During course of severe AP, constitutive pSTAT3 and LPS-stimulated pNF-κB show improvement during one week in patients without OD. In patients with OD, pNF-κB remains low.

Generating Pancreatic Ductal Adenocarcinoma From Normal Human Acinar and Ductal Cells

P. Wang,¹ N. Akanuma,¹ J. Liu,¹ M. Nipper,¹ M. Gao,¹ K. Bejar,¹ A.D. Singhi,² H. Wang,³ H. Crawford.⁴¹UT Health Science Center, The University of Texas Health San Antonio, San Antonio, TX; ²Division of Anatomic Pathology, University of Pittsburgh, Pittsburgh, PA; ³Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX; ⁴Department of Molecular and Integrative Physiology & Internal Medicine, University of Michigan Health System, Ann Arbor, MI.

Over the past thirty years, the survival rate for many cancers has improved, but pancreatic ductal adenocarcinoma (PDAC) continues to be the most deadly common cancer with a five-year survival rate of less than 7%. Few models are available to study the molecular mechanisms of human PDAC tumorigenesis. Lineage tracing experiments in mouse PDAC models demonstrated that pancreatic intraepithelial neoplasia (PanINs) lesions are mainly derived from acinar cells undergoing acinar to ductal metaplasia (ADM), suggesting that ADM might be an early event that promotes KRAS-driven PDAC tumorigenesis. We have developed a flow cytometry based system to identify and separate human primary pancreatic acinar and ductal cells. We showed that, unlike mouse acinar cells, human acinar cells undergo ADM though TGFβ signaling. This system allows us for the first time to isolate and culture human acinar cells, providing an experimental method to investigate whether human acinar and ductal cells can be transformed to PDAC. To model human PDAC development, we introduced the four most frequent mutations in PDAC, KRAS, p16, p53, and SMAD4, into human acinar and ductal cells. Two million of the genetically modified acinar derived ductal like cells (AD cells) or ductal cells were transplanted subcutaneously or orthotopically into NOD-SCID mice. The xenografts were harvested two months after transplantation. Pathological analysis found that invasive PDAC was generated from both acinar and ductal cells. However, only acinar derived PDACs had liver metastasis. Thus, for the first time, we have generated PDAC from normal human acinar and ductal cells, suggesting that both cell types are the origins of PDAC. Our model provides a unique system to study many aspects of human PDAC development.

Validation Study for Acute Pancreatitis Quality Indicators (APQI)

W. Wassef,¹ M. Mahmoud,¹ E. Vivian,² V.K. Singh,³ P. Tarnasky,² N. Parsa,⁴ S. Han,⁵ S. Wani,⁵ C.M. Wilcox,⁶ S. Herndon,⁶ S.J. Pandol.⁷¹Gastroenterology/Internal Medicine, UMassMemorial Medical Center, Worcester, MA; ²Gastroenterology/Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; ³Gastroenterology/Internal Medicne, Johns Hopkins Hospitals, Baltimore, MD; ⁴Gastroenterology/Internal Medicne, Johns Hopkins Hospitals, Baltimore, MD; ⁵Gastroenterology/Internal Medicne, University of Colorado Anschutz Medical Center, Aurora, CO; ⁶Gastroenterology/Internal Medicne, University of Alabama, Birmingham, AL; ⁷Gastroenterology/Internal Medicne, Cedar-Sinai Medical Center, Los Angeles, CA.

Background: The Acute Pancreatitis Quality Indicators (APQI) is a 6-item list created for the optimal management of acute pancreatitis. It was developed using a modification of the RAND/UCLA appropriateness model using a literature review presented at the APA (2014) and a 2-step Delphi method discussed with experts in the field at DDW (2015) and at the APA (2015).

Aim: The goal of this study was to test the validity of these quality indicators.

Methods: Patients with acute pancreatitis (AP) were identified from 5 sites using ICD 9/10 codes. Records were pulled and data was collected to evaluate the potential impact of: cholecystectomy on readmission rates in appropriate patients with non-severe biliary pancreatitis; and hydration, nutrition, ERCP, walled off pancreatic necrosis (WOPN) drainage, and antibiotic use on survival in severe acute pancreatitis (SAP).

Results: Patients with non-severe acute gallstone pancreatitis and intact gallbladders had a lower readmission rate (30 day) with in-house cholecystectomy compared to those without 11/127 (2.4%) vs. 12/85 (8.2%; P = 0.063). Those with SAP and adequate hydration (>300 cc/hr) in the first 6 hours had lower mortality than those who did not 4/52 (6.5%) vs. 4/23 (14.3%; P = 0.075). Furthermore, early nutrition (<24 hours) decreased mortality in SAP patients compared to those without 1/38 (2.6%) vs. 7/37 (13.7%; P = 0.071). Subgroup analysis for the role of ERCP, WOPN drainage, and use of antibiotics was not helpful due to small sample size.

Conclusions: Cholecystectomy, early hydration and early nutrition are key items of the APQI with associated improved outcome that should be strongly endorsed and recommended to improve quality of care in the management of patients with acute pancreatitis.

Novel Calcineurin Inhibitor Strategies to Prevent Radiocontrast-Induced Organ Injury Using the Pancreas as a Prototypic Organ

L. Wen, T.A. Javed, S.Z. Husain. Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA.

Radiocontrast agents are used in a multitude of imaging procedures. However, a major problem is that radiocontrast exposure can induce debilitating end organ injury. The goal of our studies is to devise effective preventatives for radiocontrast injury. In the current work, we focused on pancreatitis resulting from radiocontrast exposure to the pancreas during ERCP. In further preliminary studies, we extended the work to studying radiocontrast-induced kidney injury, or nephropathy. A recent proof of concept discovery from our laboratory is that radiocontrast exposure in models of post-ERCP pancreatitis (PEP) induces the activation of the calcium-activated phosphatase calcineurin, specifically within the pancreatic acinar cell. To further translate this finding, we first examined whether co-administration of calcineurin inhibitors with the ERCP radiocontrast could effectively target pancreatic calcineurin. In a mouse model of PEP, we found that a novel combination of the calcineurin inhibitor FK506 (1 μM), along with the radiocontrast iohexol, prevented post-ERCP pancreatitis by 61% (n = 5; P < 0.05). To address manufacturability of the novel combination, we tested varying autoclave conditions and found that autoclaving FK506 at a standard temperature of 120°C under pressure reduced its calcineurin inhibitory activity by 7-fold. However, autoclaving at a minimum threshold temperature of 90°C did not alter inhibitory function. These findings in the pancreas also led us to examine whether the calcineurin inhibitors could prevent radiocontrast-induced nephropathy. In preliminary studies of tubular kidney cell lines, FK506 pretreatment prevented the early inflammatory change associated with radiocontrast exposure. Overall, we believe that ongoing optimization to target calcineurin will yield novel and effective strategies for preventing the problem of radiocontrast-induced injury.

A Role for Pancreatic NFAT in Pancreatitis

L. Wen, T.A. Javed, A.I. Orabi, S.Z. Husain. Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA.

Aberrant cytosolic calcium signals from within the pancreatic acinar cell are among the earliest intracellular events that play a central role in mediating pancreatitis. A potent target of the aberrant calcium signals is the calcium/calmodulin-dependent phosphatase calcineurin. A key question is which downstream targets of calcineurin primarily influence pancreatitis. A predominant effector of calcium and calcineurin is nuclear factor of activated T-cells, or NFAT. In the current study, we hypothesize that acute pancreatitis is mediated by pancreatic acinar cell NFAT in a cell-autonomous manner, through acinar cell calcium and calcineurin signaling. In isolated primary mouse and human pancreatic acinar cells, we demonstrate that each of the pancreatitis stimuli—cerulein, bile acids, radiocontrast—induce NFAT activation in a calcineurin-dependent manner. To dynamically image pancreatic NFAT activity in vivo, we generated a novel intra-pancreatic ductal infusion method for delivering adeno-associated virus serotype 6 (AAV6)-NFAT-luciferase selectively to the mouse pancreas. Using this tool and in the setting of cerulein hyperstimulation, we found that NFAT activity within the pancreas is elevated within 6 hours of inducing pancreatitis. Among the NFAT isoforms, NFATc1 and NFATc3 are strongly expressed in pancreatic acinar cells. Using RegNetwork to predict gene targets and PANTHER and IPA to map gene pathways, we found that both NFAT isoforms target the stress-induced pathways of p53, p38 MAPK, and Ras. Overall, this work suggests that acinar cell NFAT is a target of calcium and calcineurin in pancreatitis.

Activated Brain Microglia in Cerulein Induced Persistent Pancreatitis

K.N. Westlund,^1,2 S.L. McIlwrath.²¹Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM; ²New Mexico VA Health Care System, Albuquerque, NM.

Introduction: Persistent cerulein induced pancreatitis (6 weeks) produces chronic secondary hypersensitivity in mice. Pain related hypersensitivity has been shown to be related to spinal cord microglial activation. We investigated whether microglia in the brain were activated as previously reported for spinal cord in a trinitrobenzene sulfonic acid (TNBS) induced rat model.

Methods: Pancreatitis was induced by intraperitoneally injecting adult C57Bl/6 mice with 50 μg/kg, 6 hourly injections, 3 days a week, for a 6 week duration. Mechanical hypersensitivity was assessed using the up-down method on the hindpaws. Secondary heat hypersensitivity was determined by measuring the response latency on the hotplate (50°C). Histological analysis of the brain samples were immunostained for levels of Iba1, a marker for activated microglia.

Results: Mice with cerulein pancreatitis had decreased mechanical withdrawal thresholds and decreased heat response latencies, indicating hypersensitivity. In mice with persistent (6 weeks) pancreatitis, significantly increased immunohistochemical staining for Iba1 was observed in the hippocampus, thalamus, hypothalamus and amygdala. Microglial cell bodies and highly branched processes were clearly visible, indicating their activation. However, in the primary somatosensory cortex immunostaining for Iba1 was similar in mice with cerulein pancreatitis and controls.

Conclusion: Microglia in the brain are activated during persistent cerulein inflammation of the pancreas in mice and may contribute to behavioral hypersensitivity. Activated microglia in the brain may be contributory to persisting pain.

Nrf2 in Pancreatic Cancer Chemotherapy Response and the Use of Brusatol as a Chemotherapeutic Agent

D. Williams,¹ T. Gana,¹ L. Sivapalan,¹ O. Butler,¹ R. Jackson,¹ P. Perez-Mancera,¹ L. Barrera-Briceno,¹ I. Copple,¹ T. Cox,¹ C. Goldring,¹ C.M. Halloran,¹ P. Ghaneh,¹ D. Palmer,¹ O. Strobel,² W. Greenhalf,¹ J.P. Neoptolemos,¹ E. Costello.¹¹Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom; ²Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Gemcitabine resistance in pancreatic cancer has been reported to be enhanced by the Nrf2 antioxidant pathway. Nrf2 induces expression of NQO1. Brusatol, an Nrf2 inhibitor, possess anti-cancer properties with low general toxicity. This study aimed to investigate the role of Nrf2 in treatment response and determine if brusatol is a viable chemotherapeutic agent. Microarrays from 205 patients randomized to chemotherapy in the ESPAC-3 trial (with controls from ESPAC-1) were stained for expression of NQO1. Cytoplasmic NQO1 levels were categorised as high or low and groups compared using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards models. Median survival following gemcitabine treatment was 13.5 (95% CI, 9.9-16.8) months for those with low NQO1 vs 24.1 (95% CI, 15.5-28.8) months for those with high NQO1 (P = 0.01). For the 5-fluorouracil group, median survival was 13.9 (95% CI, 10.7-19.5) and 21.8 (95% CI, 16.9-25.7) months for those with low and high NQO1, respectively (P = 0.07). NQO1 levels were not predictive of survival for the 27 patients of the observation group (P = 0.69). Nrf2 and NQO1 levels were either reduced or induced following exposure of PDAC cell lines (MiaPaca2, Suit2, Panc1) to gemcitabine dependent upon concentration. Cell viability was inhibited by gemcitabine with an IC50 of between 20 nM and 888 nM dependent upon cell line. Brusatol reduced Nrf2 levels, inhibited all detectable protein synthesis, and reduced viability with an IC50 of between 6 nM and 71 nM. Gemcitabine treatment appears to both induce and reduce Nrf2 and NQO1 levels in cell lines dependent upon concentration, however high NQO1 levels correspond to better outcome following gemcitabine treatment in patients.

Influence of Ambulatory Triglyceride Levels on Risk of Recurrence in Patients With Hypertriglyceridemic Pancreatitis

B.U. Wu,¹ M. Batech,² E. Dong,³ D. Yadav,⁴ W. Chen.⁵¹Kaiser Permanente Los Angeles, CA; ²Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; ³Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; ⁴Gastroenterology, University of Pittsburgh, PA; ⁵Kaiser Permanente Research and Evaluation, Pasadena, CA.

Aim: To evaluate impact of ambulatory triglyceride levels on risk of recurrent episodes of pancreatitis in patients with hypertriglyceridemic pancreatitis.

Methods: We conducted a longitudinal retrospective cohort study of patients with serum triglyceride level ≥500 mg/dL during an index hospitalization for acute pancreatitis between 2006 and 2013 across a regional integrated healthcare system. Cases were identified based on diagnosis codes and elevation in serum amylase/lipase >3 times normal confirmed by manual chart review. We used multivariable robust Poisson regression to determine the independent effect of baseline (first outpatient) triglyceride measurement on risk of recurrent pancreatitis. Ambulatory triglyceride levels were categorized as normal (0–200 mg/dL), moderately elevated (201–500 mg/dL) and highly elevated (>500 mg/dL). We further assessed factors related to likelihood of normalization of serum triglycerides (<200 mg/dL) in the outpatient setting.

Results: 151 patients met study inclusion criteria. Median follow-up was 3 years. Overall, 45 (29.8%) of patients experienced at least 1 recurrent attack of pancreatitis with 25 (16.6%) of patients experiencing multiple episodes. In multivariable analysis, patients with moderately elevated (adjusted RR 5.47 (95% CI, 1.80–16.65) as well as highly elevated (RR 8.45; 95% CI, 2.55–27.96) triglycerides were at increased risk of disease recurrence compared to patients that achieved normalization. Patients with triglyceride measurement performed within 30-days from discharge were more likely to have triglyceride <200 mg/dL, 40% vs. 26%, P=0.03.

Conclusion: For patients with hypertriglyceridemic pancreatitis, even moderate elevation in subsequent triglyceride levels was associated with increased risk of recurrence. Timely follow-up was associated with impoved triglyceride control.

Analysis of Survival After Surgical Management of Pancreatic Neuroendocrine Neoplasms (PNENs) in a Single Center

J. Wu,¹ W. Xu,¹ J. Wei,¹ K. Zhang,¹ X. Liu,¹ M. Li,² Z. Zhang,² Z. Lu,¹ Y. Miao.¹¹Pancreas Center and ²Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Pancreatic neuroendocrine neoplasms (PNENs) are rare, indolent, heterogeneous tumors with unknown natural history. In spite of emerging specific therapeutic options recently, tumor resection of PNENs is still the only treatment for potentially curative intent. The purpose of this study is to reveal the clinicopathologic and operation-related features and to investigate prognostic factors in resected PNENs.

Methods: From January 2009 to December 2014, the clinical data of 118 consecutive patients who underwent surgical resection for PNENs was analyzed. Survival analysis was conducted in 106 patients with follow-up.

Results: Of the 118 patients, females accounted for 55.9% and nonfunctional PNENs constituted 63.6% of all. The median age at diagnosis was 50 (range, 19–78) years. Synchronous liver metastasis existed in 9 patients (7.6%). All patients received complete resection of primary tumor. Total morbidity rate after surgery was 61.9%. Pancreatic fistula occurred in 61 cases (51.7%). A total of 106 patients were included in the final survival analysis. Five-year OS rates for all 106 patients was 78.9%. Median follow-up of patients was 30.7 months. Univariate analysis of predictors for overall survival showed that tumor size >2cm, R1/R2 resection status, lymphovascular invasion, lymph node metastasis, synchronous liver metastasis, tumor graded G2/G3, TNM stage III/IV were poor prognostic factors of survival. In multivariate analysis, WHO G2/G3 grading (P = 0.037) and TNM stage III/IV (P = 0.018) were independent predictors.

Conclusion: In this study, we found that G2/G3 grading and TNM stage III/IV were independent prognostic factors of survival in PNENs. Stratification of prognosis and strategy of treatment can be made on the basis of these two systems before and after surgery. Surgical resection is still the treatment of first choice for PNENs regardless of liver metastasis. Our results suggest surgical treatment for small nonfunctional PNENs.

IL-22/IL-22RA1 Axis Drives Stemness and Tumorigenicity of Pancreatic Cancer Stem Cells Via STAT3 Signaling

J. Xue, W. He, J. Wu. School of Medicine, Shanghai Jiaotong University, Shanghai, China.

IL-22/IL-22RA1 axis has been reported to play a vital role in acute and chronic panreatitis progression, via mediating crosstalk between immune cells and acinar cells or stellate cells respectively. High IL-22RA1 expression on pancreatic tumor is associated with poor patient survival, however little is know about how IL-22/IL-22RA1 axis involved in pancreatic cancer development. In our study, we firstly identified IL-22RA1hi population harbored pancreatic cancer stem cell potential, and IL-22 acted on the IL-22RA1hi cancer cells to promote expression of core stem cell genes (NANOG, SOX2) via activation of transcription factor STAT3, resulting in increased cancer stemness and tumorigenesis. Together, IL-22RA1 might become a potential marker for pancreatic CSCs, and blocking this network via STAT3 inhibitor, together with gemcitabine, provides a therapeutic strategy for targeting pancreatic stem cells.

Alcohol, Smoking, Pancreatitis-Susceptibility Mutations, and the Risk of Chronic Pancreatitis (CP)

D. Yadav,¹ J.N. Abberbock,² J. LaRusch,³ V.K. Singh,⁴ S. Sherman,⁵ G.A. Cote,⁶ S. Amann,⁷ R.E. Brand,⁸ N.M. Guda,⁹ C.E. Forsmark,¹⁰ C.M. Wilcox,¹¹ D.L. Conwell,¹² A. Slivka,² D.C. Whitcomb.¹¹Division of Gastroenterology, Hepatology, and Nutrtion, UPMC, Pittsburgh, PA; ²University of Pittsburgh, Pittsburgh, PA; ³ARIEL Precision Medicine, Pittsburgh, PA; ⁴Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD; ⁵Departments of Medicine and Radiology, Indiana University, Indianapolis, IN; ⁶Department of Medicine, Medical University of South Carolina, Charleston, SC; ⁷North Mississippi Medical Center, Tupelo, MS; ⁸Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Shadyside Hospital, Pittsburgh, PA; ⁹Department of Gastroenterology, Aurora St.Luke's Medical Center, Milwaukee, WI; ¹⁰Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL; ¹¹Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL; ¹²The Ohio State University Wexner Medical Center, Columbus, OH.

Objectives: Although independent association of alcohol and smoking with CP is known, significance in subgroups (women, blacks) is limited due to sample sizes in prior studies, and contribution of genetic factors to this risk has not been assessed. We evaluated the association of alcohol, smoking and known genetic susceptibility mutations on CP risk in the expanded NAPS cohort.

Methods: CP patients (1024) and controls (824) prospectively enrolled in the NAPS2 studies were studied. Demographic and risk factor information was obtained from detailed questionnaires. Genotyping was performed for known mutations in PRSS1, CFTR, SPINK1, CTRC [disease associated, G60G] and CLDN2 genes. Multivariable logistic regression models assessed the relationship of risk factors to CP.

Results: Overall, there was a significant association of very heavy drinking (≥5 drinks/d vs. never/light drinkers) [OR, 3.7; 95% CI, 2.7-5.1] and dose-dependent association of smoking (≥1 ppd: 2.6; 95% CI, 2–3.4; <1 ppd: OR, 1.7; 95% CI, 1.4-2.2 vs. never smokers). These associations were replicated in subgroups analysis in men, women, whites and blacks. An interaction was observed between very heavy drinking and ever smoking. In white CP patients and unrelated controls, the association for very heavy drinking and smoking remained significant, while independent association existed with trypsin-linked genes (PRSS1/SPINK1/CTRC) (OR, 4.5; 95% CI, 2.4-8.4), CFTR (OR, 1.7; 95% CI, 1.1-2.6), and CLDN2 (OR, 1.8; 95% CI, 1.3-2.7). CP patients with alcohol etiology were more likely to carry the CLDN2 risk haplotype.

Conclusion: For the first time, using an expanded cohort, we demonstrate and quantify the independent effects of major risk factors of CP. Very heavy drinking and smoking have interactive relationship for the risk of CP.

CD110 is Associated With Pancreatic Cancer Patient Survival and Promotes Cancer Progression, Especially Liver Metastasis

Z. Yan,¹ K. Ohuchida,¹ B. Zheng,¹ T. Okumura,¹ K. Koikawa,¹ S. Takesue,¹ N. Nakayama,¹ K. Shirahane,² Y. Shimizu,³ T. Moriyama,¹ T. Ohtsuka,¹ K. Mizumoto,¹ Y. Oda,⁴ M. Nakamura.¹¹Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan; ²Saga-ken Medical Centre Koseikan, Saga, Japan; ³Kyushu University Hospital Cancer Center, Fukuoka, Japan; ⁴Department of Anatomic Pathology, Pathology Sciences, Kyushu University, Fukuoka, Japan.

Background: Thrombopoietin (TPO) is primarily produced by the liver, which regulates the production of platelets. Its receptor, CD110, was reported as an organ-specific marker for liver metastasis of colorectal cancer and is known to be involved in JAK-STAT pathway activation. However, its significance and functional role in pancreatic cancer remain unknown.

Aim: To investigate the significance of CD110 expression and its function in pancreatic cancer.

Methods: We performed immunohistochemical staining to investigate the clinical significance of CD110 expression in pancreatic cancer. We investigated the expression of CD110 of pancreatic cancer cell lines using qRT-PCR and western blotting. We performed transwell migration and invasion assays following knockdown of CD110 expression using RNAi. Furthermore, we evaluated expression of TPO in pancreatic tissues and cell lines, then performed transendothelial migration assay to investigate the effect of TPO on cancer cell extravasation in vitro and in vivo. Moreover, we investigated the effect of TPO on cancer cell viability and its related signaling pathway. Finally, we performed splenic xenograft experiment to investigate the functional role of CD110 on liver metastases formation.

Results: In the immunohistochemical analysis, CD110 expression in cancer cells is associated with low histological grade of pancreatic invasive ductal carcinoma, while patients with high CD110 expression had a poorer prognosis. High CD110 expression is an independent predictor of liver metastasis formation. Inhibition of CD110 expression significantly attenuated tumor cell migration and invasion. Furthermore, CD110’s ligand TPO chemoattracted cancer cell extravasation in vitro and in vivo. After the treatment of TPO, CD110 increased cell viability through activation of ERK-MYC signaling pathway. In vivo, knock out of CD110 expression inhibited liver metastases formation in splenic xenograft mouse model.

Conclusion: CD110 promotes pancreatic cancer progression and may be a promising predictive factor for liver metastasis.

Inhibition of ERK1/2 Targeting Cancer-Associated Fibroblasts Suppresses Pancreatic Cancer-Stromal Interaction

Z. Yan,¹ K. Ohuchida,¹ W. Guan,¹ H. Feng,¹ S. Kibe,¹ Y. Ando,¹ K. Nakata,¹ K. Shindo,¹ H. Toma,² Y. Tominaga,³ Y. Miyasaka,¹ T. Ohtsuka,¹ M. Nakamura.¹¹Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan; ²Harasanshin Hospital, Fukuoka, Japan; ³Fukuoka Sanno Hospital, Fukuoka, Japan.

Background: Extracellular signal–regulated kinases (ERK) has been related to multiple human cancers and metastases. Recently, ERK inhibitor was reported to suppress Kras-mutant pancreatic tumor growth by targeting pancreatic cancer cells. However, its effect on cancer-stromal interaction is unknown.

Aim: To investigate the therapeutic effect of ERK inhibition on pancreatic cancer-stromal interaction.

Methods: We established highly metastatic cancer cells by splenic xenograft mouse model and characterized them compared with their parent cells. We performed immunohistochemistry to evaluate p-ERK1/2 expression in pancreatic tumor tissues derived from KPC(LSL-Kras(G12D/+);LSL-Trp53(R172H/+);Pdx-1-Cre) mice. We also performed westernblotting to investigate p-ERK1/2 expression in human pancreatic stellate cells (PSCs) derived from pancreas without tumors, cancer-associated fibroblasts (CAFs) and human pancreatic cancer cells (PCs). We measured IC50 of ERK inhibitor SCH772894 on highly-metastatic cells, their parent cells, and CAFs and evaluated related gene expression of CAFs following SCH772894 treatment. Finally, we performed indirect co-cultures to investigate the effect of SCH772894 on cancer-stromal interaction.

Results: Highly-metastatic cells presented significantly increased abilities of migration, invasion, proliferation, and liver metastases formation. These cells exhibited an epithelial-mesenchymal transition phenotype. p-ERK1/2 was detectable on both PCs and cancer-surrounding stroma in the tumors of KPC mice. p-ERK1/2 protein level of CAFs was higher than those of PSCs and PCs. p-ERK expression was up-regulated in PCs after co-cultures with CAFs. The cell sensitivity to SCH772894 is followed: CAFs> highly-metastatic cells> their parent cells. SCH772894 treatment down-regulated p15, p16, IL-6, MMP2, and MMP3 expression in CAFs and suppressed CAF-induced migration and invasion of PCs.

Conclusion: The present data suggest that inhibition of ERK1/2 targeting CAFs suppresses cancer-stromal interaction.

Use of Beta Blockers Has No Impact on Survival of Patients With Pancreatic Ductal Adenocarcinoma

A. Yang, A.L. Lucas. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY.

Background: Previous preclinical studies have suggested that β-adrenergic signaling may regulate the progression of various cancers, including pancreatic cancer. In this study, we investigate the association between the incidental use of β-blockers for various conditions on the survival of patients with pancreatic ductal adenocarcinoma (PDAC).

Methods: Histologically confirmed records of patients diagnosed with PDAC between 2007 and 2011 were extracted from Surveillance, Epidemiology, and End results registry (SEER)-Medicare linked database. Multivariable Cox Proportional-Hazard models adjusted for confounders, including Charlson comorbidity index, stage, treatment, chronic kidney disease and sociodemographic characteristics, were used to examine the association between β-blocker usage and survival.

Results: From 2007 to 2011, 13,717 patients were identified as diagnosed with PDAC, with 2564 (19%) of these patients using β-blockers at the time of diagnosis. Patients receiving β-blockers had a mean survival time of 5.1 months compared to 6.2 months for non-users (P < 0.01). After adjustment for confounders, β-blockers usage was not associated with improved survival (Hazard Ratio (HR), 1.04; 95% Confidence Interval (CI), 0.98-1.09; P = 0.19). After stratification by conditions associated with β-blockers usage, including hypertension, coronary artery disease and cardiac arrhythmia, β-blocker users did not demonstrate any differences in survival compared to non-users in all groups (P > 0.05). When stratified by β-blocker receptor selectivity, this lack of association with survival persisted regardless of selectivity (P > 0.05 for all).

Conclusion: Our data suggests that β-blocker usage does not confer a survival advantage in patients with PDAC.

Insulin Enhances the Sensitivity of Pancreatic Cancer to Gemcitabine by Regulating NF-κB/hENT-1 Pathway

L. Yin, Y. Peng, Z. Lu, J. Wei, Y. Fu, S. Guo, X. Zhu, X. Liu, Y. Zhu, J. Zhang, Y. Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Insulin could promote proliferation, invasion and metastasis of pancreatic cancer cells in vitro. However,whether insulin could affect the sensitivity of pancreatic cancer to Gemcitabine is still unknown. Objective: To explore the effects of insulin on the sensitivity of pancreatic cancer to Gemcitabine and its underlying mechanisms.

Methods: After treatment of 100nM insulin, the effect of Gemcitabine on cell viability was measured by CCK-8 assayin five pancreatic cancer cell lines (BXPC-3, SW1990, PANC1, MiaPaca-2, CFPAC-1) and IC50 was calculated. Apoptosis assay was performed by flow cytometry. The expression of hENT-1 and RRM1was evaluated by qRT-PCR and Western blot. The location of NF-κB (nuclear factor kappa B) in the nucleus and cytoplasm was observed by immunofluorescence and further confirmed by Western blot. Human pancreatic cancer cells were injected subcutaneously in the nude mice. Tumor-bearing mice were randomly divided into four groups (control group, GEM group, Insulin group, and combination group). Then the growth of tumors and the inhibition effect of GEM were observed.

Results: After treatment of 100nM insulin, sensitivity of MiaPaca-2 and CFPAC-1 to Gemcitabine was significantly increased (lower IC50 of Gemcitabine and higher apoptosis). Mechanism studies suggested that insulin treatment caused upregulation of hENT-1 and promote the nuclear transport of NF-κB. After we added the NF-κB inhibitor,NF-κB in the nucleus and hENT-1 were significantly down-regulated and the IC50 became higher accordingly. In a xenograft mouse model, the combination treatment of insulin with GEM significantly reduced tumor volume compared to mono-therapy.

Conclusion: Insulin can enhance the sensitivity of pancreatic cancer to Gemcitabine by upregulating NF-κB/hENT-1 pathway and may be used as a chemotherapy sensitizer to improve the prognosis of patients.

Early Dual Drainage - Combining Transpapillary- and Percutaneous-Drainage: A Novel Approach for Pancreatic Infection Associated With Pancreatic Fistula in Severe Acute Pancreatitis

Y. Yokoi,¹ M. Kikuyama,² T. Satoh.³¹Shinshiro Municipal Hospital, Shinshiro, Japan; ²Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan; ³Shizuoka General Hospital, Shizuoka, Japan.

Background: Although pancreatic infection associated with pancreatic fistula (PF) is the most critical condition in acute pancreatitis, no therapeutic strategies have been established. We hypothesized that early induction of dual drainage combining endoscopic pancreatic duct (PD) intervention for PF and percutaneous catheter drainage (PCD) for pancreatic infection may improve outcomes.

Methods: Whenever feasible, fine-needle aspiration for peripancreatic fluid collection (PFC) was performed percutaneously or endoluminally. For infection and PF with amylase-rich fluid (>3X serum amylase level), PCD and transpapillary PD drainage (preferably naso-pancreatic drainage ENPD) were carried out. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters.

Results and Comments: Infectious PFC and PF were detected in 13 (72.2%) of 18 patients. PD disruption detected by pancreatography occurred exclusively in patients (n = 8) with PFC amylase levels ≥10,000 U/L The median timing of PCD and PD endotherapy was 8 and 13.5 days, respectively. No serious complications resulted from intervention procedures. Surgical intervention due to uncontrollable infection and visceral perforation, and bleeding was avoided. PF was closed in 12 (92.3 %) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (5.5%) patient. Our results were better than those of the previous studies using conservative or PCD treatments; conversion to surgical intervention (0 % vs. 26-38%) and disease-related mortality (6.7% vs. 7-20%), respectively.

Conclusion: PFC ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early induction of dual drainage combining PD endotherapy and PCD is feasible and safe, and may ameliorate pancreatic infection associated with PF.

Anti-inflammation Effect of NecroX-7 With Mesenchymal Stem Cells in Acute Pancreatitis

K.S. Yoo, H.S. Choi. Division of Gastroenterology and Hepatology, Hanyang University Guri Hospital, Guri, Korea.

Background: Extensive research has evaluated pharmacologic agents that target the various steps in the pathogenesis of acute pancreatitis (AP). However, no evidence suggests that any of the current targeted therapies provide benefit. NecroX-7 (C25H32N4O4S2) (NX-7) is participated mitochondrial ROS and RNS inhibition of apoptosis on oxidative stress materials. It also has cytoprotective and antioxidant effects. Mesenchymal stem cells (MSCs) have self-proliferation and differentiation capabilities of serve as a source of multipotent stem cells. Although, MSCs homing in damage process, induced inflammation of promoted the growth of stellate cells, the detailed mechanism has not been elaborated. The aim of this study was to investigate paracrine effect of NX-7 with MSCs infused on AP.

Methods: Mice were fed the choline/methionine-deficient diet with 0.5% DL-ethionine for 4 days. Before induction of the AP, mice were fasted overnight then injected I.P. with NX-7 (20mg/kg). MSCs were transplantated via tail vein after 36 hours from the feeding diet. The pancreas was harvested and observed under a light microscope. Detection of MSCs was analyzed by RT-PCR.

Results: Pancreas from NX-7 and NX-7+MSCs infusion showed decreased edema, collapsed cell structure, and inflammatory cells compared with AP. Serum amylase and lipase levels decreased by NX-7 and NX-7+MSCs infusion. NX-7 and NX-7+MSCs infusion significantly reduced expression levels of pro-inflammatory cytokines, but they increased anti-inflammatory cytokines. Moreover, MPO activity significantly increased in AP. NX-7 and MSCs infusion were observed to decrease MPO activity than AP. AIFM1 was not observed in control, AP, and AP+NX-7, whereas that was detected MSCs infusion groups.

Conclusion: NX-7 and MSCs infusion improved anti-inflammatory cytokines and suppressed pro-inflammatory cytokines. Also, they decreased serum amylase and lipase levels. Therefore, NX-7 and MSCs infusion had anti-inflammation effects and paracrine effect in AP. Furthermore, NX-7 assisted in homing of MSCs in an early stage of AP.

A Case of Minute Pancreatic Carcinoma With Focally Fatty Change of the Pancreatic Parenchyma

K. Yoshida,¹ A. Kitagawa,² Y. Nakashima,¹ H. Aoki,² K. Hino.²Departments of ¹Interventional Bilio-Pancreatology and ²Department of Hepatology and Pancreatology, Kawasaki Medical School, Kurashiki, Japan.

A 75 year-old woman was pointed out focal atrophy in the pancreatic body by computed tomography (CT) during a follow-up period of post partial hepatectomy for hepatocellular carcinoma. Seven years after hepatectomy, magnetic resonance Image (MRI) showed dilatation of the main pancreatic duct in the tail. Contrast CT and MRI did not show a mass, while endoscopic ultrasonography (EUS) revealed hypoechogenic tumor of 5 mm in diameter adjacent to the dilatation of main pancreatic duct. Endoscopic retrograde pancreatography (ERCP) showed irregular narrowing of the main pancreatic duct. As we find malignant cells by pancreatic juice cytology, distal pancreatectomy was performed. Pathologically, high grade pancreatic intraepithelial neoplasia lesions were observed in the pancreatic body with minute invasion and fibrosis and high degree of fatty changes of the pancreatic parenchyma adjacent to the carcinoma lesion. This case suggests that focal atrophy of the pancreatic parenchyma with fatty change could indicate pancreatic carcinoma in situ. We have to recognize that fatty change on CT as a risk of pancreatic cancer.

A Case of Pancreatic Carcinoma In Situ Associated With Lymphoplasmacytic Sclerosing Pancreatitis

K. Yoshida,¹ H. Aoki,² Y. Nakashima.¹Departments of ¹Interventional Bilio-Pancreatology and ²Hepatology and Pancreatology, Kawasaki Medical School, Kurashiki, Japan.

A 65-year-old man was pointed out a round mass in the pancreatic tail by abdominal ultrasonography performed during a follow-up period of chronic gastritis and renal failure and was referred to our department for further examination of pancreatic mass. Computed tomography (CT) showed slight swelling of the pancreatic tail. Magnetic resonance cholangiopancreatography (MRCP) did not show dilatation of the main pancreatic duct and branch ducts in the tail. T1 weighted Image (T1WI) revealed the pancreatic mass low intensity, T2WI high, and diffusion impairment. Endoscopic ultrasonography (EUS) revealed hypoechogenic tumor of 20mm in diameter with irregular shape in the pancreatic tail. We did not find any malignant cells by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and pancreatic juice cytology. Endoscopic retrograde pancreatography showed irregular narrowing of the main pancreatic duct and slight dilatation of branch ducts. Three month later, the swelling was improved on CT and MRI. One year later, pancreatic tail was swelled again and main pancreatic duct was slightly dilatated on CT. The tumor marker CA 19-9 and serum IgG4 were within normal limits. As we could not completely rule out pancreatic cancer for the pancreatic tumor in pancreatic tail, distal pancreatectomy was performed. Pathologically, high grade pancreatic intraepithelial neoplasia lesions were observed in the pancreatic tail with severe fibrosis where IgG4-positive plasma cells were infiltrated, which led to the diagnosis of concomitant lymphoplasmacytic sclerosing pancreatitis (LPSP). This is a rare case that suggests an association between LPSP and pancreatic carcinoma in situ.

Overexpressed HSPA2 Correlates With Tumor Angiogenesis and Unfavorable Prognosis in Pancreatic Carcinoma

L.L. Zhai, T.F. Ju. Department of General Surgery, Hangzhou First People’s Hospital, Nanjing Medical University, Hangzhou, China.

Background & Aim: Heat shock-related 70-kDa protein 2 (HSPA2) is known to correlate with tumor development and progression. This work aimed to determine the expression and prognostic roles of HSPA2 in pancreatic carcinoma.

Methods: Tumor and their corresponding non-tumor tissues were obtained from 80 patients with pancreatic carcinoma. HSPA2 expression in tumor and non-tumor tissues was evaluated by immunohistochemistry. Expression of vascular endothelial growth factor (VEGF) and CD31 in tumor tissues were also evaluated by immunostaining. The relationships of HSPA2 with clinicopathological data, tumor angiogenesis and prognosis were analyzed.

Results: The results showed that HSPA2 expression was significantly elevated in tumor tissues compared with adjacent non-tumor tissues (P < 0.05). High HSPA2 expression was significantly associated with aggressive clinicopathological characteristics. HSPA2 staining was positively correlated with VEGF (r = 0.466; P < 0.001) and microvessel density (MVD) (r = 0.366; P = 0.001) in tumor tissues. Patients with high HSPA2 expression showed worse relapse-free survival (RFS) (P < 0.001) and overall survival (OS) (P < 0.001) than those with low HSPA2 expression. Multivariate analysis indicated that high HSPA2 expression was an independent predictor for poor RFS (P < 0.001) and OS (P = 0.001).

Conclusion: Taken together, overexpressed HSPA2 is correlated with tumor angiogenesis and poor prognosis in pancreatic carcinoma. HSPA2 may play an important role in tumor progression, and serve as a potential biomarker for the prediction of adverse prognosis in pancreatic carcinoma.

Elevated Intracellular Trypsin Activity Increased the Severity of Acute Pancreatitis and Promoted the Development of Chronic Pancreatitis in Transgenic Mice

X. Zhan,¹ G. Zhang,¹ Y. Zhang,¹ L. Zhuang,¹ R. Dawra,² Y. Li,¹ Y. Yao,¹ F. Gui,¹ J. Chen,¹ A. Haddock,¹ L. Zhang,³ A.K. Saluja,⁴ C.D. Logsdon,⁵ Y. Bi,⁶ B. Ji.¹¹Department of Cancer Biology, Mayo Clinic, Jacksonville, FL; ²Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL; ³Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; ⁴Department of Surgery, University of Miami, Miami, FL; ⁵Department of Cancer Biology, MD Anderson Cancer Center, Houston, TX; ⁶Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL.

Background and Aims: Intra-acinar trypsinogen activation occurs early during the development of pancreatitis and trypsin activity has been believed to play important roles in the pathogenesis of pancreatitis. Yet, the role of intra-acinar trypsin activity in pancreatitis remains controversial. The aim of the study was to examine the effects of intra-acinar trypsin activity on the severity of pancreatitis using a previous developed transgenic mouse model with conditionally expression of an activatable mutant trypsinogen in pancreatic acinar cells.

Methods and Results: We found that transgenic expression of the mutant trypsinogen did not lead to spontaneous pancreatitis. However, when these transgenic mice were challenged with cerulein, they developed much more severe acute pancreatitis than WT control mice, as indicated by elevated edema, serum amylase, inflammatory cell infiltration and acinar cell damage. Increased trypsin activity caused more apoptotic cell death and was associated with the severity of pancreatitis. Repeated injections of cerulein caused the development of chronic pathological changes in the pancreata of transgenic mice. The chronic changes including inflammatory cell infiltration, parenchymal cells loss, fibrosis and fatty replacement mimicked the histological changes of human hereditary pancreatitis, while these changes were not obvious in control mice treated with cerulein.

Conclusion: Taken together, we provide in vivo evidence that that increased intra-acinar activation of trypsinogen plays important roles in the initiation and progression of both acute and chronic pancreatitis.

Non-Alcohol - Non-Biliary Pancreatitis is Associated With Increased Readmission for Pancreatitis in the First 30 Days

H. Zhang, M. Ling, J. Cho, B. Chong, M. Quezada, N. Gupta, J.L Buxbaum. Division of Gasteroenterology and Hepatology, University of Southern California Keck School of Medicine, Los Angeles, CA.

Background: Limited data exists regarding characteristics and outcomes of acute pancreatitis which is not due to alcohol or gallstones. Our aim was to define the salient characteristics and clinical course of patients with non-alcohol non-biliary (NANB) pancreatitis.

Methods: Between March 2015 and April 2017, consecutive unique patients hospitalized for acute pancreatitis at Los Angeles County Hospital were prospectively evaluated. Etiology, readmission, ICU admission, and sixty additional variables were collected. The primary endpoint of the study, early readmission, was defined as evaluation for pancreatitis symptoms within 30 days of discharge.

Results: Among 455 individual patients who presented with acute pancreatitis, 116 (25.5%) had NANB origin. Of the NANB group, the most frequent etiologies were medications (38, 32.8%), infections (16, 13.8%), and hypertriglyceridemia (17, 14.7%). NANB pancreatitis patients were less likely to be Hispanic (OR, 0.59; 95% CI, 0.36-0.98) and more likely to have diabetes (OR, 2.57; 95% CI, 1.64-4.04). Overall 15 (12.9%) patients with NANB pancreatitis were readmitted within 30 days. Multivariate analysis controlling for significant baseline differences (i.e. DM) revealed that patients with NANB pancreatitis were more likely to be readmitted in 30 days (OR, 1.96; 95% CI, 1.04-3.69). Multivariate analysis controlling for the same covariates revealed that they were less likely to be admitted to the intensive care unit (OR, 0.47; 95% CI, 0.22-0.97).

Conclusion: Non-Alcohol-Non-Biliary Pancreatitis has an increased rate of early readmission for pancreatitis in the first 30 days though less severe disease. Accurate identification and treatment of specific etiology may lessen the requirement for early readmission.

Efficacy and Safety of Low Molecular Weight Heparin Prophylaxis in Patients With Severe Acute Pancreatitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

R. Zhang,¹ P. Ren,¹ Q. Xia,¹ L. Deng,¹ W. Huang,¹ R. Sutton. ¹Integrated Traditional Chinese and Western Medicine, West China Medical School/West China Hospital, Sichuan University, China; ²Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.

Background & Aims: The effects of Low molecular weight heparin (LMWH) have been controversial in treating acute pancreatitis (AP). We sought to systematically assess the effectiveness and safety of prophylaxis subcutaneous injection of LMWH comparing with conventional treatment in predicted severe AP patients.

Methods: Major databases were searched up to June 2017 without language constriction. Randomized and quasi-randomized controlled trials regarding this topic were included. The primary endpoint was mortality. Secondary endpoints included multiple organ dysfunction syndrome (MODS) and other available clinical outomes. Relative risk (RR) or weighted mean difference (WMD) with 95% confidence interval (CI) were calculated. Evidence of quality was determined by GRADE.

Results: Twelve trials including 760 patients were included and analyzed. Compared with conventional treatment, the pooled estimates suggest that LMWH was significant associated with reduction in mortality (RR, 0.33; 95% CI, 0.22-0.52), MODS (RR, 0.26; 95% CI, 0.13-0.52), any organ failure (RR, 0.52; 95% CI, 0.38-0.71), local complications (RR, 0.50; 95% CI, 0.37-0.69) and surgical intervention (RR, 0.35; 95% CI, 0.23-0.53; all P < 0.001) without heterogeneity. LMWH also reduced length of hospitalization (WMD, -2.22; 95% CI, -3.36 to -1.07; P = 0.02) albeit with high heterogeneity. Furthermore, the APACHE II score, serum C-reactive protein and procalcitonin levels (all P < 0.05) before and after LMWH application were signfincatly decreased (all P < 0.05), while the prothrombin time remained unaltered. The GRADE scores for these endpoints were rated from very low to low, except for MODS with a moderate evidence quality.

Conclusion: Prophylactic use of LMWH was safe and may associate with improved clinical outcomes for AP patients. However, high quality evidence is needed to ascertain our findings.

Aurora Kinase a Inhibitor MLN8237 Inhibits the Growth of Pancreatic Cancer Both In Vitro and In Vivo

Y. Zhang,¹ Y. Ma,¹ Y. Wang,² A. Haddock,¹ D. Mukhopadhyay,² Y. Bi,³ B. Ji.¹Departments of ¹Cancer Biology and ²Biochemistry and Molecular Biology, ³Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL.

Backgound: Aurora kinase-A is a member of a family of mitotic serine/threonine kinases. It is implicated with important processes during mitosis. Recent studies have highlighted the potential role of Aurora kinase-A in the initiation and progression of several types of tumors. However, the effects of a specific inhibitor MLN8237 on the progression of pancreatic cancer remain unclear.

Methods and Results: We observed increased protein expression of Aurora kinase-A in both human and mouse pancreatic cancer cells. The specific Aurora kinase-A inhibitor MLN8237 dose-dependently inhibited the proliferation and migration of four human pancreatic cancer cell lines including AsPC-1, BxPC-3, MIA PaCa-2 and PANC-1. Both cellular apoptosis and senescence were observed upon Aurora kinase-A inhibition. The senescence is at least partly mediated by Aurora kinase-A-regulated retinoblastoma protein (Rb) protein phosphorylation. Furthermore, MLN8237 is able to inhibit pancreatic stellate cell growth. In in vivo studies, MLN8237 was administered to both the orthotopic and genetically engineered mouse pancreatic cancer models. MLN8237 was able to significantly suppress the tumor growth in both models and the inhibition effects were superior to gemcitabine treatment alone. Combination of MLN8237 and gemcitabine did not yield better effects.

Conclusion: Our results indicated that MLN8237 could be an effective alternative treatment for pancreatic cancer.

A Novel Transgenic Mouse Model of Human Hereditary Pancreatitis

Y. Zhang,¹ G. Zhang,¹ X. Zhan,¹ L. Zhuang,¹ Y. Li,¹ Y. Yao,¹ J. Guo,¹ A. Haddock,¹ E. Radisky,¹ L. Zhang,¹ S.J. Pandol,² C.D. Logsdon,³ Y. Bi,¹ B. Ji.¹¹Mayo Clinic, Jacksonville, FL; ²Gastroenterology/Internal Medicne, Cedar-Sinai Medical Center, Los Angeles, CA; ³Department of Cancer Biology, MD Anderson Cancer Center, Houston, TX.

Background: Hereditary pancreatitis (HP) is an inherited form of pancreatitis characterized by recurrent acute pancreatitis (AP) which progresses to chronic pancreatitis (CP). The cumulative risk of pancreatic cancer in HP patients is 40%. We aimed to generate an HP mouse model for studying the pathogenesis of HP.

Methods: We used a human Bacterial Artificial Chromosome harboring the full-length human PRSS1 gene with intact PRSS1 promoter, exons, and introns. An R122H point mutation was introduced using Galk-mediated recombineering technology. Transgenic mice were produced by pronuclear injection.

Results: This transgene expressed PRSS1R122H at ~50% of the endogenous human PRSS1 protein level. Taking into account that the PRSS1 R122H mutation in human is heterozygous and mutated PRSS1 would constitute 50% of total PRSS