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Abstracts of Papers Submitted to the Joint 50th Anniversary Meeting of the American Pancreatic Association and Japan Pancreas Society, November 6–9, 2019, Maui, Hawaii

doi: 10.1097/MPA.0000000000001419
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Risk Factors for Surgical Site Infection After Pancreatectomy and the Characteristics of the Pathogens: A Retrospective Study

K. Abe,1 M. Kitago,1 S. Uno,2 M. Shinoda,1 H. Yagi,1 Y. Abe,1 G. Oshima,1 S. Hori,1 S. Uchida,2 T. Yokose,1 Y. Endo,1 Y. Kitagawa.1Departments of 1Surgery and 2Infectious Diseases, Keio University School of Medicine, Tokyo, Japan.

Background: Surgical site infections (SSI) are crucial complications after pancreatectomy, and antibiotic-resistant pathogens are the emerging concerns. This study aimed to assess the risk factors for SSI and to identify the profile of the pathogens.

Methods: We enrolled patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from January 2012 to December 2018. We investigated the incidence of SSI, and compared the clinical backgrounds and operative outcomes between SSI group and non-SSI group. We also analyzed the microbiological results of culture in the SSI group, especially the culture results from drainage fluid via a clean procedure.

Results: A total of 366 patients were enrolled, of whom 221 underwent PD, 146 underwent DP (one both PD and DP). The overall SSI rate was 24.3%, classified into organ-space SSI (21.3%), and superficial SSI (5.2%). SSI was frequent in patients who underwent PD than in DP (32.1% vs 12.3%, P < 0.001). Among PD patients, the SSI group included a higher number of male patients (77.1% vs 63.3%, P = 0.045) and patients with a higher median body mass index (23.5 kg/m2 vs 21.5 kg/m2, P = 0.001) than non-SSI group. There were significant differences between two groups in the median operation time (462 min vs 420 min, P = 0.04), and median blood loss (410 ml vs 270 ml, P = 0.001). The most common pathogen was Enterococcus faecalis, followed by Enterobacter cloacae and Candida albicans. However, the most predominant microorganism isolated from the drainage fluid was C. albicans. The detected pathogens were frequently resistant to cefazolin and ampicillin-sulbactam.

Conclusions: Among PD patients, Male sex, high BMI, long operation time, and a high volume of blood loss were identified as risk factors for SSI. E. faecalis was still a frequent identified pathogen; however, we should consider Candida infection in case of abscess formation refractory to broad-spectrum antibiotics.

Role of an Interdisciplinary Pancreaticobiliary Tumor Board Review in the Evaluation of Main Duct IPMN: A Single Center Case Series

A.M. Ahmed,1 L.C. Shipley,2 D. Harrison,1 R. Mitchell,1 S. Reddy.3Departments of 1Gastroenterology and Hepatology, 2Internal Medicine, and 3Surgery, University of Alabama at Birmingham, Birmingham, AL.

Background: Seemingly ubiquitous use of cross-sectional imaging has identified an increasing number of cystic lesions of the pancreas. In particular, main duct intraductal papillary mucinous neoplasms (IPMN) are particularly worrisome due to an increased risk of malignancy. Our institution recently developed an interdisciplinary approach with weekly patient review by expert physicians in surgery, radiology, oncology, gastroenterology and pathology.

Methods: Retrospective chart review from the initiation of the interdisciplinary group in June 2018 until present identified three cases having main duct IPMN.

Results: Two of the three patients were male and collectively had an average age of 61, with a mean main pancreatic duct diameter of 8.7 mm. Two patients had liver disease; one a prior transplant and another was being listed. One had a mixed main duct, side branch IPMN which was evaluated by EUS FNA and notable for elevated CEA (614) and amylase (8327). The other two cases were evaluated by per-oral pancreatoscopy where biopsy of the main duct demonstrated mucinous neoplasm without dysplasia. The interdisciplinary group recommended surgery in two of the three patients. The pre-transplant patient was recommended to proceed with liver transplant with close follow up by the group and may eventually require surgery for the IPMN. The mixed type IPMN patient had a successful Whipple with pathology demonstrating low to intermediate grade dysplasia with low grade PanIN.

Conclusions: Complex pancreaticobiliary diseases may benefit from the interdisciplinary review in a group setting. This study is limited by the small number of cases but highlights the merits of an interdisciplinary approach for these complex cases.

Optimal Follow-up of Incidental Pancreatic Cystic Lesions: Clinical Outcome After Long-term Follow-up

D.W. Ahn,1,2 S.H. Lee,1,3 W.H. Paik,1,3 J.B. Jeong,1,2 J.K. Ryu,1,3 Y.T. Kim.1,31Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea; 2Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea; 3Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.

Background: Although it is generally accepted that cystic lesions in the pancreas (CLPs) 3 cm or less in size and without features suggesting malignancy can be managed conservatively with follow-up, the optimal duration and interval of follow-up for CLPs is not yet well established. This study was performed to investigate the optimal duration and interval of follow-up for CLPs in clinical practice.

Methods: Patients with CLPs 3 cm or less in size and without high-risk stigmata or worrisome features received follow-up with computed tomography at 6, 12, 18, and 24 months and then per 12 months. A retrospective analysis with prospectively collected data was performed.

Results: A total of 223 patients with CLPs detected from 2004 to 2014 (initial mean size, 1.3 ± 0.6 cm) received follow-up during the median period of 103.8 months. Within the first 12 months of follow-up, no patients experienced the growth of cyst or the development of surgical indication and three patients (1.3%) underwent simultaneous surgery for another intra-abdominal lesion. A total of 20 patients underwent surgery during follow-up and two malignant cysts were detected. Overall rate of malignant progression during follow-up was 0.9%. In these two cases with malignancy, the malignant progression occurred after 62 months and 69 months of follow-up in each case, respectively. The development of surgical indication occurred even after 10 years of follow-up (2.2%). In CLPs 2 cm or less in size, development of surgical indications did not occur within 36 months of follow-up.

Conclusions: Long-term follow-up more than 10 years should be performed because of the potential for malignant transformation of CLPs. The 12 months interval of follow-up for asymptomatic CLPs might be sufficient in clinical practice. For the first follow-up, the 24 months interval might be sufficient in CLPs 2 cm or less in size.

Targeting MUC4 in Pancreatic Cancer Using Non-shed Cell Surface Bound Antigenic Epitopes

A. Aithal,1 C. Orzechowski,1 W.M. Junker,1 P. Kshirsagar,1 A. Shah,1 S.K. Gautam,1 G.C. Varshney,1 S.K. Batra,1,2 M. Jain.1,2

1Department of Biochemistry & Molecular Biology; 2Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE.

Background: Pancreatic cancer (PC) is a lethal disease with high mortality rates. Targeting of cell surface antigens like MUC4 that are differentially expressed on PC cells holds promise for future therapeutic avenues. The C-terminal membrane anchored MUC4β subunit harbors important domains for tumorigenesis of PC and is believed to be resistant to shedding and cleavage. This study is an attempt to test the hypothesis that antibodies specific to MUC4β domain can be efficient tools for targeting MUC4. These efforts show implications for future development of MUC4 targeted antibody based immunotherapies.

Methods: Mice were immunized with MUC4β domain and monoclonal antibodies (mAbs) were generated. Routine immunoassays were used to characterize binding properties of mAbs. Pair-labeled biodistribution was performed using radioiodinated mAbs to demonstrate uptake in pancreatic cancer xenografts growing in nude mice.

Results: Two mAbs (6E8 and E9) recognized intact full length MUC4 and low levels of a cleaved form that migrated at approximately 180 kDa on SDS PAGE. Upon deglycosylation with PNGase F, the molecular weight shifted to approximately 80kDa that is similar to predicted molecular weight of MUC4β apoprotein. No heterodimerization of cleaved subunits was apparent. The mAbs were capable of binding to surface of live MUC4 expressing PC cells. Upon extended exposure, mAbs slowly internalized into cells in a time and temperature dependent manner. MAbs decreased the proliferation and migration of MUC4 expressing PC cells. Preliminary in vivo biodistribution experiments indicate uptake of radiolabeled mAb in pancreatic cancer xenografts in a MUC4 dependent manner.

Conclusions: Due to their ability to target live cells, accumulate intracellularly and localize into MUC4 expressing tumors, these mAbs are promising candidates for development of mAb based therapeutic modalities for PC.

The Impact of Preoperative Biliary Drainage Followed by Ascitic Bacterial Contamination on Clinically Relevant Pancreatic Fistula After Pancreaticoduodenectomy

M. Akashi,1,2 Y. Nagakawa,1 Y. Hosokawa,1 Y. Sahara,1 C. Takishita,1 Y. Hijikata,1 H. Osakabe,1 Y. Kiya,1 H. Nishino,1 T. Shirota,1 T. Nakajima,1 K. Katsumata,1 A. Yoshito,2 T. Itoi,3 A. Tsuchida.11Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan; 2Department of Surgery, Kurume University School of Medicine, Kurumi, Japan; 3Department of Gastroenterological Medicine, Tokyo Medical University, Tokyo, Japan.

Background: Preoperative biliary drainage (PBD) for tumor around pancreatic head region may increase intra-abdominal bacterial contamination during surgery and postoperative infectious complications including pancreatic fistula due to biliary tract infection. In this study, the influence of preoperative biliary drainage and ascitic infection on clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy was examined.

Methods: 345 patients underwent pancreatoduodenectomy from January 2011 to October 2017 were divided into PBD group and non-PBD group, and Perioperative factors were compared. Drainage fluid cultures were performed 1, 2, 3 days after surgery, and the positive rate, the bacterial species, and the relationship with the occurrence of CR-POPF were examined retrospectively.

Results: In 187 PBD group and 158 non-PBD group, the breakdown of PBD group was 159 in internal PBD group and 28 in external PBD group. In PBD group vs non-PBD group, the positive rate of drainage fluid culture (51.1% vs 18.4%) was significantly higher in PBD group (P < 0.001). Multivariate analysis revealed positive drainage fluid culture was one of the independent risk factors for CR-POPF (OR, 2.20; P = 0.018).Internal PBD was one of the independent risk factors for positive drainage fluid culture (OR, 4.10; P <0.001). In drainage fluid culture, endogenous bacteria such as Enterococcus, Enterobacter and Klebsiella were detected in the ratio of 80.8% in internal PBD group, 36.4% in external PBD group and 52.5% in non-PBD group. PBD group had a higher match rate of species between the drainage fluid culture and POPF-causing bacteria than non-PBD group (60.7% vs 20.0%, P = 0.005).

Conclusions: PBD, especially Internal PBD was a risk factor for postoperative ascitic infection involving CR-POPF after PD.

Lipophilic Statins Suppress LPS-induced IL-6 Production in Macrophages Through Inhibition of the Mevalonic Acid Pathway

S. Ako,1 H. Chang,1 A. Hernandez,1 R. Massoumi,1 J. Sinnett-Smith,2 J. King,1 O.J. Hines,1 E. Rozengurt,2 G. Eibl.1Departments of 1Surgery and 2Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: We have previously reported that obesity-induced inflammation in visceral adipose tissue (VAT) is a promotional factor for pancreatic ductal adenocarcinoma (PDAC) and statins attenuated obesity-promoted early pancreatic cancer development. Critical to obesity-induced AT inflammation are pro-inflammatory, M1-polarized macrophages. In this study we examine the effects and mechanisms of statins on macrophage M1-polarization to understand the tumor-suppressive actions of statins in PDAC.

Methods and Results: As a model of macrophage M1-polarization, the macrophage cell lines RAW264.7 and J774A.1 were stimulated with lipopolysaccharide (LPS) at 100 ng/mL for 6 hours and IL-6 production was analyzed using qRT-PCR. Exposure of RAW264.7 and J774A.1 to lipophilic statins (cerivastatin, simvastatin, fluvastatin) attenuated LPS-induced IL-6 expression (reduction of 97%, 75%, and 89% in RAW264.7 with 2 μM of statins, and 90%, 85%, and 79% in J774A.1 with 0.1 μM of statins, respectively). Inhibition of HMG-CoA reductase by statins leads to decreased levels of mevalonate. Accordingly, the effects of cerivastatin on LPS-induced IL-6 expression was reversed by mevalonate (0-250 μM). Mevalonic acid is a precursor for cholesterol biosynthesis and geranylgeranyl pyrophosphate (GGPP), important for protein prenylation. Exposure of macrophages to the oxidosqualene cyclase inhibitor Ro 48-8071 in the cholesterol biosynthesis pathway did not affected LPS-induced IL-6 expression. In contrast, an inhibitor of geranylgeranyl transferase-I (GGTi-298) attenuated LPS-induced IL-6 expression. Addition of GGPP reversed the suppression of LPS-induced IL-6 expression by cerivastatin. Geranylgeranylation of Rho family small GTPases is known to activate proteinkinase D (PKD) and is important for actin polymerization. Inhibitors of PKD or actin polymerization attenuated LPS-induced IL-6 expression dose-dependently.

Conclusions: Our data demonstrate that lipophilic statins suppress LPS-induced IL-6 production, a marker of macrophage M1-polarization, through inhibition of the mevalonate pathway and protein prenylation, but not cholesterol biosynthesis. These results indicate a potentially important mechanism, by which lipophilic statins attenuate obesity-promoted PDAC.

Sarcopenia as a Surrogate Method of Nutritional Assessment in Patients With Chronic Pancreatitis (CP): Comparison With Body Mass Index (BMI) and Bioelectrical Impedance Vector Analysis (BIVA)

P. Alarcón-Murra,1 J. Hernández-Calleros,1 A. Soriano-Ríos,1 P. Estrada-Arzate,1 L. Uscanga-Domínguez,1 L. Velásquez-Rodríguez,2 A. Rumoroso-García,2 M. Peláez-Luna.1,3Departments of 1Pancreas, Gastroenterology and 2Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; 3Research Division, Department of Experimental Medicine, Universidad Autónoma de México, Mexico City, Mexico.

Background: Nutritional assessment in CP is challenging. Sarcopenia can be assessed using computed tomography (CT) scan imaging and BIVA. We aimed to describe the frequency of sarcopenia by CT in CP and to evaluate if its comparable to BIVA.

Methods: Exploratory study, of 13 CP patients with BIVA and CT scans performed within 4 months of each other. Sarcopenia was assessed using BIVA and CT images by manually demarking the skeletal muscle area (SMA) at L3 vertebra. Skeletal muscle index (SMI) and skeletal muscle radiation attenuation value (SMRA) were obtained. Priory reported SMI cutoffs for sarcopenia were used. Patients were grouped according to BMI as underweight (<18.5 kg/m2), normal weight (18.5–24.9 kg/m2) and overweight (≥25 kg/m2). Sarcopenia frequency according to BIVA and SMI was compared between them and according to BMI.

Results: Mean age was 47.15 years. Sarcopenia by SMI occurred in 7 cases (54%); 3 cases had normal SMI and low SMRA (muscular fat infiltration) and 3 cases had normal SMI and SMRA. BIVA reported normal body composition in 5 patients, water-overload in 2 and decreased muscle mass in 6. According to BMI, sarcopenia by SMI presented in 5/7 normal weight and in 2/5 overweight. Comparison of BIVA and SMI found low SMI in 3/5 normal composition, 1/2 with water overload and, 3/6 decreased muscle mass cases. One of 3 cases with muscular fat infiltration was underweight and had decreased muscle mass by BIVA; the remaining 2 were overweight (1 water-overload and 1 normal body composition by BIVA).

Conclusions: Sarcopenia is frequent in CP. BMI does not provide muscle mass information. BIVA and SMI are comparable in assessing sarcopenia. Sarcopenia by BIVA and SMI can be used in nutritional assessment in CP. We favor SMI since is available from CT scans performed regularly, at no extra cost.

Are Intra-operative Bile Cultures Obtained During Pancreatoduodenectomy of Clinical Benefit?

E.A. Aleassa,1,2 S. Gordon,3 N. Anzlovar,4 G. Morris-Stiff.11Department of Hepato-Pancreato-Biliary Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH; 2Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates; Departments of 3Infectious Diseases, Medicine Institute and 4Quality Data Registries, Cleveland Clinic Foundation, Cleveland, OH.

Background: Surgical site infections (SSIs) remain a major source of morbidity following pancreatoduodenectomy (PD). The presence of infected bile has been implicated in the pathogenesis of organ-space SSIs and thus determining the nature of bacteria in the bile at the time of PD would potentially allow for early and targeted treatment of subsequent infections, and also the offer the opportunity for prophylaxis.

Hypothesis: The hypothesis was that routine intraoperative bile culture (IOBC) provides data allowing for targeted therapy of SSIs. The aim of the study was to assess the practice of IOBC during PD to determine if it is of value to clinical practice.

Methods: Prophylactic antibiotics were administered at the time of induction. Patients underwent routine IOBC at the time of division of the bile duct with specimens sent for culture and sensitivity (C+S) analysis. The proximal duct was then immediately controlled with a bulldog clamp and the distal bile duct oversewn to prevent contamination of the peritoneal cavity. A prospectively maintained departmental database was used to identify patients and to obtain data on SSIs, and in particular organ-space SSI (OS-SSI). The results of the IOBC were obtained from the electronic medical record (EMR) as were C+S results of subsequent SSIs and the organisms present in each setting were compared.

Results: From May 2015 to December 2017, 249 patients underwent PD. In 157 cases an IOBC was sent and processed, of which in 95 cases there were bacteria/fungi cultured, and in 61 there was no growth at the end of the culture period. In the remaining 93 cases no specimen was sent. In the positive culture group 10/93 (10.8%) developed an OS-SSI of which 2 were organisms not covered by the prophylactic antibiotics prescribed (Carbapenem resistant Klebsiella [n = 1]; Vancomycin resistant enterococci [n = 1]). 86/95 (90.5%) with a positive culture had a pre-operative biliary stent as did 9/10 (90%) with an OS-SSI. In the no growth group, 6/61 (9.8%) developed an OS-SSI of which IOBC grew an organism not covered by the prophylaxis (Candida [n = 1]). Interestingly, in the no growth group none of the patients had received a stent. Overall, the IOBC provided vital information to change antimicrobial therapy in 3/157 (1.9%). With the cost of an IOBC at $50 the cost per change in therapy was $2617, approximately the cost of a day of hospital stay.

Conclusions: Routine use of IOBC yields a small but an important number of cultures that change clinical practice, allowing for earlier commencement of targeted antimicrobial therapy.

Diverting From Protocol Prophylaxis Due to Penicillin Allergy in Pancreatoduodenectomy is Associated With a Negative Impact on SSI and Pancreatic Fistula Formation

E.A. Aleassa,1,2 N. Anzlovar,3 G. Morris-Stiff.11Department of Hepato-Pancreato-Biliary Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH; 2Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates; 3Quality Data Registries, Cleveland Clinic Foundation, Cleveland, OH.

Background: Surgical site infections (SSIs) remain an important cause of postoperative morbidity for patients undergoing pancreatoduodenectomy (PD). Second-line prophylaxis is not standardized for patients with penicillin allergy. The anecdotal observation of a higher rate of SSI amongst this population prompted further evaluation. Hypothesis: We hypothesize that use of alternative antibiotic regimen in patients reporting a penicillin allergy is associated with an increased rate of SSIs. Furthermore, many patients do not have objective evidence of penicillin allergy.

Methods: A prospectively maintained departmental database was used to identify patients and to obtain data on SSIs and postoperative pancreatic fistulae (POPF)s. The incidence of SSI and POPF were then compared in patients with and without a penicillin allergy.

Results: From January 2014 to December 2017, 329 patients underwent PD. Of which 47 (14.3%) patients self-reported a penicillin allergy. Therefore, they were prescribed alternate SSI prophylaxis, most commonly vancomycin (n = 21) or ciprofloxacin and metronidazole (n = 15). 12/47 (25.5%) developed an SSI and 7/47 (14.9%) developed a clinically relevant POPF. Of note, none of the patients had formal allergy testing documented in their EMR prior to PD. However, 10 patients were tested postoperatively and all were deemed negative for penicillin allergy. In the same period, 280 without a penicillin allergy underwent PD of which 49/282 (17.4%) developed an SSI and 31/282 (11.0%) a CR-POPF. Of those without penicillin allergy that received the optimal combination of ceftriaxone and metronidazole 18/164 (10.8%) developed an SSI (P = 0.01) and 6/164 (3.7%) developed a CR-POPF (P < 0.01).

Conclusions: The presence of a penicillin allergy and subsequent need for alternative prophylaxis is associated with a significantly increased risk of both SSI and CR-POPF. Given the lack of proof of allergy in the majority of cases, pre-operative testing may help to reduce morbidity in patients undergoing PD by offering them first-line antibiotic prophylaxis.

Invasion or Metastasis Inhibition in Pancreatic Cancer Using the Oral Iron Chelating Agent Deferasirox

S. Amano, S. Kaino, Y. Fujimoto, S. Shinoda, H. Harima, I. Sakaida.

Department of Gastroenterology and Hepatology, Graduate School of Medicine, Yamaguchi University, Ube, Japan.

Background: Iron is an essential requirement for cellular metabolism. Therefore, iron starvation in cancer cells can serve as a novel approach towards cancer therapy. We report here the first instance of application of deferoxamine, an iron chelating agent, as a treatment for advanced liver cancer. In addition, in vitro and in vivo studies have shown that deferasirox (DFX), a next-generation iron chelating agent exhibits a dose-dependent antitumor effect on pancreatic cancer cell lines when administered internally. Furthermore, microarray analysis of transplanted tumor fragments indicates that DFX may inhibit invasion or metastasis in pancreatic cancer cell lines.

Methodology and Results: In this study, baseline efficacy of DFX in suppressing in vitro invasion or metastasis in several pancreatic cancer cell lines was investigated. A scratch assay and Boyden chamber assay were performed to evaluate the invasion or metastatic ability of these cell lines. In the scratch assay, a significant reduction in invasiveness was observed in the DFX administration group compared with the control group. Similarly, the Boyden chamber assay showed significant reduction in metastatic ability in the DFX administration group. To elucidate the mechanism of action through which DFX suppresses invasiveness and migratory capacity of cancer cells, we investigated the Rho family of proteins involved in the cellular migration pathways. Expression of Cdc42 and Rac1 proteins was estimated by the G-protein-linked immunosorbent assay and found to be significantly reduced in the DFX administration group.

Conclusions: Our findings suggest that DFX may suppress the invasiveness or metastatic ability of cancer cells by decreasing the expression of Cdc42 and Rac1 proteins. Metastatic lesions are frequently observed in pancreatic cancers, and DFX administration may not only induce an inhibitory effect on tumor growth but may also diminish the ability of cancer cells to invade other tissues and metastasize.

Necroptosis in Pancreatic Cancer Promotes Cancer Cell Migration and Invasion by Release of CXCL5

Y. Ando,1 K. Ohuchida,1 Y. Otsubo,1 A. Sagara,1 S. Kibe,1 S. Takesue,1 M. Nakayama,1 K. Shindo,2 T. Moriyama,1 K. Nakata,1 T. Ohtsuka,1 K. Mizumoto,1 M. Nakamura.1Departments of 1Surgery and Oncology and 2Endoscopic Diagnostics and Therapeutics, Kyushu University, Fukuoka, Japan.

Background: Necroptosis is a form of programmed cell death that is accompanied by release of intracellular contents, and reportedly contributes to various diseases. Here, we investigate the significance of necroptosis in pancreatic cancer.

Methods: We used immunohistochemistry and western blot analysis to evaluate expression of the key mediators of necroptosis—receptor-interacting serine/threonine protein kinase 3 (RIP3) and mixed lineage kinase domain-like (MLKL)—in human pancreatic cancer. We also tested the effects of conditioned media (CM) from necroptotic cells on pancreatic cancer cells in Transwell migration and Matrigel invasion assays. Protein array analysis was used to investigate possible mediators derived from necroptotic cells.

Results: RIP3 and MLKL are highly expressed in human pancreatic cancer tissues compared with normal pancreas. MLKL expression was particularly intense at the tumor invasion front. CM derived from necroptotic cells promoted cancer cell migration and invasion, but not CM derived from apoptotic cells. C-X-C motif chemokine 5 (CXCL5) was upregulated in CM derived from necroptotic cells compared with CM derived from control or apoptotic cells. Moreover, expression of the receptor for CXCL5, C-X-C-motif chemokine receptor-2 (CXCR2), was upregulated in pancreatic cancer cells. Inhibition of CXCR2 suppressed cancer cell migratory and invasive behavior enhanced by necroptosis.

Conclusions: These findings indicate that necroptosis at the pancreatic cancer invasion front can promote cancer cell migration and invasion via the CXCL5–CXCR2 axis.

Risk Modeling for Pancreatic Fistulae After Pancreatic Head Resections in a Single Tertiary Center

C. Antoine, K.C. Honselmann, L. Frohneberg, S. Deichmann, L. Bolm, H. Lapshyn, E. Petrova, U. Wellner, T. Keck, D. Bausch.

Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.

Background: Postoperative pancreatic fistulae (POPF) presents a serious and life-threatening complication after pancreatic head resections. Therefore, reliable risk stratification to prevent or quickly treat these sequelae is needed.

Methods: 182 patients who underwent pancreaticoduodenectomy from 2012 and 2017 from our center were retrospectively analyzed. POPF was defined according to the International Group on Pancreatic Fistula (ISPGF) classification of 2005. Multivariate logistic regression was performed using the GLM (general linear model) method for model building. Accuracy and area under the receiver operating characteristic curve (AUC) were used to define the best linear regression model.

Results: Clinically relevant pancreatic fistulae (CR-POPF) were present in 16 % (n = 29) of patients. Patients with CR-POPF experienced significantly more insufficiencies of gastroenterostomies, delayed gastric emptying and more extraluminal bleeding than patients without CR-POPF. Postoperative laboratory risk factors for the occurrence of POPF were serum and drain amylase and lipase, c-reactive protein, white blood cells and serum urea on postoperative day 1. Multivariate analysis revealed multiple postoperative predictive models, the best one including BMI, need of care, normal main pancreatic duct diameter, soft pancreatic texture, operation time, drain amylase, serum lipase as well as leucocytes of day 1. This model was able to predict CR-POPF with an accuracy of 90 % and an AUC of 0.903.

Conclusions: Clinically relevant fistula can be predicted by using simple clinical parameters. This knowledge could help stratifying patients and possibly help to prevent and treat POPF sufficiently in the early postoperative period.

Efficacy of Neoadjuvant Chemotherapy Using Gemcitabine and S-1 for Resectable and Borderline Resectable Pancreatic Cancer

T. Aoki, S. Mori, Y. Sakuraoka, T. Suzuki, Y. Nishi, T. Arakawa, T. Shimizu, K. Tago, K.H. Park, N. Harada, T. Shiraki, Y. Iso, K. Kubota.

Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan.

Background: Significance of neoadjuvant chemotherapy (NAC) for resectable (R) and borderline resectbale (BR) pancreatic cancer has not been established, although some recent reports have documented promising results. The purpose of this study was to assess the efficacy of NAC using gemcitabine and S-1 (GS) for R and BR pancreatic cancer.

Methods: Patients with R and BR pancreatic cancer receiving treatments with curative intent between 2006 and 2018 were retrospectively evaluated. From 2014, NAC using 2 cycles of GS was started. The preoperative assessment of resectablity was conducted using Classification of Pancreatic Carcinoma edited by Japan Pancreas Society, and was stratified into R, BR-PV, and BR-A. The efficacy of NAC was assessed by the changes in tumor size, CA 19-9 value, and pathological response. The resection rate, R0 resection rate, and survival outcomes were compared between patients with and without NAC.

Results: In total, 221 patients (R: 145; BR-PV: 51; BR-A: 25) were identified. Seventy-three patients received NAC (R: 32%; BR-PV: 29%; BR-A: 48%, P = 0.245). NAC induced a median of 16.5% decrease in tumor size, and 36.4% decrease in CA 19-9 value, and the ratios were similar among R, BR-PV, and BR-A groups. The pathological response was 1a in 33 cases, 1b in 18 cases, and 2 in 10 cases, respectively. The NAC was associated with increased R0 resection rate in the BR-PV group (P = 0.04), and increased performance rate of adjuvant chemotherapy in the R group (P = 0.01). The overall survival was significantly better in the R group (P = 0.02). NAC was not associated with better survival outcome, while adjuvant chemotherapy was associated with better overall survival in BR-PV and BR-A groups with borderline significance (P = 0.08).

Conclusions: NAC using GS failed to improve patient outcome. More powerful regimen without adverse influence on the performance of adjuvant chemotherapy is needed for BR pancreatic cancer.

Plasma suPAR in Diagnostics Between Malignant and Benign Pancreatic Masses

A. Aronen,1 J. Aittoniemi,2 R. Huttunen,3 A. Nikkola,1 J. Nikkola,1 O. Limnell,4 J. Sand,1 J. Laukkarinen.1,41Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; 2Fimlab Laboratories, Tampere, Finland; 3Department of Internal Medicine, Tampere University Hospital, Tampere, Finland; 4Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.

Background: Plasma soluble urokinase plasminogen activator receptor (P-suPAR) is a novel biomarker elevated in several inflammatory conditions and cancers. It has recently been shown to be elevated in patients with pancreatic cancer (PC) (Loosen et al., Carcinogenesis 2019). Serum carbohydrate antigen 19-9 (S-CA 19-9) is current primary biomarker for PC but has several limiting factors. Our aim was to study if P-suPAR could be used to differentiate malignant and benign pancreatic masses.

Methods: P-suPAR and CA 19-9 were preoperatively measured from 46 patients [median age 67 (range, 34–84) years, 50% male] undergoing surgery for malignant-suspicious pancreatic mass. The final histopathological diagnosis was pancreatic cancer (PC) in 25 patients, premalignant in 14 patients, and benign in 7 patients.

Results: Preoperative P-suPAR was significantly higher in patients with PC (median, 3.7 [IQR, 3.1–4.4] ng/mL) compared to patients with benign (2.1 [1.9–2.7] ng/mL; P = 0.004) or premalignant (2.2 [1.7–3.8] ng/mL; P = 0.007) histology. There was no significant difference between P-suPAR values of patients with premalignant and benign histology. ROC-curve analysis for discriminating malignant and benign pancreatic masses resulted AUC (ROC) = 0.93 (95% CI, 0.84–1.00); P = 0.001. A cutoff value of 2.8 ng/mL was calculated with sensitivity of 85% and specificity of 86%. S-CA 19-9 between patients with PC or benign lesion resulted 252 (29–384) U/mL vs 6 (4–48) U/mL; P = 0.001; respectively with a sensitivity of 72% and specificity of 71%. Adding P-suPAR to S-CA 19-9 increased diagnostic sensitivity up to 96% and specificity to 86% with positive and negative predictive values of 96% and 86%, respectively.

Conclusions: P-suPAR measured before pancreatic resection is significantly higher in PC patients compared to patients with benign or cancer premalignant lesion. P-suPAR may improve diagnostic accuracy when combined to S-CA 19-9. Thus P-suPAR may be a promising tool in differentiating malignant pancreatic mass from benign one.

Fully Automated Pancreatic Cancer Tumor Analysis in CT Images Using Artificial Intelligence and Deep Learning Neural Networks

V. Asadpour,1 R.A. Parker,2 S.J. Sampson,2 W. Chen,1 B.U. Wu.31Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; 2Department of Diagnostic Imaging and 3Center for Pancreatic Care, Gastroenterology, Kaiser Permanente, Los Angeles, CA.

Background: Automatic identification of pancreatic tumors in cross sectional images is a challenging concept due to the indistinguishable change of intensity on the edges of the tumor and uncertain shape of pancreas compared to organs with more rigid forms such as liver or kidney. We proposed an automated volumetric shape extraction method to segment, detect and classify pancreatic tumors. This method can be used for scanning large amount of imaging data.

Methods: The algorithm was developed and trained based on 22,590 CT slices of 45 subjects selected from 2785 pancreatic cancer patients. The selected subjects include metastasis and non-metastasis cases with tumors located in the head, body, tail, uncinate process or multiple areas of pancreas. First, a hierarchical atlas model was applied to find the estimated location of a pancreas. Next, a multi-resolution convolutional neural network was developed to label the patches of CT images to refine resolutions. An edge detection algorithm was then developed based on a structured map to find the accurate edges of pancreas and tumor. Finally, a multi-resolution rendering was used to extract the volumetric shape of the pancreas and tumor. All the images were labeled by radiologists as the gold standard for both training and validation. The Dice Similarity Coefficient (DSC), Jaccard Index (JI), precision and recall were reported.

Results: The subjects had a mean and standard deviation age of 56 ± 24.3 years. The proposed method yielded a DSC, JI, precision and recall of 85.8%, 83.5%, 87.8%, 92.4% for pancreas and 71.2%, 70.1%, 74.8%, 82.3% for tumor, respectively.

Conclusions: The proposed multi-step approach for volumetric extraction of pancreas and tumor shape rendered higher level of accuracy compared to previous work. The approach can be applied to large volume of images to assist diagnosis and treatment of pancreatic cancer.

A Case of Groove Pancreatitis Successfully Treated With Endoscopic Pancreatic Duct Stenting Via the Minor Ampulla

S. Asai, T. Ichinona, K. Ito, H. Jimbo, K. Matsuo, K. Takeshita, E. Akamine, N. Fujimoto.

Department of Gastroenterology, Tane General Hospital, Osaka, Japan.

Groove pancreatitis (GP) is an uncommon and difficult-to-treat disease which occasionally needs surgical treatment. There have been few reports of endoscopic treatment for GP. We herein report a case of GP successfully treated with stenting in the duct of Santorini. A 51 year-old male was referred to our hospital with the chief complaints of abdominal pain and vomiting. Abdominal CT and MRCP showed inflammatory findings and a cyst formation in the pancreaticoduodenal area, and the duct of Santorini was not described well. Esophagogastroduodenoscopy revealed reddish edematous duodenum causing stenosis. We diagnosed this case as GP, and conservative treatment with nil per os (NPO) was initiated. Although he got better with NPO, symptoms recurred with the start of food ingestion. Because impairment of the Santorini’s duct and leakage of pancreatic juice followed by cyst formation were estimated as the etiology, endoscopic pancreatic drainage via minor ampulla was attempted. ERCP showed the leakage from the impaired duct of Santorini with cyst formation as expected. As minor ampulla was undetectable partly because of the edematous duodenum, rendezvous through the major ampulla was performed. And then, a 5-Fr plastic stent was placed via minor ampulla. He became able to eat solid food and was discharged. The following ERCP aiming stent removal 3 months later showed no leakage and cyst formation, and there has been no recurrence of GP so far for a year.

Geminin Controls Growth and Differentiation in the Murine and Human Pancreas

L. Baeyens,1 D.W. Scheel,2 K. Yang,2 Y. Lei,1 M.S. German.2,31Reproduction - Genetics and Regenerative Medicine, Free University Brussels (VUB), Brussels, Belgium; 2Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research and 3Department of Medicine, University of California San Francisco (UCSF), San Francisco, CA.

Background: Geminin (Gmnn) is able to influence gene expression through various transcription factors or chromatin-remodeling complexes. Early in development, Gmnn can interact with Polycomb proteins to restrict neuronal lineage allocation. Later in development, Gmnn works to prevent premature neuronal differentiation. Gmnn regulates expression of key transcription factors involved in differentiation, such as the proneuronal bHLH genes, including neurogenins and their targets. During pancreas development the morphogenic clues that coordinate cellular and molecular events from the initial specification of the pancreatic primordium to the establishment of the progenitor pool are still largely undetermined. During secondary transition the endocrine precursors are derived from bipotent trunk progenitors. Neurogenin-3 (Ngn3) is considered the master regulator of all endocrine differentiation. Definitive insight into the control of Ngn3 regulation is currently still pending.

Methods: For mouse studies wildtype embryos are used to study the expression pattern of Gmnn while conditional knockout embryos are used to elucidate the mechanisms behind Gmnn actions. Rescue experiments are performed ex vivo using pancreas explant cultures and lentiviruses. For human studies human fetal pancreases were used to perform descriptive and functional assays. RNA and ChIP sequencing were used to investigate downstream effects of Gmnn modulation.

Results: We found Gmnn expression at early stages of mouse and human pancreas development with a decreased expression as development progressed. Inhibition of Gmnn during early development significantly reduced the overall pancreas size, it inhibited cell cycle activation and progenitor pool expansion and it prevented the initiation of endocrine differentiation. Cell cycle control and endocrine differentiation are governed by separate Gmnn effects with the latter being dependent on casein kinase 2 action.

Conclusions: Gmnn is now identified as a novel regulator of pancreas development and differentiation. Understanding Gmnn functions may provide important insight into pancreas homeostasis, diabetes and susceptibility to oncogenic transformations.

Seasonal Influence on the Incidence of Acute Pancreatitis: A Single Center Study in Northeast China

X. Bai.

Harbin Medical University, Habin, China.

Background and Aims: Seasonal differences have been observed in general surgical diseases, such as peptic ulcers. To explore if acute pancreatitis (AP) exhibits specific seasonal patterns, we carried out this retrospective single-center study.

Methods: Totally 1080 patients with AP were recruited from January 2010 to December 2015. All cases were categorized into four groups (spring, summer, autumn and winter) according to date of onset. Association between AP morbidity and seasons was analyzed. Then, all cases were stratified according to sex, age, etiology, infection rate/severity. Potential correlations between these factors and seasons were explored.

Results: Morbidity of AP was differed significantly by seasons (P = 0.002), which was the highest in winter (4%), especially for hyperlipidemic AP (4.3%). The rate (21.1%) and severity of infection were the highest in summer. Morbidity of AP was the highest among males in winter (2.3%).

Conclusions: Seasonal difference in morbidity of AP has been identified in Northeast China. This correlation is modified by sex, etiology, and infection. Our results provide clues for early prevention and clinical therapy of AP.

Developing a Porcine Model to Study Pancreatic Cancer

K.L. Bailey,1 N. Patel,1 N. Remmers,2 M.A. Carlson.1,3,41Department of Surgery, University of Nebraska Medical Center, Omaha, NE; 2College of Medicine, University of Nebraska Medical Center, Omaha, NE; 3Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE; 4Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha, NE.

Background: Pancreatic cancer (PC) is an aggressive cancer with a 5-year survival rate of only 8%. Mice are the current animal model being used to study PC. However, the therapeutic approval rate for new anti-cancer drugs utilizing the murine model is only 5-8%. Therefore, there is a need to develop a new PC model that recapitulates the human disease more accurately. Our goal has been to generate a new PC model using the pig, since this species has increased genetic, epigenetic, physiological, metabolic and immunological similarity to humans compared to mice.

Methods: To generate a porcine tumor model two strategies were used. (1) Porcine epithelial cells were isolated from the pancreas of a pig and transformed with overexpression of mutant KRASG12D and dominant negative TP53R167H. These transformed cells were injected in vivo on the anterior and posterior surface of the duodenal lobe of the pancreas (allogeneic recipients). Swine were euthanized after 2 months of incubation. (2) The connecting lobe of the transgenic Onco-pig (floxed KRAS/TP53 mutants) was injected with adenovirus expressing Cre recombinase (AdCre) + IL-8 to induce epithelial cellular transformation.

Results: Injection of transformed cells into the duodenal lobe of the pancreas resulted in complete ablation of tumor cells by the immune system (i.e., rejection of the allograft). In the Onco-pig, malignant transformation was evident in the pancreas 2 weeks after AdCre administration. Tumor regions stained positive for pan-keratin, indicating cells of epithelial origin.

Conclusions: We were able to generate pancreatic epithelial tumor utilizing the Onco-pig (autochthonous transgenic model). We hope to refine our methodology in order to have a immunocompetent orthotopic implant model as well. Possession of a porcine PC model should assist investigators with the development of diagnostic and interventional technologies.

Migration Signature Biomarker Panel Improves Gold Standard CA 19-9 Performance for Detection of Early Stage Pancreatic Cancer in the Blood

S. Balasenthil,1 Y. Huang,2 S. Liu,3 T. Marsh,2 J. Chen,4 S.A. Stass,5 D. KuKuruga,5 R. Brand,6 N. Chen,1 M.L. Frazier,4 J.J. Lee,3 S. Srivastava,7 S. Sen,1 A.M. Killary.11Department of Translational Molecular Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX; 2Fred Hutchison Cancer Research Center, Seattle, WA; Departments of 3Biostatistics and 4Epidemiology, The University of Texas M. D. Anderson Cancer Center, Houston, TX; 5University of Maryland Medical Center, Baltimore, MD; 6University of Pittsburgh Medical Center, Pittsburgh, PA; 7National Cancer Institute, Rockville, MD.

Background: Blood-based biomarkers for early detection of pancreatic ductal adenocarcinoma (PDAC) are urgently needed. Current biomarkers lack high sensitivity and specificity for population screening.

Methods: To validate a functional genomics-based plasma migration signature biomarker panel, tissue factor pathway inhibitor (TFPI), tenascin C (TNC-FN III-C), and CA 19-9 levels were measured by enzyme-linked immunosorbent assays in three early-stage PDAC plasma cohorts, including two independent blinded validation cohorts containing a total of 43 stage I, 163 stage II, 86 chronic pancreatitis, 31 acute biliary obstruction, and 108 controls. Logistic regression models developed classification rules combining TFPI and/or TNC-FN III-C with CA 19-9 for patient cases and control subjects, with or without adjustment for age and diabetes status. Twosided P values were calculated using bootstrap method.

Results: The TFPI/TNC-FN III-C/CA 19-9 panel improved CA 19-9 performance in all earlystage cohorts, including discriminating stage IA/IB/IIA, stage IIB, and all early-stage cancer from healthy controls. Statistical significance was reached for a number of subcohorts, including for all early-stage cancer vs healthy controls (cohort 1 AUC = 0.92, 95% CI, 0.86–0.96, P = .04; cohort 3 AUC = 0.83; 95% CI, 0.76–0.89; P = 0.045). Among subcohorts without diabetes and pancreatitis history, the panel approaches potential clinical utility for early detection to discriminate early-stage PDAC from healthy controls including an area under the curve (AUC) of 0.87 (95% CI, 0.77– 0.95) for stage I/IIA, an AUC of 0.93 (95% CI, 0.87– 0.98) for stage IIB, and a statistically significant AUC of 0.89 (95% CI, 0.82– 0.95) for all early-stage cancer (P = 0.03). Additional blinded studies strengthen results.

Conclusions: TFPI/TNC-FN III-C migration signature adds statistically significantly to CA 19-9’s predictive power to detect early-stage PDAC and may have clinical utility for early detection of surgically resectable PDAC.

Liver Fibrosis After Pylorus-Preserving Pancreatoduodenectomy

T. Bando,1 K. Shibuya,2 I. Yoshioka,2 T. Fujii.21Department of Surgery, Saiseikai Toyama Hospital, Toyama City, Japan; 22nd Department of Surgery, Toyama University School of Medicine, Toyama City, Japan.

Background: Pylorus-preserving pancreatoduodenectomy (PPPD) is a surgical procedure that dynamically alters the metabolic absorption of nutrients after surgery leading to various problems and recently causing liver fibrosis has been experienced at long-term observation. The aim of this study was to evaluate liver fibrosis clinicopathologically in long-term following after PPPD.

Methods: The subjects were about 10 years survival 15 cases without recurrence after PPPD. The median observation period was 109 months and the average age at surgery was 68.5. Primary diseases include ampulla of Vater carcinoma, invasive pancreatic ductal carcinoma and others. This was a retrospective cohort study using medical records. The index of liver fibrosis was M2BPGi and FIB-4 index (calculated from age, AST, ALT, and platelet count). The index of fatty liver was defined by the ratio of liver and spleen CT value.

Results: FIB-4 index and M2BPGi were significantly correlated (P = 0.006). Liver fibrosis with FIB-4 index 2.67 or more were six cases (40%). Liver fibrosis with M2BPGi 1.0 or more were five cases (33%). FIB4-index and M2BPGi showed significantly inversely correlated with serum albumin levels. FIB4-index and M2BPGi were also inversely correlated with serum cholesterol levels, but there was no significant difference. FIB4-index and M2BPGi tended to be correlated with HbA1c levels. Liver cancer occurred in 2 cases of the 3 which both FIB-4 index and M2BPGi were high. One case was developed synchronous hepatocellular carcinoma and cholangiocellular carcinoma 10 years after, and the other one was developed hepatocellular carcinoma 4 years after PPPD. Fatty liver was not found in the two cases. Both cases had underwent hepatectomy. Histopathologically liver fibrosis degree of two cases are grade F2 and grade F1 fibrosis.

Conclusions: Caution should be exercised in long-term follow-up cases after PPPD, as digestive and absorption disorders may cause liver fibrosis and may also cause liver cancer.

Pirfenidone Improves Features of Well-Established Chronic Pancreatitis in Mouse Models by Immune-modulation

E.P. Bava, J. George, M. Tarique, S. Iyer, R. Dawra, A.K. Saluja, V. Dudeja.

Department of Surgery, University of Miami Miller School of Medicine,Miami, FL.

Background: Chronic pancreatitis (CP) is considered an irreversible fibro-inflammatory disease of pancreas. Pirfenidone is FDA approved antifibrotic drug for idiopathic pulmonary fibrosis. However, exact molecular mechanism of its action is unclear. We have shown that pirfenidone reduces CP related changes. The aim of this study was to understand mechanism(s) of amelioration of CP in response to pirfenidone treatment.

Methods: Cerulein-CP was induced in C57BL/6 mice by cerulein injections (50 ug/kg ×7, i.p., hourly × twice weekly ×10). After 11 weeks from start, animals were randomized and assigned to either saline or pirfenidone group (400 mg/kg/d by oral gavage for 5 weeks). Mice were euthanized after 17 weeks of start of model. L-arginine induced CP was induced by i.p. injections of L-arginine (4.5g/kg ×2 hourly, once a week ×4) and treatment was started after 5 weeks of start of model. Mice were sacrificed at early time-points after starting treatment. Single-cell suspension of pancreata were used for flow-cytometry. Pancreatic atrophy, fibrosis and cytokine mRNA profile were evaluated.

Results: At 17 weeks, pirfenidone treated cerulein-CP mice had higher pancreas/mouse weight ratio compared to the CP alone group (7.03 ± 0.41 vs 4.75 ± 0.28; P < 0.0001), showing reversal of pancreatic atrophy. Pirfenidone reduced inflammatory infiltrate, fibrotic changes and collagen deposition. Fibrosis markers α-SMA and vimentin were reduced. Pancreatic atrophy showed significant improvement by as early as day 21 of treatment in L-arginine CP. Flow cytometry revealed that as early as 7 days after starting treatment, there was significant reduction in macrophage infiltration (1.09 ± 0.18 % vs 3.26 ± 0.4 %; P < 0.001) and pro-fibrotic M2 macrophage markers [IL-4 (1.5 ± 0.1 % vs 2.8 ± 0.2%; P = 0.007)], while M1 marker (MHC II) did not change. mRNA of pro-inflammatory and pro-fibrotic cytokines showed reduction, while anti-inflammatory ones increased.

Conclusions: Pirfenidone ameliorates well-established CP in mouse models by immune and cytokine-modulation.

Pirfenidone Treatment Reduces Severity of Acute Pancreatitis in Mouse Models by Reducing Immune Infiltration and Protecting Pancreatic Acinar Cells

E.P. Bava, J. George, M. Tarique, S. Iyer, R. Dawra, A.K. Saluja, V. Dudeja.

Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.

Background: There are no targeted treatments for acute pancreatitis (AP). The aim of this study was to explore the effect of pirfenidone, an anti-inflammatory agent, when given in therapeutic and prophylactic setting in AP, and to investigate its mechanism(s).

Methods: L-arginine AP was induced in C57/BL6 mice (4.5 g/kg × 2) and Pirfenidone treatment was started at 72 h therapeutically (at peak of injury). The mice were sacrificed at 96-144 h post-L-arginine injection. Effect of treatment on AP was evaluated by histology and its mechanism was investigated by flow-cytometry. To explore the effect of pirfenidone in prophylactic setting, AP was induced by administration of cerulein (50 ug/kg, i.p., hourly ×8). Pirfenidone gavages were given prophylactically 12 h & 1 h prior to start of cerulein AP. The effect of treatment on AP was evaluated by histology, myeloperoxidase (MPO) activity and leukocytic infiltration by IHC. Effect of pirfenidone on cerulein-induced injury in pancreatic acinar cells was evaluated by LDH assay.

Results: Therapeutic Pirfenidone treatment significantly improved histological changes of AP. Flow-cytometry showed a significant decrease in macrophage infiltration at 144h (2.72 ± 0.56% vs 6.32 ± 1.3%) and in Ly6G+, Ly6C+, or Gr1+ cell infiltration with pirfenidone treatment at 120 h. Pirfenidone treatment as prophylactic agent improved histology and reduced amylase levels significantly. Neutrophil recruitment, as measured by MPO activity in pancreas (1.35 ± 0.49 vs 3.75 ± 1) and lungs (28 ± 5 vs 47.5 ± 3) as well as leukocyte staining were also decreased significantly. In-vitro assay with acinar cells showed significant reduction in acinar cell death (as measured by LDH release) even when pirfenidone was given after up-to 1h of cerulein treatment.

Conclusions: Our data show that prophylactic as well as therapeutic treatment with pirfenidone reduces severity of acute pancreatitis, through modulation of immune-cells infiltration and protection of pancreatic acinar cells.

Depression and Anxiety Measured With the Patient Reported Outcomes Measurement Information System (PROMIS) Questionnaires are Associated With Clinical Diagnosis of Depression and Anxiety in Patients Undergoing TPIAT in POST

M.D. Bellin,1 Y. Yang,1 P. Witkowski,2 M. Wijkstrom,3 J.L. Steel,3 K. Smith,4 V.K. Singh,5 S.J. Schwarzenberg,1 T.L. Pruett,1 A. Posselt,6 B. Naziruddin,7 J.D. Nathan,8 K. Morgan,9 R. Mitchell,1 L.F. Lara,10 V. Kirchner,1 M. Hughes,11 J. Hodges,1 B. Hatipoglu,12 T.B. Gardner,4 M.L. Freeman,1 D.L. Conwell,10 S. Chinnakotla,1 A.N. Balamurugan,11 S. Ahmad,13 D. Adams,9 M. Abu-El-Haija,8 G.J. Beilman.11University of Minnesota, Minneapolis, MN; 2University of Chicago, Chicago, IL; 3University of Pittsburgh Medical Center, Pittsburgh, PA; 4Dartmouth-Hitchcock Medical Center, Lebanon, NH; 5John Hopkins Medical Institutions, Baltimore, MD; 6University of California San Francisco, San Francisco, CA, 7Baylor Health, Dallas, TX, 8Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 9The Medical University of South Carolina, Charleston, SC; 10The Ohio State University Medical Center, Columbus, OH; 11University of Louisville, Louisville, KY; 12Cleveland Clinic, Cleveland, OH; 13University of Cincinnati Medical Center, Cincinnati, OH.

Background: Patients undergoing total pancreatectomy with islet autotransplant (TPIAT) for severe recurrent acute and chronic pancreatitis may struggle with psychological comorbidities including depression and anxiety. We assessed clinical diagnoses and patient-report measures of anxiety and depression in the Prospective Observational Study of TPIAT (POST).

Methods: The NIH Patient-Reported Outcomes Measurement Information System (PROMIS) depression and anxiety questionnaires were administered to patients before TPIAT. From these instruments, T-scores were generated, with higher values indicating greater levels of depression or anxiety. We examined associations between PROMIS depression/anxiety scores and psychiatric diagnoses of depression, bipolar disorder, anxiety, or PTSD from the medical record and other patient/disease characteristics: age, sex, smoking history, alcohol abuse history, opioid use duration and current use, and treatment by health psychologist, using linear regression. To adjust for multiple comparisons, p <0.001 was considered significant.

Results: 213 patients, 39.4% male, with median age 31.3 years (IQR, 16.5–44.3) and median duration of disease 4.58 years (IQR, 2.38–8.56) were enrolled. Eighty-eight patients (41%) had a physician-assigned diagnosis of depression and/or anxiety disorder. Clinical diagnosis of depression (n = 67) and anxiety (n = 69) was associated with higher scores on the PROMIS scales for depression (57.6 vs 49.2 and 56.7 vs 49.6 respectively, P < 0.0001) and for anxiety (61.9 vs 55.2 and 62.7 vs 54.6 respectively, P < 0.0001). There were non-significant trends towards association of smoking history with depression and anxiety scores and for age with depression score (0.001 ≤ P < 0.005).

Conclusions: Higher PROMIS scores for anxiety or depression at pre-TPIAT baseline were associated with physician diagnoses of depression and anxiety, suggesting that these psychological comorbidities are identified clinically before surgery for many patients. There was a trend towards association of depression or anxiety with smoking and age that may warrant further investigation in a larger sample.

Morbid Obesity Rather Than Metabolic Syndrome Impacts Clinical Outcomes of Acute Pancreatitis: A National Survey

A.M. Blaszczak,1 S.G. Krishna,2,3 D.L. Conwell,2,3 P.A. Hart,2,3 D. Bradley,1 L. Lara,2,3 H. Hussan,2,3 A. Hinton,4 W.A. Hsueh,1 Z. Cruz-Monserrate.2,31Diabetes and Metabolism Research Center, Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, 2Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; 3The Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH; 4Division of Biostatistics, College of Public Heath, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: The incidences of acute pancreatitis (AP), morbid obesity, and metabolic syndrome (MetS) are increasing in the U.S. While morbid obesity (MO) has been shown to be associated with adverse clinical outcomes in AP, we sought to investigate the impact of MetS on outcomes of AP.

Methods: The Nationwide Readmissions Database (NRD) from 2010 to 2014 was reviewed to identify all adult inpatients (≥18 years) with a principal discharge diagnosis of AP. MetS was defined by the presence of at least three of the following criteria; obesity (BMI >30 kg/m2), elevated triglycerides, reduced HDL, elevated blood pressure, or elevated fasting glucose. Primary clinical outcomes were mortality and severe AP (SAP). Propensity score-matched analysis comparing patients with and without MetS was the primary analysis. Secondary propensity score-matched analyses comparing patients with and without morbid obesity (MO) were performed among the two subgroups, among those with and without MetS.

Results: Metabolic syndrome was associated with 12.91% (139,165/1,078,183) of all admissions with AP. Propensity-score matched analysis demonstrated that MetS did not impact mortality (OR, 0.62; 95% CI, 0.54–0.70) but was associated with increased SAP (OR, 1.21; 95% CI, 1.17–1.25). Subgroup propensity-score matched analyses revealed that MO was independently associated with increased mortality in subjects with (OR, 1.92; 95% CI, 1.41–2.61) and without MetS (OR, 1.55; 95% CI, 1.26–1.84). MO was also associated with SAP in subjects with (OR, 1.59; 95% CI, 1.48–1.70) and without (OR, 1.72; 95% CI, 1.60–1.84) MetS.

Conclusions: MO and not MetS appears to be the primary driver of increased mortality in subjects hospitalized with acute pancreatitis. This has significant implications for patient management and future research given the current increasing prevalence of MO and MetS in the US.

Regulation of Glucocorticoid Receptor and p38 MAPK Activation by Hydrocortisone in Mono- and Co-cultures of Mouse Pancreatic Acinar and Stellate Cells

M. Bläuer,1 J. Sand,1 J. Laukkarinen.1,21Tampere Pancreas Laboratory, Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere Finland; 2Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.

Background: Our group has previously shown that perioperative administration of hydrocortisone is able to reduce major complications after pancreaticoduodenectomy and distal pancreatectomy (Laaninen, Ann Surg 2016; Antila, Pancreatology 2019). Glucocorticoids are potent anti-inflammatory steroids that exert their actions via binding to their cognate receptors, the glucocorticoid receptors (GRs), which translocate into the nucleus to regulate GR-responsive genes. p38 MAPK is known to interact with GR thereby modulating the regulatory potential of GR. This study was undertaken to elucidate the effects of hydrocortisone on GR and p38 MAPK activation in pancreatic acinar cells (PACs) and stellate cells (PSCs) in vitro.

Methods: The long-term co-culture model for mouse PACs and PSCs developed in our laboratory (Bläuer, Pancreatology 2016) was employed to study changes in the cellular and subcellular expression of GR and p38 MAPK in response to hydrocortisone. PACs and PSCs were maintained for 4d in parallel mono- and co-cultures with or without 10 nM hydrocortisone. Immunocytochemical analysis was performed by probing the cells with antibodies against GR and phospho-p38 MAPK, representing the activated form of the molecule.

Results: Ligand-independent nuclear translocation of GR was prominent in co-cultured PACs and PSC monocultures. With hydrocortisone, ligand-dependent activation of GR was observed in mono-and co-cultures of PACs and in co-cultures of PSCs. No marked activation of p38 MAPK was seen in monocultures. Co-culture activated p38 MAPK in PACs and PSCs in the absence of hydrocortisone whereas its presence reduced p38 MAPK activation in both cell types.

Conclusions: Ligand-independent GR activation in PSC monocultures and co-cultured PACs indicates modulation of the GR signalling mechanism in these microenvironments and may increase cellular sensitivity to glucocorticoids. Hydrocortisone attenuates p38 MAPK activation in co-cultured PACs and PSCs and may thereby alleviate cellular stress reactions evoked by PAC-PSC cross-talk.

Clinical Significance of Surveillance-Detected Ductal Abnormalities in Individuals at High Risk for Pancreatic Cancer

O.I. Brewer Gutierrez,1 M.H. Dbouck,2 R.H. Hruban,2 M.G. Goggins,1,2 A.M. Lennon,2 M.I. Canto.1Departments of 1Pathology and 2Medicine, Johns Hopkins Hospital, Baltimore, MD.

Background: Surveillance of high risk individuals (HRI) for pancreatic adenocarcinoma (PDAC) leads to frequent detection of pancreatic cysts. A dilated main pancreatic duct (MPD) raises concern for intraductal neoplasm or occult invasive neoplasm. Clinical significance of duct dilation in HRI is uncertain. Aims: 1) To determine natural history of MPD abnormalities in HRI, 2) To correlate imaging with pathology.

Methods: 354 HRI enrolled in Cancer of the Pancreas Screening (CAPS) prospective cohort studies from 1998 to 2014 were included. Endoscopic ultrasound, MRI, computed tomography, and/or ERCP were compared with pathology and follow-up. A dilated MPD was defined as diameter >3, >2, or >1 mm in the head, body and tail, respectively. Primary endpoint was the prevalence of main duct HGD or PDAC in HRI with dilated MPD. Secondary endpoint was the outcome of MPD dilation at last follow-up.

Results: 354 HRI (47% male, mean age 56, 84% PDAC relatives, 16% mutation carriers) were under surveillance (median 5.6 years). 109 (31%) had diffuse or focal MPD dilation at baseline (76) or during follow-up (33). In the former group, 27 (36%) had stable dilated duct size throughout the follow-up, while remainder had intermittent or normal MPD. Twenty-seven (24%) HRI with MPD dilation had surgery; 7 with MPD > 5 mm developed PDAC (2) or lower grade neoplasms (5). Twenty HRI with dilated MPD <5 mm developed PDAC (5) or other neoplasm, 3 of which had 2 combined IPMN (2) and PanIN3 (1). These 3 patients had mean duct diameter of 3.6 mm with cyst worrisome features (mural nodule(s) in the duct or adjacent cyst, MPD irregularity, thickened cyst septae) or MPD stricture with minimal upstream dilation and no mass.

Conclusions: MPD dilation may be associated with high-grade neoplasia, combined IPMN, or PDAC, even when duct dilation is mild <5 mm.

Validation of the END-PAC Model for Prediction of Pancreatic Cancer in New Onset Diabetes

R.K. Butler,1 E. Lustigova,1 A. Maitra,2 S.T. Chari,3 J.A. Rinaudo,4 B.U. Wu,5 W. Chen.11Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; 2Departments of Pathology and Translational Molecular Pathology, Ahmad Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, TX; 3Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 4Division of Cancer Prevention, National Cancer Institute, Rockville, MD; 5Center for Pancreatic Care, Gastroenterology, Kaiser Permanente Southern California, Los Angeles, CA.

Background: Diabetes mellitus is a commonly-observed sequala of pancreatic cancer, leading to the hypothesis that pancreatic cancer screening may be beneficial in a subpopulation of patients with new-onset diabetes (NOD). A clinical prediction rule (END-PAC) has been developed to further stratify patients with NOD by 3-year risk of pancreatic cancer. We aimed to externally validate the algorithm in a large, independent population at Kaiser Permanente Southern California.

Methods: Patients aged 50 to 85 with American Diabetes Association-defined NOD were identified between 2006 and 2014. The cohort was limited to patients with data availability for the END-PAC algorithm parameters: age, one-year average blood glucose change, and one-year weight change. The END-PAC algorithm was implemented, and each patient was classified into a low-, intermediate-, or high-risk group, within which algorithm performance measures were assessed.

Results: 127,539 patients with NOD were identified, of which 31,493 had complete model parameter values and met additional eligibility criteria. In this cohort, 174 (0.55%) cases of pancreatic cancer were identified in the three years of follow-up. The low- and medium- risk strata contained 46% and 33% of total patients with 3-year pancreatic cancer risks of 0.29% and 0.19%, respectively. The high-risk stratum defined by the END-PAC algorithm contained 6,810 (22%) of our patients and 112 (64%) of our total pancreatic cancer cases, yielding a 3-year risk of 1.64% in the high-risk stratum.

Conclusions: The algorithm provided some risk-stratification, but further enrichment is needed to target higher-risk individuals who would benefit most from pancreatic cancer screening. Limited availability of algorithm parameters in routine practice may prove to be a barrier for real-world implementation.

Peritumoral Lymph Nodes in Pancreatic Cancer Revisited: Is it Truly Metastatic?

Y. Byun, Y. Han, E.J. Kim, Y.J. Choi, H. Kim, J.Y. Jang, W. Kwon.

Division of Pancreatobiliary Surgery, Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.

Background: Lymph node metastasis in pancreatic cancer has been already known to affect the prognosis significantly. However, it is necessary to consider whether all lymph nodes obtained are sufficiently meaningful to affect the survival outcome. Although there are few studies on lymph nodes located around the tumor, the number of subjects was small or the results was not clear. Therefore, this study aims to investigate the impact of peritumoral lymph node (PTLN) on the survival outcome of pancreatic cancer patients.

Methods: Medical records of 506 patients who were performed radical resection for pancreatic ductal adenocarcinoma from January 2012 to December 2018 were reviewed. Pathological examination was performed in the cases of more than one lymph node metastasis by one experienced pathologist. The PTLN was defined as the lymph node adjacent to the main lesion and others as the regional lymph node (RLN).

Results: Of 506 patients, N0 was 176 (34.8%), N1 was 237 (46.8%), and the remaining 93 (18.3%) were N2. Of these, 112 patients (22.1%) were metastasis in PTLN. The metastatic lymph nodes were subdivided according to the metastasis of PTLN; N0 group without lymph node metastasis; N0+PTLNM group which was classified as N1 because of PTLN metastasis; N1 group. When the survival results of each group were compared, there was no significant difference between N0 and N0+PTLNM (2-year survival rate: 69.4% vs 73.8%, P = 0.488). On the other hand, N0+PTLNM and N1 showed statistically significant differences (73.8% vs 46.7%, P < 0.001).

Conclusions: The metastasis in PTLN has not a significant effect on survival outcome, rather it is concerned for the overstaging if the metastatic PTLN is regarded as RLN. Therefore, the reconsideration is needed for current staging system that regards PTLN as other lymph nodes, and large-scale multicenter study is needed to confirm the effect of PTLN metastasis.

Sub-adventitial Divestment Technique for Artery-involved Pancreatic Cancer: Safety and Oncological Efficacy

B.B. Cai, Z.P. Lu, Y. Gao, L.D. Yin, J.L. Wu, W.T. Gao, J.M. Chen, F. Guo, J.S. Wei, C.C. Dai, K.R. Jiang, Y. Miao.

Pancreas Center, the First Affiliated Hospital of Nanjing Medical University,Nanjing, China.

Background: Artery involvement is the major obstacle of curative operation for non-metastatic pancreatic cancer patients. Here we present the sub-adventitial divestment technique (SADIT) in therapeutic surgery of artery involved pancreatic cancer (ai-PC).

Methods: From April 2014 to June 2016, a total of 73 consecutive ai-PC patients identified with contrast-enhanced CT and surgical exploration received curative pancreatectomy with SADIT served as the study group (SADIT). To evaluate safety of SADIT, 247 concurrent pancreatic cancer patients without artery involvement who received curative pancreatectomy were enrolled as control (CTRL). Univariate and multi-variate analysis was performed to reveal risk factors of prognosis. Another 13 T4NxM0 patients who received chemotherapy alone without resection (Chemo) were induced to evaluate oncological efficacy of SADIT.

Results: Sex, age, preoperative CA 19-9, and serum albumin showed no difference between two groups. SADIT group tend to have more major vein resection and reconstruction, combined organ resection and extended lymph node dissection. Longer operation time was needed in SADIT group (SADIT vs CTRL: 265.4 ± 101.4 min vs 228.7 ± 90.2 min, P = 0.003) without significant increase in surgical blood loss (SADIT vs CTRL: 347 ± 323 mL vs 283 ± 315 mL, P = 0.131). Over-all morbidity, and the incidence of ISGPS post-operative pancreatic fistula, delayed gastric emptying and re-operation rate were of no difference between two groups, while SADIT group had more post-operative hemorrhage (SADIT vs CTRL: 52.1% vs 49.0%, 20.5% vs 19.0%, 17.8% vs 15.8%, 1.4% vs 1.6%, and 16.4% vs 6.5%, P = 0.743, 0.904, 0.817, 1.000, and 0.015, respectively). All receiving chemotherapy, T4NxM0 patients would have significantly longer MOS after resection with SADIT (SADIT+Chemo vs Chemo: 18.0 months vs 12.4 months, P = 0.003).

Conclusions: Sub-adventitial divestment technique is safe in surgery of ai-PC. Resection with SADIT provided MOS benefit of 6 months to ai-PC patients with chemotherapy. Valid prediction method for tumor biology is warranted to provide more beneficial therapeutic strategy.

Metabolic Crosstalk Between Adipocytes and Pancreatic Cancer Cells: A Potential Mechanism for Cancer-Induced Diabetes Mellitus

Z.W. Cai, C.Y. Jiang, W. Wang.

Department of General Surgery, Huadong Hospital, Fudan University,Shanghai, China.

Background: Pancreatic cancer (PC) is often under a powerful diabetogenic state and new-onset diabetes in PC patients is likely to be induced by the secreted products from cancer cells. Dysfunctional adipocytes are in close correlation with the pathogenesis of insulin resistance (IR) and diabetes. However, little attention has been paid to the metabolic alteration of adipocytes in the context of PC. The purpose of this study was to assess the metabolic impact of PC cells on adipocytes.

Methods: We established an adipocyte-PC cell indirect transwell coculture system. Real-time quantitative PCR and Western blot were used to detect metabolic-associated mRNAs and proteins in both adipocytes and PC cells. Transwell cell migration assay was used to measure the ability of PC aggressiveness.

Results: After exposure to PC cells, the decreased mRNA and protein expressions of FASN, FABP4, HSL and PPAR-γ were observed, indicating the impaired lipid homeostasis in coculture adipocytes, which was accompanied by the presence of insulin resistance, with a decrease in insulin-stimulated phosphorylation of Akt, as well as reduced GLUT4 and IRS1 mRNA expression. In contrast, coculture PC cells showed enhanced glycolysis with the increased expression of GLUT1, HK2, LDHA, and GAPDH at both mRNA and protein levels, and they also showed an increased ability to migrate through the transwell membrane.

Conclusions: The metabolic reprogramming of adipocytes by PC would serve to save nutrients (such as lipid and glucose) to fulfill the energetic demands of tumor cells during tumor progression. The harmful effect of PC on lipid homeostasis and insulin signaling in adipocytes could lead to hyperglycemia and participate in the development of new-onset diabetes.

Cancer Worry, Overall Satisfaction, and Health Relation Quality of Life of High Risk Individuals (HRI) Operated for Surveillance-Detected Pancreatic Neoplasms

M.I. Canto,1,2 T. Kerdsichairat,1 M. Chuidian,3 A.M. Lennon,1 O.I. Brewer-Gutierrez,1 M. Dbouk,3 A. Almario,1 E.J. Shin,1 E. Fishman,4 I. Kamel,4 C.L. Wolfgang,5 R. Burkhart,4 J. He,5 R. Hruban,3 M. Goggins.1,3

Departments of 1Medicine (Gastroenterology), 2Oncology, 3Pathology, 4Radiology, and 5Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD.

Background: There are limited data on the impacts of surveillance and surgical treatment of detected lesions in HRI with an inherited genetic predisposition for PDAC.

Methods: Using prospectively collected data from CAPS1-4 cohort studies conducted in a pancreas surveillance program from 1998-2017, we compared baseline and follow-up quality of life of HRI with a PDAC family history or genetic mutation who underwent complete or partial surgical resection of their pancreas for suspected pancreatic neoplasms. HRI completed the RAND SF36-item health survey and additional questions on cancer worry (5-point Likert scale,1 = not worried, 5 extremely worried) and overall satisfaction with life (7-point Likert scale, 1 = completely satisfied, 7 = completely dissatisfied). We calculated the composite score for each of the 8 domains and used the Wilcoxon signed rank test to compare the scores before and after the surgery.

Results: Out of 354 HRI enrolled and followed a median of 7.6 years, 48 patients underwent 57 operations (35 partial, 13 total pancreatectomy or completion prancreatectomy) for suspected neoplasms. 85% of patients (50% female, mean age 70) completed surveys. Post-operative complication rate was 32.6%, including delayed gastric emptying (19.6%), weight loss (54.3%), steatorrhea (19.6%). The preoperative and post-operative mean composite scores for physical functioning (90 versus 95), physical role functioning (100 versus 100), bodily pain (90 versus 90), general health perception (70 versus 65), vitality (70 versus 65), social functioning (100 versus 100), emotional role functioning (100 versus 100), and mental health (84 versus 88) were not significantly different. Cancer worry significantly improved after surgery (median decrease 2, P < 0.0001). 93% of HRI were delighted or mostly satisfied with their life and overall patient satisfaction was high (median score 2).

Conclusions: Surveillance and treatment positively impacted cancer worry. Health-related quality of life of asymptomatic HRI was preserved and remained high after partial or total pancreatectomy for screening-detected neoplasms.

Surgical Outcomes After Pancreatic Resection of Screening-Detected Lesions in Individuals at High Risk for Developing Pancreatic Cancer

M.I. Canto,1 T. Kerdsirichairat,1 O.I. Brewer-Guitierrez,1 C.J. Yeo,2 R.H. Hruban,3 E.J. Shin,1 J.A. Almario,1 A. Blackford,4 M. Ford,3 A.P. Klein,4 A.A. Javed,5 A.M. Lennon,1 A. Zaheer,6 I.R. Kamel,6 E.K. Fishman,6 R. Burkhart,5 J. He,5 M. Makary,5 M.J. Weiss,5 R.D. Schulick,7 M.G. Goggins,1,3 C.L. Wolfgang.51Department of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; 2Department of Surgery, Thomas Jefferson University, Philadelphia, PA; Departments of 3Pathology, 4Oncology, 5Surgery, and 6Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; 7University of Colorado School of Medicine, Denver, CO.

Background: Screening high-risk individuals (HRI) for pancreatic ductal adenocarcinoma (PDAC) and its precursors can detect potentially curable lesions. We describe the outcomes of high-risk individuals (HRI) after pancreatic resection of screen-detected neoplasms.

Methods: Asymptomatic HRI enrolled in the prospective Cancer of the Pancreas Screening (CAPS) studies from 1998 to 2014 based on family history or germline genetic mutations who were undergoing surveillance for at least 6 months were included. Pathologic diagnoses, hospital length of stay, incidence of diabetes mellitus, operative morbidity, need for repeat operation, and disease-specific mortality were determined.

Results: Among 354 HRI, 48 (13.6%) had 57 operations (distal pancreatectomy [31], Whipple [20], and total pancreatectomy [6]) for suspected pancreatic neoplasms presenting as a solid mass (22), cystic lesion(s) (25), or duct stricture (1). The median length of stay was 7 days (IQR, 5–11). Nine of the 42 HRI underwent completion pancreatectomy for a new lesion after a median of 3.8 years (IQR, 2.5–7.6). Postoperative complications developed in 17 HRI (35%); there were no perioperative deaths. New-onset diabetes mellitus after partial resection developed in 20% of HRI. Fourteen PDACs were diagnosed, 11 were screendetected, 10 were resectable, and 9 had an R0 resection. Metachronous PDAC developed in remnant pancreata of 2 HRI. PDAC-related mortality was 4/10 (40%), with 90% 1-year survival and 60% 5-year survival, respectively.

Conclusions: Screening HRI leads to detection of PDAC with a high resectability rate. Surgical treatment is associated with a relatively short length of stay and low readmission rate, acceptable morbidity, zero 90-day mortality, and significant long-term survival.

Survival of High Risk Individuals With Surveillance-Detected Ductal Adenocarcinoma

M.I. Canto,1 A. Blackford,2 T. Kerdsichairat,1 A.M. Lennon,1 A. Almario,1 O.I. Brewer-Gutierrez,1 M. Dbouk,3 M. Chuidian,3 E.J. Shin,1 E. Fishman,4 I. Kamel,4 C.L. Wolfgang,5 R. Burkhart,5 J. He,5 C. Yeo,6 R. Schulick,7 R. Hruban,3 M. Goggins.1,3Departments of 1Medicine (Gastroenterology), 2Oncology, 3Pathology, 4Radiology, and 5Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, MD; 6Department of Surgery, Thomas Jefferson University, Philadelphia, PA; 7Department of Surgery, University of Colorado School of Medicine, Denver, CO.

Background: The survival of symptomatic pancreatic ductal adenocarcinoma (PDAC) patients is poor. Screening of individuals at high risk due to family history or genetic mutation (high risk individuals, HRI) is an alternative approach to improving outcome. However, to date, the data supporting screening programs are limited. This study aimed to compare the survival of HRI with screening-detected non-metastatic PDAC with controls.

Methods: We performed a case-control study using data from prospective Cancer of the Pancreas Screening (CAPS) studies from 1998-2017. For each CAPS PDAC patient, we matched 2 sporadic PDAC patients from the Johns Hopkins Hospital (JHH) surgical database, and 5 individuals from the SEER Registry by year of diagnosis, sex, tumor location, race, year of diagnosis, and age at diagnosis. We also compared results using SEER controls without age matching. We compared clinical and demographic characteristics, PDAC size, and AJCC stage, as well as overall survival using Kaplan-Meier method and Cox proportional hazards modeling.

Results: We compared 10 resectable PDAC (CAPS cohort) patients with 20 sporadic PDAC (JHH cohort) and 100 sporadic PDAC (SEER cohort). Mean tumor size was significantly smaller in the CAPS cohort (2.5 cm) compared to JHH (4 cm) and SEER (3.8 cm) (P < 0.001). There was a significant tumor stage shift (16.7% stage 1 in CAPS, versus 6.4% and 5.3% in JHH and SEER cohorts, respectively, P = 0.03). The overall 3-year (80%) and 5-year survival (60%) was significantly better in CAPS cohort compared to JHH (33% 3-year, 22% 5-year; HR, 4.3; P = 0.01), and SEER non-age matched (3-year 40%, 5-year 33% (HR, 3.2; P = 0.05). There was no difference in the survival of JHH and SEER cohorts.

Conclusions: Screening-detected PDAC in HRI are more likely to be smaller and earlier stage. The overall 3- and 5- year survival of HRI are significantly improved compared to sporadic PDAC patients.

Pancreatic Stellate Cells Promote Epithelial-mesenchymal Transition of Cancer Cells by Notch-3 Promoter Demethylation

F. Cao, J. Li, H. Sun, S. Liu, Y. Cui, F. Li.

Department of General Surgery, Xuanwu Hospital, Capital Medical University,Beijing, China.

Background: Pancreatic stellate cell (PSC) promoted epithelial-mesenchymal transition (EMT) in pancreatic cancer cells. However, the potential mechanism had not been fully elucidated. The aim of this study was to explore the effect of Notch-3 on EMT of PANC-1 cells induced by PSC.

Methods: We explore the effect of PSC on PANC-1 cell EMT by co-culture. The potential signal pathway involved in EMT induced by PSC is determined by adding different inhibitors. The role of Notch-3 in EMT process is verified through Notch-3 siRNA transfection. Bisulphite sequencing PCR and chromatin immunoprecipitation are performed to explore the methylation status of Notch-3 promoter. To confirm the relationship between EMT, Notch-3 status and patient survival, Kaplan-Meier analysis is carried out.

Results: After co-culture with PSC, the ability of migration is significantly enhanced, and the PSC can also induce EMT phenomenon of PANC-1. Meanwhile, the Notch-3 expression is also promoted. The effect blocked by Notch signal pathway inhibitor (L1790) and Notch-3 siRNA revealed the critical role of Notch-3 in EMT process. The methylation status of three CpG islands located in promoter region of Notch-3 has been uninfluenced after co-culture with PSC. However, immunoprecipitation reveals a significant increase in hmC for Notch-3 promoter. Our study also demonstrate that Notch-3 level is positively correlated with Vimentin and negatively with E-cadherin expression in pancreatic cancer patients. Overexpression of Notch-3 also predicts the poor prognosis of pancreatic cancer.

Conclusions: PSC induces Notch-3 expression by demethylation and promote EMT phenotype of PANC-1 cell. EMT and Notch-3 are the poor prognostic factors in pancreatic cancer patients. Notch-3 might be a potential target for treatment of pancreatic cancer.

Single Step Versus Step-up Laparoscopic Assisted Necrosectomy for Infected Pancreatic Necrosis

F. Cao, N. Duan, C. Gao, A. Li, F. Li.

General Surgery Department, Xuanwu Hospital, Capital Medical University,Beijing, China.

Background: Minimal invasive step-up necrosectomy had been widely accepted in treatment of infected pancreatic necrosis (IPN) and percutaneous or endoscopic drainage was usually performed as the first step. However, drainage was unnecessary or unavailable in some patients. The aim of this study was to explore the safety and therapeutic effect of single step approach compared with step-up approach.

Methods: IPN patients received surgical therapy in our center between January 2015 and December 2017 were included in this study. Patients were assigned to either single or step-up group according to the received therapeutic approach. Incidence of complications, death, total number of surgical intervention and total hospital stay were compared. Logistic regression and nomogram were used to explore the risk factors and probability for patients undergoing surgical intervention ≥3.

Results: There were 45 and 49 patients included in single step and step-up group, respectively. There were no significant difference between groups in terms of new organ failure (14.29% vs 14.33%, P = 0.832), death (8.89% vs 8.17%, P = 0.949) and long-term complications (18.37% vs 15.56%, P = 0.717). However, the number of surgical intervention in single step group was significant less than in step-up group (2.36 ± 1.54 vs 3.96 ± 1.47, P = 0.000) with shorter hospital stay (50.62 ± 35.58 days vs 63.98 ± 25.07 days, P = 0.040). After multivariate analysis, CRP (P = 0.019), IL-6 (P = 0.024), and surgical approach (P = 0.000) were independent predicators for patients undergoing surgical intervention ≥3. A nomogram was built with area under ROC curve 0.891.

Conclusions: Compared with step-up approach, single up surgery was safe and effective in treatment of IPN with less number of surgical intervention and shorter hospital stay.

Opening the Door to the Molecular Pathogenesis of Pancreatic Neuroendocrine Tumors

A.C. Carter,1 J.A. Bibb,1 R. Telange,1 W. Howse,1 J. Schrader,2 C. Tan,3 B. Robinson,4 S. Reddy.11Department of Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 3Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX; 4Department of Cancer Genetics, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia.

Background: Pancreatic neuroendocrine tumors (PNET) are seen with increasing frequency and associated with substantial morbidity and mortality. There is great need to understand these cancer’s molecular biology. Current genetic animal models are all based on rare functional PNET (insulinoma or gastrinoma); they do not recapitulate human disease. We have previously shown aberrant cyclin dependent kinase 5 (Cdk5) activity with its activating cofactor p25 in medullary thyroid cancer. Here we sought to investigate Cdk5’s role in PNET pathogenesis and develop a murine model that replicates human disease.

Methods: p25/Cdk5 expression was quantified in human PNET (hPNET) tissues by immunoblotting and immunohistochemical staining. hPNET cell lines were treated with Cdk5 inhibitors. Bi-transgenic C56BL/6j mice were created with (1) tet-operon driving p25 and (2) insulin promoter driving reverse tetracycline-transactivator. p25 overexpression was induced with dietary doxycycline (dox) at 24 weeks. Phosphoproteomic analysis was performed of growing (on dox) and arrested/control (off dox) mouse tumors to identify phosphorylation sites that were upregulated in growing tumors. Short interfering peptides (SIPs) were generated to these targets to determine effects on hPNET cell survival and identify potential actionable signaling pathways.

Results: All hPNET samples tested had increased expression of p25/Cdk5 (sporadic nonfunctional [9/9], MEN1 [3/3], von Hipple Lindau [1/1], sporadic functional tumors [3/3]). Cdk5-specific inhibitors abrogated growth of hPNET-derived cells(BON IC500.28nM, NT3 IC502.13nM, NT18 IC500.12nM) in a dose-dependent manner without affecting control fibroblasts. Cdk4 inhibitors did not affect these cells. All transgenic mice developed PNET with a variety of phenotypes (25 nonfunctional, 1 insulinomas, 3 glucagonomas) on dox. Signaling analysis revealed 50 potential p25/Cdk5 protein targets; SIPs to 15 sites inhibited growth of BON cells but not fibroblasts.

Conclusions: Aberrant Cdk5 activity is seen in all hPNET and is a potential therapeutic target. We have created the first transgenic model of PNET that behaves like human disease. This mouse is a powerful tool that can be used to interrogate pathways driving these tumors.

SNPs Within Chronic Pancreatitis (CP) Risk Allele CEL-HYB Increase Its Proteotoxicity

B. Cassidy,1 S. Zino,1 K. Fjeld,2,3 A. Molven,2,4,5 X. Xiao,1 M.E. Lowe.11Department of Pediatrics, Washington University School of Medicine, St. Louis, MO; 2Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway; 3Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway; 4Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Bergen, Norway; 5Department of Pathology, Haukeland University Hospital, Bergen, Norway.

Background:CEL-HYB results from the recombination of carboxyl ester lipase (CEL) and its neighboring pseudogene, CELP. The carrier frequency is 0.5-1% in Northern Europeans. CEL-HYB increases the risk for CP about 5-fold. The pathogenesis appears to involve toxic protein misfolding. Two missense SNPs, c.1463T>C (p.I488T) and c.1643C>T (p.T548I), exist within the CEL-CELP crossover region and are present in some CEL-HYB alleles. Our aim was to determine whether these SNPs increase CEL-HYB misfolding, thereby influencing susceptibility to CP.

Methods: HEK293T cells were transfected to express CEL-HYB, CEL-HYB p.I488T, CEL-HYB p.T548I or CEL-HYB p.I488T/T548I. The misfolding of HYB variants was assessed by secretion and detergent partitioning of intracellular protein.

Results: Compared to CEL, the secretion of CEL-HYB was decreased by ~ 30% assessed by activity assay and by protein immunoblotting. Intracellular CEL-HYB was largely detergent-insoluble whereas CEL was largely detergent-soluble, consistent with increased misfolding of CEL-HYB. Both p.I488T and p.T548I further decreased CEL-HYB secretion, with p.I488T having more pronounced impact. Additionally, the two SNPs in concert decreased CEL-HYB secretion more than the individual SNPs alone. CEL-HYB p.I488T/T548I decreased secretion to ~ 25% of CEL-HYB and triggered more robust ER stress when evaluated by BiP mRNA and protein abundance. Both SNPs also increased the misfolding of CEL showing that they influence aberrant folding independent of CEL-HYB.

Conclusions: The SNPs in CEL-HYB increase protein misfolding, as evidenced by reduced secretion and increased intracellular aggregation and upregulation of ER stress. This knowledge may help stratify the genetic risk of CEL-HYB for CP.

DCLK1 Polarized M2 Macrophages Inhibit CD8+ T-cell Activity

P. Chandrakesan,1,2 J. Panneerselvam,1,2,3 R. May,1 K. Pitts,1 D. Qu,1,2 N. Weygant,1,2 N. Ali,1,4 M. Bronze,1 M. Li,1,2 C.V. Rao,1,2,3 C. Houchen.1,2,3,41Department of Medicine and 2Stephenson Cancer Center, OUHSC, Oklahoma City, OK; 3Oklahoma City VA Health Care System, Oklahoma City, OK; 4COARE Biotechnology, Oklahoma City, OK.

Introduction: The response of PDAC to immunotherapy has been disappointing. It is considered a “cold” tumor as far as immune activity is concerned. The PDAC TME contains several immunosuppressive components that contribute to the inactivity of CD8+ T cells. We have previously demonstrated that the tumor stem cell protein DCLK1 is upregulated in PDAC and when cells are forced to express DCLK1 they participate in immunosuppressive macrophage polarization. In this study, we investigated the mechanism by which DCLK1 polarized macrophages regulate CD8+ T-cell cytotoxic function.

Methods: Gain and loss of function of DCLK1 by lenti-virus infection and si-RNA transfection. DCLK1 overexpressing PDAC cells were co-cultured with macrophages and analyzed for M1 and M2 markers. DCLK1 induced M2-macrophages were co-cultured with CD8+ T cells, analyzed for T-cell proliferation and apoptosis. M2 co-cultured CD8+ T cells were separated after 48 h for co-culturing with PDAC cells, analyzed for tumor cell proliferation and apoptosis.

Results: DCLK1 overexpressing PDAC cells convert M1 macrophages into M2-phenotypes based on the reduced expression of HLA-DR and CD86 (M1 markers) and increased expression of CD206 and CD163 (M2 Markers). DCLK1 induced M2-macrophages co-cultured with CD8+ T cells inhibits T cell proliferation (P < 0.001) at 48h and induces T-cell apoptosis (P < 0.001) at 72 h. CD8+ T cells co-cultured with parental PDAC cells induces tumor cell apoptosis after 48 h. However, DCLK1 induced M2 macrophages primed CD8+ T cells were not able to induce tumor cell apoptosis.

Conclusions: Our data strongly suggest that DCLK1-mediated polarization of M2 macrophages results in immunosuppression by inhibiting cytotoxic CD8+ T-cell function. Our findings identify a novel association between DCLK1 and an immunosuppressive feature of the PDAC TME. These data provide a rationale for targeting DCLK1 to reactivate host anti-tumor immunity.

Lipophilic Statins Inhibit YAP Activity and Attenuate Early Neoplastic Progression Promoted by Diet-induced Obesity in the Conditional KrasG12D Mouse Model

H. Chang,1 F. Hao,2 J. Sinnett-Smith,2 O.J. Hines,1 E. Rozengurt,2 G. Eibl.1Departments of 1Surgery and 2Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease with virtually no efficacious treatments. Obesity is a known risk factor, thus making PDAC amenable for preventive strategies. In this context, the transcriptional co-activator Yes-associated Protein (YAP) has emerged as a key transcriptional regulator downstream of oncogenic Kras in PDAC and a potential novel target. We examined the impact of statins, a class of lipid-lowering drugs inhibiting 3-hydroxy-methylglutaryl (HMG) CoA reductase, on YAP localization, phosphorylation and transcriptional activity in PDAC cells. Also, we characterized the chemo-preventive effects of simvastatin (Zocor) on initial stages of PDAC development using the KrasG12D model subjected to diet-induced obesity (DIO).

Results: Exposure of human and mouse PDAC cells to cerivastatin or simvastatin prevented YAP nuclear import and inhibited the expression of the YAP target genes Connective Tissue Growth Factor (CTGF) and Cysteine-rich angiogenic inducer 61 (CYR61). Cerivastatin, simvastatin, atorvastatin and fluvastatin also dose-dependently inhibited colony formation, with IC50 values in the sub-micro molar range (0.03–0.3 μM). In contrast, the hydrophilic statin pravastatin did not exert any inhibitory effect even at a high concentration (10 μM). Mechanistically, cerivastatin did not alter the Hippo pathway-mediated YAP phosphorylation (Ser127) stimulated by neurotensin and insulin. Rather, statins blunted the assembly of actin stress fiber, a surrogate of Rho activity. Importantly, orally administration of simvastatin to KC (LSL-KrasG12D; p48-Cre) mice subjected to a high-fat, high calorie diet (HFCD) prevented early pancreatic acini depletion and the formation of advanced pre-neoplastic (PanIN-3) lesions (P < 0.05).

Conclusions: In summary, our results show that lipophilic statins restrain YAP activity and proliferation in PDAC cell models and attenuate early neoplastic progression of DIO-promoted PDAC in vivo.

The Extravesicular Connection in Pancreatic Circulating Tumor Cells: “Evading the Active Immune System”

H.K. Charles Jacob,1 A.R. Ferrantella,1 J. Tao,1 T. Kashuv,2 S. Kurtom,1 T.M. Giret,3 U. Vaish,1 S. Lavania,1 A.K. Saluja,1 V. Dudeja.11Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL; 2Department of Biochemistry and Molecular Biology, University of Miami, Miami, FL; 3Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL.

Background: Circulating tumor cells (CTCs) have been implicated in evading the host immune system and seeding in metastatic sites. The mechanism of association of CTCs with circulating blood cells, forming clusters in the early stages of extravasation and EMT transition, has not been well explored. Extracellular vesicles (EVs) are secreted from cells by both active and passive processes encapsulating biological information in the form of DNA, mRNA, sRNA, lncRNA and proteins. We hypothesize that CTCs secrete exosomes that are intermediates, allowing for association of CTCs with Neutrophils and Platelets. Furthermore, we propose that the proteomic signature of the primary CTC is also conserved in the EVs, providing a snapshot of biomarkers for liquid biopsy.

Methods: Three CTC cell lines representing Hispanic and Caucasian populations were generated. Cells were cultured in growth media supplemented with EV depleted FBS. The supernatant was collected by ultracentrifugation and CD9 beads were used for enrichment of extracellular vesicles. Dried peptide and phosphopeptide samples were run on an Easy-nLC 1000 coupled online with a hybrid high-resolution LTQ-Orbitrap Velos Pro mass spectrometer to identify proteins and phospho proteins.

Results: The Proteomic composition of the CTCs revealed several key proteins that mediate granulation of neutrophils and platelets that would allow for them to form clusters and evade the active immune system. The proteome is also indicative of the signaling dynamics of the CTC, which in turn, could be a better liquid biopsy strategy to identify proteome modulations in the CTC and or the primary tumor.

Conclusions: EVs released from CTCs mediate degranulation of granulocytes and neutrophils, allowing for cluster formation, immune evasion, and distant metastatic site seeding. The phosphoproteome of CTCs is also indicative of the inherent signaling dynamics of the CTC, and in extension, the primary tumor as a novel liquid biopsy tool.

Perioperative Outcome and Prognosis After Extended Pancreaticoduodenectomy for Pancreatic Head Ductal Adenocarcinoma

D.L. Chen, R.Q. Wei, A.A. Liu, J.T. Tang, L. Tang, L.G. Shi, Z.P. Fu, X. Liang, M. Ji, G. Yang, C.H. Shao.

Department of General Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China.

Background: Extended pancreaticoduodenectomy (EPD) aims to achieve R0 resection for patients with pancreatic cancer. However, its clinical benefit remains controversial.

Methods: The clinicpathological data of 146 patients with pancreatic head ductal adenocarcinoma who underwent PD from January 1, 2013 to June 30, 2016 in Department of General Surgery, Changhai Hospital and Changzheng Hospital, the Navy Medical University were reviewed retrospectively. The same surgical group performed extended PD (EPD) for 36 patients (PD+PV/SMV: 31, PD+PV/SMV+right hemicolectomy: 2, PD+PV/SMV+left lateral hepatectomy: 1, PD+right hemicolectomy: 2) and standard PD (SPD) for 110 patients. The operation time, intraoperative blood loss, surgical margin status, postoperative length of hospital stay, postoperative morbidity and mortality, the median survival time etc. of the two groups were collected and analyzed.

Results: In the EPD group, the operation time (252.3 ± 60.4 vs 190.6 ± 41.5 min, P < 0.001) and intraoperative blood loss (1141.7 ± 724.0 vs 404.6 ± 453.1 ml, P < 0.001) were higher than those of the SPD group. There were no statistically significant differences in postoperative length of hospital stay (18.9 ± 13.6 vs 15.7 ± 9.8 d, P = 0.146), postoperative complications (41.7% vs 41.8%, P = 0.987), R0 resection rate (88.9% vs 94.5%, P = 0.432), positive nodal ratio (55.6% vs 40%, P = 0.103) or perioperative mortality (1.8% vs 5.6%, P = 0.254) between the two groups. The differences in TNM stage of the two groups (EPD group I–II: 105 (95.5%), III–IV: 5 (4.5%) vs SPD group I–II: 26 (74.3%), III–IV: 9 (25.7%), P = 0.001) had statistically significance. Long-term survival was statistically significant different between patients with extended PD and those with standard PD (median survival time 14.6 vs 20.4 months, P < 0.001).

Conclusions: Extended PD is safe and feasible for pancreatic head ductal adenocarcinoma especially for the cases of borderline resectable pancreatic cancer which require PV/SMV to be excised and reconstructed, but its clinical benefit is limited.

UBL4A Inhibits Autophagy-Mediated Proliferation and Metastasis of Pancreatic Ductal Adenocarcinoma Via Targeting LAMP1

H.Z. Chen,1,2 L. Li,1,2 J.S. Hu,1,2 Z.J. Zhao,1,2 L. Ji,2,3 C.D. Cheng,1,2 G.Q. Zhang,1,2 T. Zhang,1,2 Y.L. Li,1,2 H. Chen,1 S.H. Pan,1,2 B. Sun.1,21Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China; 2Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, China; 3Department of Breast Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.

Background: Ubiquitin-like protein 4A (UBL4A) plays a significant role in protein metabolism and the maintenance of cellular homeostasis. In cancer, UBL4A represses tumorigenesis and is involved in various signaling pathways. Pancreatic ductal adenocarcinoma (PDAC) is still a major cause of cancer-related death and the underlying molecular mechanism of UBL4A and PDAC remains unknown.

Methods: First, the prognostic role of UBL4A and its expression in human PDAC patients and in pancreatic cancer cell lines were detected. Next, the effects of UBL4A on proliferation and metastasis in pancreatic cancer were evaluated by functional assays in vitro and in vivo. In addition, chloroquine was introduced to determine the role of autophagy in UBL4A-related tumor proliferation and metastasis. Ultimately, coimmunoprecipitation was used to confirm the interaction between UBL4A and lysosome associated membrane protein-1 (LAMP1).

Results: We found that UBL4A was decreased in PDAC and that high levels of UBL4A correlated with a favorable prognosis. We observed that UBL4A inhibited tumor proliferation and metastasis through suppression of autophagy, a critical intracellular catabolic process that reportedly protects cells from nutrient starvation and other stress conditions. UBL4A caused impaired autophagic degradation in vitro, a crucial process in autophagy, by disturbing the function of lysosomes and contributing to autophagosome accumulation. We found a positive correlation between UBL4A and LAMP1. Furthermore, UBL4A caused lysosomal dysfunction by directly interacting with LAMP1, and LAMP1 overexpression reversed the antitumor effects of UBL4A in pancreatic cancer. In addition, we demonstrated that UBL4A suppressed tumor growth and metastasis in a pancreatic orthotopic tumor model.

Conclusions: These findings suggest that UBL4A exerts an antitumor effect on autophagy-related proliferation and metastasis in PDAC by directly targeting LAMP1. Herein, we describe a novel mechanism of UBL4A that suppresses the progression of pancreatic cancer. UBL4A might be a promising target for the treatment and prognostication of PDAC.

Mortality in Patients With Chronic Pancreatitis in a Diverse Integrated Healthcare Setting

Q. Chen,1 B.U. Wu.21Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; 2Center for Pancreatic Care, Gastroenterology, Kaiser Permanente Los Angeles, CA.

Background: Chronic pancreatitis (CP) is associated with reduced survival compared to the general population. Our specific aims were to examine the underlying causes of death and assess potentially modifiable risk factors associated with overall mortality among patients with CP in a diverse community-based integrated healthcare system.

Methods: We performed a retrospective cohort study using data from the Kaiser Permanente Southern California (KPSC) health plan members between 2006 and 2015. Adult patients were identified by using ICD-9 diagnosis code of CP and imaging features captured from radiology reports through natural language processing. Advanced morphology was defined as calcification and/or ≥2 CP image findings. We evaluated the all-cause mortality rate and the most frequent underlying causes of death in patients with CP. The Cox proportional hazard model was applied to examine risk factors associated with the overall mortality. The adjusted hazard ratios (aHR) and the 95% confidence intervals (CI) were reported.

Results: 3672 CP patients were included (median age 58 [IQR, 46–70] years, 49% women, 36.8% advanced morphology, 48.4% former or current smoker, 29.7% alcoholic). The overall mortality rate was 62 per 1000 person-years among patients with CP. A total of 928 (25.3%) patients died during a median follow-up time of 3.3 [IQR, 1.5–6.3] years. The most frequent causes of death were: cardiovascular diseases (23.1%), non-pancreatic cancer malignancy (22.7%), digestive system diseases (16.1 %), and pancreatic cancer (12.2%). Underweight (aHR [95% CI] 1.56 [1.19–2.04]), smoking (1.35 [1.09–1.62]), diabetes (1.34 [1.17–1.54]), advanced morphology (1.17 [1.03–1.34]), male (1.15 [1.01–1.32]), and age (1.04 [1.03–1.04]) were associated with an increased risk of all-cause mortality. Drinking was not a significant risk factor for this cohort.

Conclusions: Advanced morphology, smoking, diabetes and weight are potentially modifiable risk factors for mortality among patients with CP.

Prediction of Pancreatic Cancer Based on Duct Abnormalities Using Prediction Models

W. Chen,1 R.K. Butler,1 Y. Zhou,1 R.A. Parker,2 C.Y. Jeon,3 B.U. Wu.41Kaiser Permanente Southern California Research and Evaluation, Pasadena, CA; 2Department of Radiology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA; 3Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA; 4Center for Pancreatic Care, Department of Gastroenterology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA.

Background: Screening based on imaging studies has been recommended to identify morphologic features present in patients at high risk for developing pancreatic ductal adenocarcinoma (PDAC). Statistical models or machine learning approaches incorporating clinical features have also been attempted to identify patients with high risk of PDAC. We aimed to develop and validate algorithms that predicts the risk of PDAC using imaging features identified on cross-sectional imaging and other clinical patient characteristics collected through electronic medical records.

Methods: In this retrospective cohort study, adult patients (≥18 years of age) whose pre-diagnostic abdominal computed tomography or magnetic resonance imaging between 01/2006 and 06/2016 indicated pancreas duct dilatation were identified. Additional pancreas-related morphologic features were extracted from radiology reports using natural language processing. The cumulative incidence of PDAC with death as a competing risk was estimated using the R package mstate. The models were internally validated using bootstrapping. Calibration, discriminative power, and other accuracy measures (sensitivity, specificity, and positive predictive value) were reported.

Results: The cohort consisted of 7819 patients (mean age 71.3). A total of 781 (10%) patients developed PDAC within three years after the first eligible imaging study. The final models achieved a reasonable discrimination (c-index of 0.825–0.833). The three-year risk of PDAC in the top 5% of the total eligible patients with duct dilatation was 56.0%. Targeting patients with more than 5% of risk of developing PDAC could reach approximately 90% of the total PDAC cases. With a three-year risk threshold of 10%, which included about 30% of all eligible patients, 75% of the PDAC cases were identified.

Conclusions: Prediction models combining imaging features with additional clinical data can provide accurate estimates of cancer risk in patients with evidence of pancreatic duct abnormality. Implementation of such an algorithm in a clinical setting could greatly enhance the value of radiographic reporting.

Tanshinone IIA Protects Acute Pancreatitis in Mice Via Inhibition of Oxidative Stress and Modulation of the ROS/Nrf2 Pathway

W. Chen,1,2 C. Yuan,2 Q. Zhu,3 Y. Lu,2 X. Ma,2 J. Chen,1 D. Deng,1 J. Liu,1 X. Xiang,1 W. Xiao,3 W. Gong,4 G. Lu,2,3 W. Li.21Department of Gastroenterology, Clinical Medical College, Yangzhou University, Yangzhou, China; 2Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China; 3Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China; 4Department of Immunology, School of Medicine, Yangzhou University, Yangzhou, China.

Background: Oxidative stress plays a vital role in the pathogenesis of acute pancreatitis (AP). Tanshinone IIA (TSA) is a monomer with confirmed antioxidant activity. However, the effects of TSA on AP have not been determined. In this study, our objective was to investigate the protective effects of TSA on AP using three mice models.

Methods: Three AP models were induced in mice by cerulein, sodium taurocholate and L-arginine, respectively. In the cerulein-induced AP model, TSA was injected intraperitoneally at low-dose (5 mg/kg), middle-dose (25 mg/kg) and high-dose (50 mg/kg). Pancreatic histopathological characteristics, serum amylase and lipase levels were evaluated. Changes in oxidative stress injury and mitochondria structure of the pancreatic tissue were observed. Reactive Oxygen Species (ROS) inhibitor N-Acetyl-cysteine (NAC) and nuclear factor erythroid 2-related factor 2 (Nrf2) knockout mice were also applied in cerulein-induced model. In the other two AP models, TSA was injected at middle-dose. Pancreatic histopathological characteristics, serum amylase and lipase levels were also evaluated.

Results: In the cerulein-induced AP model, TSA administration reduced serum amylase and lipase levels as well as alleviated the histopathological manifestations of pancreatic tissue. Meanwhile, TSA decreased the ROS release, protected the mitochondria structure and increased the protein expression of Nrf2 and HO-1 greatest at the middle-dose. In addition, after administering NAC, we found the protective effects of TSA were not better than NAC group alone. After applying Nrf2 knockout mice, we failed to observe the protective effects of TSA on cerulein-induced knockout AP model. Furthermore, we found that TSA mitigated the severity of pancreatic tissue injury, serum amylase and lipase levels in two severe AP models induced by sodium taurocholate and L-arginine.

Conclusions: Our data confirmed the protective effects of TSA on AP in mice via inhibition of oxidative stress and modulation of the ROS/Nrf2 pathway.

Pancreatic Lesions Less Than 10 mm Studied by Endoscopic Ultrasonography With Fine-needle Aspiration

K. Chiba, M. Kikuyama, S. Kuruma, T. Kamisawa.

Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.

Background and Aim: To improve the prognosis of pancreatic diseases including pancreas cancer, early diagnosis of diseases by detecting small lesions is important. Endoscopic ultrasonography (EUS) can contribute to detecting a pancreatic lesion even if it is small with a diameter of 10mm or less, while histopathology of pancreatic lesions with a diameter of 10mm or less, especially 5mm or less, has not been fully studied.

In this study, we evaluated histopathology and image characteristic of pancreatic lesions with a diameter of 10mm or less recognized on EUS with successful EUS- fine needle aspiration (FNA).

Methods: Retrospectively, we evaluated histopathologically 93 lesions with a diameter of 10mm or less in 93 patients (males/females = 49/44, average age: 67 [44–85] years old) and compared histopathological diagnosis between 2 groups with a diameter of 5 mm or less and 6–10 mm. Moreover, image characteristics of the lesions on EUS were also researched.

Results: The average diameter of the lesions was 6 [2–10] mm. The location of the lesions was head, body, and tail in 15 (16%), 29 (31%), and 49 (52%), respectively. The most common reason for EUS was examining IPMN or pancreatic cyst in 47 (51%). Histopathological diagnosis was neuroendocrine tumor (NET), pancreatic cancer (PC), and solid pseudopapillay neoplasm (SPN), in 12 (13%), 3 (3%), and 1 (1%), respectively. The remaining 77 (83%) lesions revealed no neoplastic disorder but acinar or lymphoid tissue. By comparing 2 groups of lesions with a dimeter of 5 mm or less in 41 lesions and of 6–10 mm in 52 ones, a disease positive rate was significantly higher in the latter group (23%) including NET, cancer, and SPN in 9, 2, and 1, respectively, while the former group had 3 NETs and 1 cancer with a low disease positive rate of 10%. On EUS, NETs had a characteristic feature of homogenously hypoecho, round shape, and clear margin with halo and lateral shadow. Cancer also showed hypoecho but no other characteristics.

Conclusions: NET is the most common disorder among small lesions with a diameter of 10 mm or less, but not frequent (13%). Cancer is rare (3%). Many of the lesions recognized as a tumor are a part of pancreatic parenchyma or an adjacent lymph node.

Endoscopic Treatment for Pancreaticojejunal Anastomotic Stricture Following Pancreaticoduodenectomy

K. Chikugo, T. Kin, H. Toyonaga, H. Ueki, Y. Yamamoto, S. Honta, T. Ishii, K. Yane, T. Hayashi, K. Takahashi, A. Katanuma.

Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan.

Background: Pancreatitis due to the pancreaticojejunal anastomotic stricture (PJ-s) is a serious complication following pancreaticoduodenectomy. Endoscopic treatment for PJ-s has been attempted with balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) or endoscopic ultrasound (EUS), though its efficacy is not fully understood.

Aim: To evaluate the efficacy of the endoscopic treatment for PJ-s.

Patients and Methods: Patients with pancreatitis due to PJ-s following pancreaticoduodenectomy who underwent endoscopic treatment between July 2009 and March 2019 were analyzed retrospectively. We initially tried BE-ERCP, and the patients with difficult approach to PJ-s using BE underwent EUS-guided pancreatic intervention.

In this study, technical success was mainly measured primarily, which was defined as a successful pancreatic ductal stenting (PD-s). Adverse event and clinical outcomes after endoscopic treatment were also evaluated.

Results: A total of 23 patients [7 men, 16 women; median age 58 years (range, 28–86 years)] were included in this study. PD-s was achieved in 13 (56%) patients under BE-ERCP. Among them, 11 patients received successful PD-s on initial attempt, and another patient received PD-s after second attempt. Meanwhile, 5 of 11 patients without successful PD-s with BE-ERCP underwent EUS-guided treatment, and 3 of them received successful PD-s. In total, successful endoscopic treatment was acquired in 16 (69%) patients. As for adverse events, mild pancreatitis was observed in 1 patient who underwent EUS-guided treatment (20%). PD-s was finally extracted after median of 110 (range, 53–387) days. The recurrent pancreatitis after successful endoscopic treatment was observed in 1 patient, who finally required surgical treatment.

Conclusions: Endoscopic treatment for PD-s, which remained challenging technically, showed high clinical efficacy.

Feasibility and Efficacy of a Novel Needle in Endoscopic Ultrasound-guided Tissue Sampling for Pancreatic Solid Lesions: A Prospective Randomized Comparative Study

C.M. Cho,1 S.J. Yeo,1 A.N. Seo,2 H.I. Bae.2Departments of 1Internal Medicine and 2Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea.

Background/Aims: Histologic confirmation is crucial in the evaluation of pancreatic solid lesions. Recently, variable needles with different shapes for endoscopic ultrasound-guided tissue sampling (EUS-TS) have been widely used to diagnose pancreatic lesion. However, most needles used currently are made from major companies and expensive. Therefore, it is urgent to develop a new needle with a novel concept technology. We evaluated the feasibility and efficacy of a newly developed prototype needle in EUS-TS for pancreatic solid lesions comparing the commercially available ones.

Methods: As a prospective randomized trial, a 22 gauge needle (ClearTip, FINEMEDIX, Daegu, Korea) with side hole of both reversed bevel (test needle) was compared to three commercially available 22G biopsy needles (control needles) in patients who undergoing EUS-TS of pancreatic solid lesions. First two passes of EUS-TS were accomplished in a random order between test and control needles. The procured specimens were prepared and compared specimen adequacy and diagnostic accuracy among needles. Additional two passes were performed using the control needle for histologic diagnosis. Two blinded pathologists evaluated the specimens based on an already agreed diagnostic criteria for cytology and histology.

Results: Between February and June 2018, 24 patients (median 63.5 years, 14 males) with pancreatic solid lesions were enrolled. Mean size of mass lesion was 32.4 mm with 2.8 mm of standard deviation. Among them, one patient had no final diagnosis due to inadequate specimen. Technical failure occurred in one case of test needle. Final diagnosis was pancreatic ductal adenocarcinoma in 19, neuroendocrine tumor in 1, metastasis in 1, and chronic pancreatitis in 2. There was no significant difference between test and control needles in terms of specimen adequacy (95.5% vs 95.7%) and diagnostic accuracy (69.6% vs 82.6%) (P = 1.000 and 0.491, respectively). There were no adverse events in enrolled patients.

Conclusions: The new prototype needle is feasible and efficient for EUS-TS in pancreatic solid lesions. However, further study including large volume and for other lesions is needed to validate these results.

A Prospective Randomized Controlled Trial of Contrast-Enhanced Harmonic Versus Conventional Endoscopic Ultrasound-Guided Fine Needle Aspiration Affecting Diagnostic Yield for Pancreatic Solid Lesions: An Interim Analysis With 268 Patients

I.R. Cho,1 S.H. Jeong,1 J.H. Cho,2 E.J. Kim,2 Y.S. Kim.21Department of Internal Medicine, Catholic Kwandong University International St. Mary's Hospital, Incheon, Republic of Korea; 2Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea.

Background: The differential diagnosis of pancreatic solid lesions is a common clinical challenge. Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS), which indicates vascularization in pancreatic lesions, has been found to be useful in the differential diagnosis of pancreatic tumors. The aim of this study was to investigate the usefulness of CEH-EUS guided fine needle aspiration (FNA) compared to conventional EUS-FNA affecting diagnostic yield for pancreatic solid lesions.

Methods: A total 268 patients with pancreatic solid lesions were prospectively enrolled in two university hospitals from January 2015. Patients were assigned to two groups: CEH-EUS-FNA group (n = 134) and conventional EUS-FNA group (n = 134). FNA was performed without an onsite cytopathologist. The sensitivity, specificity, accuracy and optimal number of needle passes for pathologic diagnosis were investigated and compared between two groups.

Results: Pancreatic malignancies were found in 245 patients (91.4% of study population). There was no statistically significant difference between two groups in age, sex, lesion size (32.2 mm vs 34.0 mm; P = 0.366), location, adverse event rate (21.6% vs 24.6%; P = 0.305), and rate of malignancy (90.3% vs 92.5%; P = 0.271). Coexistence of tissue biopsy rate was higher in CEH-EUS-FNA group (73.1% vs 66.4%; P = 0.001). Sensitivity, specificity, and accuracy of CEH-EUS-FNA group was 89%, 100%, 89% and conventional EUS-FNA group was 84%, 100%, 84%, respectively. All patients in the CEH-EUS-FNA group and most of patients in the conventional EUS-FNA group obtained pathological diagnosis within 3 needle passes. Only 2 patients in the conventional EUS-FNA group needed additional needle pass.

Conclusions: The diagnostic yield for pancreatic solid lesions were higher in CEH-EUS-FNA group than conventional EUS-FNA group. Optimal number of needle passes for pancreatic solid lesions of both groups were same as three.

Long-term Outcomes of Fully Covered Self-expandable Metal Stents in Benign Pancreatic Ductal Stricture of Chronic Pancreatitis

J.H. Cho, E.J. Kim, K.O. Kim, Y.S. Kim.

Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea.

Background: Chronic pancreatitis (CP) is a benign, irreversible, inflammatory disorder of the pancreas and it may result in symptomatic main pancreatic duct (MPD) strictures. Although plastic stents had been mainly used for treatment, fully covered self-expandable metal stent (FCSEMS) placement was introduced. We aimed to investigate the long-term outcomes of FCSEMS placement in patients with symptomatic refractory MPD strictures of chronic pancreatitis.

Methods: Between 2008 and 2018, 23 patients (21 male, median age 48 years) underwent endoscopic placement of FCSEMS for benign refractory MPD stricture. The FCSEMS diameter and length were chosen according to stricture anatomy and MPD diameter. Technical/clinical success, adverse events and recurrence were evaluated.

Results: All enrolled patients had a history of alcohol abuse, and FCSEMS placement was successful in all patients (technical/clinical success rates: 100%). Nine (39%) patients had immediate adverse events (3 mild pancreatitis, 4 hyperamylasemia, and 2 cholangitis) following FCSEMS (8–10 mm diameter, 4–8 cm length) insertion. Pancreatitis were managed conservatively and cholangitis were treated by additional biliary stent insertion. Among 21 patients with follow-up, scheduled stent removal was planned in 17 (80.9%) patients and all patients had successful FCSEMS removal at a median of 4.8 months after their placement (IQR, 4.1–5.4). In terms of long-term adverse events, 4 (19%) distal migration, 3 (14.2%) proximal migration, and 5 (23.8%) de novo MPD strictures, 3 (14.2%) cholangitis, 2 (9.5%) cholecystitis, 1 (4.8%) pancreatitis developed. Over a follow up period of 17.1 months (IQR, 10.6–34.9), MPD stricture resolution was achieved 17 (80.9%) patients, but 8 (38.1%) pancreatic ductal stricture recurred at a median of 26.2 months (IQR, 18.7–42.4).

Conclusions: FCSEMS placement appears to be safe and promising for the treatment of benign refractory pancreatic ductal strictures due to chronic pancreatitis. However. de novo biliary stricture, FCSEMS migration and long-term recurrence were major problems and deserves further assessment.

Clinical Outcomes of the Borderline Resectable Pancreatic Cancer According to the Neoadjuvant Chemo-Regimens: Gemcitabine Versus FOLFIRINOX

Y.J. Choi, J.S. Kang, Y. Byun, H.S. Kim, Y. Han, H. Kim, E. Kim, W. Kwon, J.Y. Jang.

Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.

Background: Although there have been many studies about promising effect of neoadjuvant treatment for borderline resectable pancreatic cancer (BRPC) to increase resectability, not much studies there are to recommend the first line of the neoadjuvant strategies for BRPC. This study is to compare clinical outcomes including survivals and recurrence pattern between two generally used neoadjuvant chemotherapies, gemcitabine and FOLFIRINOX, for the patients with BRPC.

Methods: 114 B.P. patients who received neoadjuvant chemotherapy and surgery between 2010 and 2018 were reviewed in this retrospective study. Of these BRPC patients, 14 patients with R2 resection or distant metastasis found in the operation were excluded. There were 2 types of neoadjuvant chemotherapies: gemcitabine (n = 35) and FOLFIRINOX (n = 65). Clinical outcomes included survival, curative resectability, and recurrence pattern. Age, preoperative stage, and tumor size were comparable between two regimens.

Results: The overall 2-year survival rate (YSR) was 70.0% with a median survival of 35 months. The 2-YSR of FOLFIRINOX was significantly higher than gemcitabine (81.4 vs 56.0%, P = 0.033). But R0 resection rate of both regimens did not show any significant difference (FOL 63.2 vs GEM 36.8%, P = 0.206). Recurrence rate in postoperative two years was significantly lower in the FOLFIRINOX group than the Gemcitabine group (21.4 vs 64.8%, P = 0.001). Neoadjuvant Gemcitabine (hazard ratio [HR], 3.95) and microscopic venous invasion (HR, 2.54) were independent predictors for poor 2 year disease free survival.

Conclusions: FOLFIRINOX, compared to the gemcitabine regimen, provided better clinical outcomes like 2-YSR and recurrence rate. FOLFIRINOX may be recommended as the first line of neoadjuvant chemotherapy. However, due to high recurrence rate of pancreatic cancer itself, we should consider to develop the potent and more effective adjuvant regimen to reduce recurrence.

Markers of Inflammation and Hemostasis for Prognosis of Organ Failure in Acute Pancreatitis

S. Chooklin, S. Chuklin, G. Shershen.

Regional Clinical Hospital, Lviv, Ukraine.

Background: Clinical data has indicated that severe acute pancreatitis (AP) is a serious disease with a systemic inflammatory response and multiple organ dysfunction. Lung and renal injury caused by AP is a common complication that is associated with a high rate of mortality. Therefore, timely prediction of these complications is very important. Proteases, inflammatory cells and its mediators which secreted from pancreas into blood circulation and impairment of blood coagulation, microcirculations are explaining as the main contributed factors for organ failure in AP.

Materials and Methods: We examined 296 patients with severe AP. We determined the blood gases, creatinine level, indicators of hemostasis and inflammation.

Results: Disorders of kidney function were in 125 patients. Disorders of lung function were in 111 patients. The emergence of pulmonary, renal dysfunction was accompanied by activation of plasma levels of hemostasis and platelets, inadequate activity of natural anticoagulants, increased synthesis of acute phase proteins, excessive production of proinflammatory cytokines. At a concentration of IL-18 >650 pg/ml, it is possible to predict pulmonary dysfunction in patients with AP with a sensitivity of 58% and a specificity of 100%, which allows it to be used as a screening test - likelihood ratio (+) >58. The sensitivity of soluble fibrin-monomer complexes for prediction of pulmonary dysfunction was 86.2%, and the specificity was 83.8% (cut-of value 137.50 mg/L), with a positive and negative predictive value of 80.65% and 88.57%, respectively. The sensitivity of the determination of IL-6 to predict renal dysfunction was 76%, and the specificity was 78% (cut-of value 111.30 pg/ml), with a positive and negative predictive value of 67.86% and 84.21%, respectively.

Conclusions: Acute pancreatitis is characterized by local and systemic inflammation, hypercoagulation which leads to multiple organ dysfunction. The markers of hemostasis and inflammation may be use for prognosis of organ failure in AP.

Soy-tomato Enriched Diet Reduces Inflammation and Disease Severity in a Pre-clinical Model of Chronic Pancreatitis

F. Choueiry,1 M. DiVincenzo,2 A. Deems,1 M. Torok,1 S.K. Kulp,3 W.E. Carson,4 P.A. Hart,1 J.L. Cooperstone,5 T.A. Mace.11Divisions of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, 2Department of Veterinary Biosciences, 3College of Pharmacy, 4Department of Surgery, 5Department of Horticulture and Crop Science, James Comprehensive Cancer Center, The Ohio State University, Columbus, OH.

Background: Chronic pancreatitis (CP) is defined as a pathological fibro-inflammatory syndrome of the pancreas in individuals who develop persistent pathological responses to parenchymal injury or stress. Novel therapeutic or dietary interventions that could lessen inflammation in this disease could significantly improve quality of life in patients with CP. Complex dietary foods like soy and tomatoes are composed of active metabolites that can modulate anti-inflammatory effects. Data from our group reports that bioactive agents in soy and tomatoes can reduce pro-inflammatory cytokines and suppressive immune populations. Additionally, our team has developed a novel tomato-soy juice to use in patient trials in healthy individuals shown to have no toxicity, good compliance and bioavailability. Thus, we hypothesize that administration of a soy-tomato enriched diet can reduce inflammation and severity of CP.

Methods: C57BL/6 mice were injected intraperitoneally with 50 μg/mg cerulein (7 hourly injections, twice weekly) for 6 weeks to induce CP. After 4 weeks of cerulein injections, mice were administered a control or a soy-tomato enriched diet for 2 weeks. Disease severity was measured via immunohistochemical analysis of pancreata measuring loss of acini, fibrosis, inflammation, and necrosis. Serum lipase and amylase levels were analyzed at study endpoint. Inflammatory factors in the serum and pancreas, and immune populations in the spleen of mice were analyzed by cytokine multiplex detection, qRT-PCR, and flow cytometry respectively. Infer-red (IR) imaging of mice was used to monitor activity and distress of mice.

Results: Mice fed a soy-tomato enriched diet had a significantly reduced level of inflammation and severity of CP compared to mice administered a control diet with restored serum lipase and amylase levels (P < 0.05). Mice with CP fed a soy-tomato diet had a reduction in inflammatory factors (IL-6, IL-1) and suppressive immune populations (MDSC) with an increase in T cells compared to control diet fed mice (P = 0.042). Soy-tomato enriched diet improved the activity and overall health of mice with CP (P = 0.011) using infrared lights to monitor movement of mice over time and mice on a control diet were determined to have a greater level of resting (P = 0.005).

Conclusions: These pre-clinical results indicate that a soy-tomato enriched diet may be novel treatment approach to reduce inflammation and pain in patients with CP.

Disruption of Argonaute2 in Pancreatic Cancer Mouse Models Reveals Its Essential Role in Oncogene-Induced Senescence

S. Chugh,1,2 J.C. Tien,1,2 V.L. Dommeti,1,2 S.Z. Wang,1,2 R.F. Siebenaler,1,2 K.M. Juckette,1,2 S. Eyunni,1,2 L. Wang,1,2 J. Shi,1,2 C.K. Sinha,1,2 S. Shankar,1,2 A.M. Chinnaiyan.1,2,3,4,51Michigan Center for Translational Pathology, 2Department of Pathology, 3Howard Hughes Medical Institute, 4Department of Urology, and 5Rogel Cancer Center, University of Michigan, Ann Arbor, Ann Arbor, MI.

Background: KRAS mutations have been identified in more than 90% of PDAC patients. Our lab has previously demonstrated a direct interaction of KRAS with Argonaute 2 (AGO2), a component of RNA-silencing machinery. This interaction enhanced cellular transformation, suggesting a role for AGO2 in KRAS driven cancers. Here, we explore the role of AGO2 in pancreatic ductal adenocarcinoma (PDAC) progression and metastasis.

Methods: AGO2 expression was ablated in well-defined KrasG12D/+; p48Cre model (KC) and Kras G12D/+; p53fl/+; p48-Cre (KPC) model of pancreatic cancer. Survival and disease progression were compared between wild-type (AGO2+/+), heterozygous (AGO2fl/+), and homozygous (AGO2fl/fl) experimental groups of KC and KPC models.

Results: Homozygous knockout of AGO2 in KC mice significantly increased survival when compared to wild-type and heterozygous mice. We did not observe PDAC and metastases in AGO2fl/fl; KRASG12D; p48Cre mice over a period of 500 days. However, wild-type and heterozygous mice showed PDAC and metastatic lesions. Pancreas from AGO2fl/fl; KRASG12D; p48Cre mice developed only early pancreatic intraepithelial lesions (PanINs), which failed to progress to PDAC. Mechanistic insights were provided by senescence-associated β-galactosidase staining that showed a strong and significant increase in senescence in PanIN lesions in AGO2fl/fl; KRASG12D; p48Cre mice when compared to AGO2+/+; KRASG12D; p48Cre mice. Increased senescence was accompanied with increased phospho-ERK signaling. Further, knockout of AGO2 in KPC mice that lacked the senescence effector p53 prevented the onset of oncogene induced senescence (OIS) and resulted in PDAC.

Conclusions: Our findings indicate that AGO2 prevents OIS as a result of KRASG12D expression and allows PanIN to PDAC progression. Additionally, loss of p53, which is a canonical inducer of cellular senescence, results in a phenotype that evades senescence.

An Elevated Serum CA 19-9 is Associated With Invasive Cancer in IPMN and Worse Survival

D. Ciprani, V. Morales-Oyarvide, M. Qadan, T. Hank, M. Weniger, C.R. Ferrone, K.D. Lillemoe, A.L. Warshaw, C. Fernández-del Castillo.

Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Current guidelines for the management of IPMN include serum carbohydrate antigen (CA) 19-9 among the worrisome features. However, the correlation of CA 19-9 with histological malignant features and survival is unclear. The aim of the current study was to assess the utility of serum CA 19-9 in the management of IPMN.

Methods: Patients with resected IPMN between 1990-2018 from the Massachusetts General Hospital were analyzed. Clinical, pathological, and survival data were collected and compared to preoperative levels of CA 19-9. Univariate analysis and Cox regression were performed comparing patients with CA 19-9 levels lower and equal or higher than 37 U/mL.

Results: 600 patients who underwent resection for IPMN and had preoperative CA 19-9 measured were identified. A total of 137 patients had elevated levels of CA 19-9 greater than 37 U/mL. Median follow up was 68 months (0–302). Patients with high CA 19-9 were more likely to have main duct IPMN than the ones with normal levels (35.2% vs 21.7%, P = 0.007), and elevated CA 19-9 was twice as likely in patients who harbored invasive carcinoma within their cyst (56.9% vs 28.4%, P < 0.001). There were no differences in CA 19-9 levels in patients with high-grade dysplasia compared to those without (28.81 % vs 22.36%, P = 0.28). Patients with elevated serum levels of CA 19-9 had worse overall and disease-free survival (HR, 2.305; P < 0.001 and HR, 3.197; P < 0.001, respectively).

Conclusions: A serum CA 19-9 greater than 37 U/mL is associated with invasive cancer in patients with IPMN and with worse overall and disease-free survival. The recent inclusion among the worrisome features appears to be justified.

The Risk of Malignancy in Small Pancreatic Cysts Does not Decrease Over Time

D. Ciprani, M. Weniger, M. Qadan, T. Hank, N.K. Horick, C.R. Ferrone, K.D. Lillemoe, A.L. Warshaw, C. Fernández-del Castillo.

Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Pancreatic cysts smaller than 15 mm at the time of diagnosis without worrisome features have a low risk of malignancy. However, optimal duration of follow up is still debated. We evaluated predictors of malignancy and attempted to identify a time to safely discontinue surveillance.

Methods: From a prospectively collected database of patients with pancreatic cysts undergoing surveillance at the Massachusetts General Hospital between 1988 and 2017, cysts measuring less than 15 mm and without worrisome features were identified. Cumulative incidence via the Kaplan Meier method and Cox-regression were utilized to estimate risk of malignant transformation.

Results: 309 patients with incidentally-discovered pancreatic cysts smaller than 15 mm were identified. Median follow up was 57 months (range, 6–347) and median cyst size at diagnosis was 10 mm (3–14). Forty-six (14.9%) cysts were resected because of development of worrisome features. Of resected cysts, 6 had high grade dysplasia (HGD) or pancreatic cancer. An additional patient had unresectable cancer for a total rate of malignancy of 2.3%. The median time to development of malignancy was 96 months. Predictors of development of malignancy included an increase in size of more than 2.5mm/year (HR, 19.2; 95% CI, 3.6–103.1; P = 0.0006), the development of worrisome features (HR, 7.2; 95% CI, 1.3–45.3; P = 0.03), and the appearance of additional cysts or septations (HR, 7.7; 95% CI, 1.3–45.3; P = 0.02). Importantly, estimating the risk to develop malignancy over the years, the cumulative incidence of malignancy was 0.07% at 5 years and 3% at 10 years.

Conclusions: Pancreatic cysts smaller than 15 mm at the time of diagnosis have a low risk for malignant transformation. Size increase of >2.5 mm/year is the strongest predictor of malignancy. Given the median time to development of malignancy was 96 months, discontinuing surveillance in patients with small pancreatic cysts is not safe.

Effect of Intraoperative Fluid Type on Postoperative Systemic Inflammatory Response and End-organ Dysfunction Following Total Pancreatectomy With Islet Autotransplantation in Children

B. Colvin,1 G. Goddard,1 M. Wagner,2 T. Jenkins,1,2 M. Abu-El- Haija,3,4 T.K. Lin,3,4 S. Goldstein,5,4 J.D. Nathan.1,21Divisions of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH; 3Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; 5Division of Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Background: This study evaluates the relationship between intraoperative fluid type [0.45% NaCl (0.45NS) or lactated Ringer’s solution (LR)] with risk of systemic inflammatory response syndrome (SIRS) and acute kidney injury (AKI) in the early postoperative period after total pancreatectomy with islet autotransplantation (TPIAT) in children.

Methods: 43 patients underwent TPIAT from 2015-2019 in a pediatric hospital. Demographics, operative details, SIRS response, and evaluation for end-organ dysfunction over the first 5 postoperative days was obtained through chart review. Mixed-effects Poisson regression was used to compare risk of SIRS and AKI by intraoperative fluid type.

Results: Patients were 65% female with mean age 12.9 ± 4.5 years at time of operation. Twenty-one patients received 0.45NS, and 22 patients received LR with no difference in patient demographic characteristics between groups. Percentage of patients with SIRS significantly declined over time: post-operative day (POD) 1, 95%; POD 3, 77%; POD 5, 74% (P < 0.01). The 0.45NS group more frequently received blood products intraoperatively (4/21 vs 0/22, P = 0.05). Intraoperative fluid type was not associated with risk of postoperative SIRS (RR, 0.91, 95% CI, 0.78–1.06; P = 0.23). Factors associated with increased risk of SIRS included: female sex (RR, 1.30; 95% CI, 1.08–1.55; P < 0.01), increased BMI (RR, 1.17; 95% CI, 1.04–1.32; P < 0.01), and longer operative time (RR, 1.07; 95% CI, 1.03–1.11; P < 0.01). Intraoperative 0.45NS use was associated with increased acute kidney injury compared to LR on POD 1 (52% vs 0%, P < 0.01), but was not significantly different on POD 3 (14% vs 0%, P = 0.11), and POD 5 (14% vs 0%, P = 0.11).

Conclusions: Intraoperative 0.45NS was associated with greater AKI after TPIAT, but did not differ from LR with risk of postoperative SIRS. Sex, BMI, length of operation were found to be predictors of SIRS. Future studies are needed to further delineate the anti-inflammatory effects of resuscitation with balanced solutions.

D52 is an Autophagy Cargo Receptor That Coordinates Secretion and Autophagy in Acinar Cells

M.M. Cooley, D.D. Thomas, M.Q. Breen, N. Ly, K. Ly, S.W. Messenger, E.K. Jones, G.E. Groblewski.

Department of Nutritional Sciences, University of Wisconsin – Madison, Madison, WI.

Background: Secretion and autophagy are essential pathways for acinar cell function that become dysregulated during pancreatitis. Previous work demonstrated that secretory stimulation induces autophagy initiation in acini, suggesting a coordination between these two processes. Here, we demonstrate that Tumor Protein D52, previously shown to regulate endolysosomal secretion, also associates with subapical autophagic structures and influences the autophagy pathway via associations with the autophagy regulatory proteins ATG16L1 and LC3 in a Ca2+-sensitive phosphorylation-dependent manner.

Methods: Co-immunoprecipitations were performed in rodent and human primary acini and cultured cells to probe protein-protein interactions. Immunofluorescent microscopy was done to determine protein colocalization. Clathrin-coated vesicles (CCVs) were purified from pancreas by subcellular fractionation. Tamoxifen-inducible, acinar-specific D52 KO mice were generated by crossing D52 floxxed mice with Ela-CreERT2.

Results: D52 accumulates in autophagic structures and undergoes lysosomal degradation which is blocked by the cathepsin inhibitor Ca074Me. D52 co-immunoprecipitated with ATG16L1 in rodent and human acini as well as HCT 116 cultured cells. D52 contains putative LC3-interacting regions and co-immunoprecipitated with LC3; this interaction was significantly enhanced with secretory CCK stimulation. D52/ATG16L1/LC3 colocalize extensively in Rab11a-positive recycling endosome compartments along acinar apical membranes, from which phagophore formation is postulated to occur. Furthermore, D52 and ATG16L1 associate with CCVs, suggesting involvement in membrane retrieval. Ela-Cre D52-/- acini exhibit loss of apical membrane integrity and a marked disruption of the Rab11a apical compartment.

Conclusions: These data implicate D52, ATG16L1, and LC3 in apical membrane trafficking pathways in response to acinar secretory stimulation. We propose that D52 is an autophagy cargo receptor protein that coordinates vesicular trafficking between secretion and autophagy to maintain acinar cell apical membrane integrity and homeostasis.

Mild Chronic Pancreatitis Caused by Persistent Endoplasmic Reticulum Stress in AT-1 KO Mice Progresses to Severe Disease With Acute Pancreatitis Induction

M.M. Cooley,1 D.D. Thomas,1 K. Deans,1 Y. Peng,2 A. Lugea,3 S.J. Pandol,3 L. Puglielli,2 G.E. Groblewski.1Departments of 1Nutritional Sciences and 2Medicine, University of Wisconsin – Madison, Madison, WI; 3Pancreatic Research Group, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: Unfolded protein response (UPR) activation occurs in response to accumulation of unfolded proteins in the endoplasmic reticulum (ER) and is observed in experimental models of both acute (AP) and chronic (CP) pancreatitis. Acetylation of newly translated ER proteins is necessary for protein folding, mediated by the ER-associated acetyl-CoA transporter AT-1. We produced acinar-specific AT-1 knockout mice to activate chronic ER stress and induce chronic pancreatitis.

Methods: Tamoxifen-inducible, acinar-specific AT-1 KO mice were generated by crossing AT-1 floxxed mice with Ela-CreERT2 mice. Tamoxifen was administered at 2 months and tissues collected 2-3 months post treatment. Pancreatitis parameters – including UPR activity, autophagic activity, inflammation, and fibrosis – were assessed by immunoblotting, qPCR, H&E staining, Sirius red staining, and immunofluoresence. AP was induced for two consecutive days by 7 hourly injections of cerulein, followed by 1 week recovery period.

Results: Ela-Cre AT-1 KO pancreas exhibited signs of mild to moderate chronic pancreatitis, with elevation of UPR markers sXBP1, p-eIF2α, ATF4, and CHOP. Autophagic inhibition was present as indicated by increased LC3-II accumulation and decreased LAMP2 levels. AT-1 KO pancreas displayed significant immune cell infiltration and inflammation as well as collagen deposition and α-smooth muscle actin expression. Interestingly, increased amylase expression and decreased lipase and elastase expression was observed with AT-1 loss, and trypsin activation was increased. Stimulated amylase secretion in AT-1 KO was enhanced over 3-30pM CCK. AT-1 KO pancreas failed to recover after AP induction, with significant acinar cell loss and overall 40% reduction in total pancreatic weight.

Conclusions: Loss of AT-1 activity promotes a phenotype consistent with mild to moderate chronic pancreatitis that progressed in severity with AP induction. This study contributes to the understanding of the importance of ER acetylation on protein folding and ER stress responses. Further investigation into the acetylation of acinar-specific proteins will reveal additional insights.

Pancreatic Adenocarcinoma Following Liver Transplantation: UNOS Data Analysis

J.E. Corral,1 S. Patel,1 P.T. Kröner,1 K. Wijarnpreecha,1 A. Patel,2 S. Al Nimri,3 Y. Bi,1 O.Y. Mousa.41Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL; 2Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL; 3Jordan University of Science and Technology, Irbid, Jordan; 4Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.

Background: Solid organ transplant recipients are at increased risk of de novo malignancies. Data regarding pancreatic cancer following liver transplantation is limited. Aims: Evaluate the incidence of pancreatic adenocarcinoma among transplant recipients in the United States. Describe survival in those patients and identify subgroup of patients at increased risk.

Methods: We examined the UNOS database and identified patients with pancreatic adenocarcinoma who underwent liver transplant between 1988 and 2016. Patients 18 years of age and older were included. Demographics, primary diagnosis and survival data were recorded. Kaplan-Meier survival analyses and log-rank tests were performed.

Results: In the UNOS database, survival data regarding 142,488 patients was available and the cause of death was identified in 14,533 transplant recipients. A total of 140 patients developed pancreatic adenocarcinoma after transplantation. Most common indications for transplantations were Hepatitis C, alcohol cirrhosis and hepatocellular carcinoma (25 [17.9%], 24 [17.1%], and 9 [6.4%], respectively).

Annual incidence was 16 cancer cases per 100,000 transplant recipients. Compared to SEER national incidence of 12.9 per 100,000 patients, the relative risk was 1.23 (95% CI, 0.59–2.56).

Compared to other liver transplant recipients, those who developed pancreatic cancer were older and transplanted earlier in the time period evaluated (P < 0.001 and P = 0.002, respectively). Sex, ethnicity, BMI, and primary diagnosis (i.e. transplant indication) were not significantly different among groups. Patient survival was significantly lower in patients who developed pancreatic adenocarcinoma (Log-rank test P < 0.001).

Conclusions: Analysis of the UNOS database showed that pancreatic adenocarcinoma is frequent among liver transplant recipients and significantly shortens their survival. Primary indications for transplantation and demographics were similar among both groups. Our findings suggest that pancreatic adenocarcinoma is more likely associated to long-standing immunosuppression and non-traditional risk factors rather than alcohol consumption or obesity. Further studies describing the natural history of pancreatic cancer after solid organ transplantation are suggested.

Medical Traumatic Stress in Pediatric Patients With Chronic Pancreatitis

A.A. Cuneo, N. Ly, M.S. Zerofsky, E.R. Perito.

Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, CA.

Background: Children with chronic pancreatitis (CP) endure recurrent exposures to burdensome medical regimens, frequent hospitalizations and invasive procedures. In other pediatric populations intensive medical care has been shown to cause Pediatric Medical Traumatic Stress (PMTS) in approximately 20% of patients; and this has been associated with decreased adherence to treatment regimens, increased opioid dependence and difficult transitions to adult care. This is the first report on prevalence and predominant symptoms of PMTS in children and adolescents with CP.

Methods: Single-center, cross-sectional survey of patients aged 8-21 with CP, using the validated UCLA PTSD-Reaction Index which assesses for exposure to a potentially traumatic event and symptoms of traumatic stress in four categories: intrusion, avoidance, negative mood, and arousal.

Results: A total of 21 children and adolescents aged 8-19 years were studied, 67% of whom were female. Exposure to a potentially traumatic “very scary or painful” event during medical care was endorsed by 80% (n = 17), with 38% (n = 8) also reporting high perceived life threat during treatment. Of the 17 patients who were exposed to a potentially traumatic event during their medical care, 53% (n = 9) had symptoms consistent with PMTS - predominantly arousal (n = 7) and intrusion (n = 6), and less frequently avoidance (n = 4) and negative mood (n = 3).

Conclusions: A high prevalence of children and adolescents with CP report exposure to potentially traumatic events during the course of their medical care. Of this pilot study, over half reported consequential PMTS symptoms, particularly arousal and intrusion symptoms. This is more than twice the rate endorsed in other pediatric populations. Further investigation is required to understand the impact of chronic exposure to traumatic medical care, identify potentially modifiable risk factors for PMTS and understand the ramifications of PMTS on the long-term medical and mental health outcomes of CP patients.

Heme Oxygenase-1 Inhibition Potentiates the Effects of Nab-paclitaxel-gemcitabine in Human Pancreatic Cancer Under Hypoxia

A.J. Dafferner,1 I.M. Ahmad,2 M.Y. Abdalla.1Departments of 1Medical Imaging and Therapeutic Sciences and 2Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the aggressive malignancies and has one of the worst prognoses. Unfortunately, most PDAC are asymptomatic and are often advanced beyond the ability to surgically remove them at the time of diagnosis. Tumor hypoxia is a major factor contributing to cancer progression in PDAC and plays an active role in promoting tumor progression, malignancy, and resistance to therapy. Hypoxia reprograms the expression profile and mediates many of its effects by upregulating heme oxygenase-1 (HO-1), which provides survival advantage. We hypothesize that inhibiting HO-1 under hypoxic conditions enhances nab-paclitaxel-gemcitabine (NPG) chemotherapy.

Methods: PDAC cells (CD18/HPAF, M3T4, MIA PaCa-2, and Capan-1) were tested for HO-1 expression, proliferation, oxidative stress, under hypoxic (2% oxygen) and normoxic conditions in the presence of various combinations of two HO-1 inhibitors (ZnPP and SnPP), Nab-paclitaxel, Gemcitabine and a HO-1 activator (CoPP).

Results: Hypoxia, as well as NPG chemotherapy, upregulated the expression of HO-1 in PDAC cells. Inhibiting HO-1 with ZnPP and SnPP sensitized PDAC cells to NPG induced cytotoxicity under hypoxia, significantly reducing their survival (P < 0.05) and increasing apoptosis (P < 0.05). Additionally, HO-1 was increased in gemcitabine resistant PDAC cells (P < 0.05) and HO-1 inhibition increased gemcitabine-resistant PDAC sensitivity to NPG (P < 0.05). Interestingly, immunofluorescence studies showed a significant increase (P < 0.05) in HO-1 localization in the nucleus in PDAC cells and the rate of nuclear HO-1 in PDAC cells was higher (P < 0.05) following either nab-paclitaxel and/or gemcitabine therapy. Mechanistically, inhibition of HO-1 increased ROS, apoptosis and disrupted GSH and HO-1 nuclear translocation.

Conclusions: Altogether, we found that HO-1 inhibition enhanced the efficacy of NPG chemotherapy, which appears linked to a reduction in PDAC cell proliferation, increased ROS, greater apoptosis and the disruption nuclear translocation of HO-1. These data suggest that the combination of inhibitors of HO-1 with NPG may provide a novel therapeutic approach for PDAC.

Hypertriglyceridemia Worsens Acute Pancreatitis Via SREBP1c/miR-153 Signaling Dysregulation

J.J. Dai,1,2 M.J. Jiang,2 Y.Y. Hu,1,2 L. Wen,1,2 X.P. Wang,1,2 G.Y. Hu.1,21Department of Gastroenterology, Shanghai General Hospital and 2Shanghai Key Laboratory of Pancreatic Disease, Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China.

Background: Hypertriglyceridemia (HTG) is independently and proportionally correlated with persistent organ failure and mortality in acute pancreatitis (AP) patients. Up to 50% severe and very severe HTG is due to lipoprotein lipase (LPL) deficiency. It is unknown what is the mechanism that LPL deficiency-induced HTG worsens AP.

Methods: Plasma from HTG-AP patients and the pancreas from HTG-AP mice were collected for qPCR and miRNA sequencing. LPL inhibitor P-407 was used to induce HTG. Lentivirus pancreatic in situ injection was used to stably express miR-153-inhibitor, miR-153 and SREBP1c genes within the pancreas in vivo. AP was induced by intraperitoneally injections of cerulein, L-Arginine and retrograde biliopancreatic ductal infusion of taurolithocholic acid 3-sulfate. AP severity was assessed by necrosis, edema and inflammatory infiltration in the pancreas and systemic damages assessed by acute lung injury (ALI) and serum cytokines. miR-153 target genes were verified using dual luciferase reporter assay.

Results: miR-153 was upregulated in HTG-AP mice and patients, but not in other AP etiologies. In HTG mice, miR-153 inhibition significantly alleviated pancreatic necrosis and inflammation and pancreatitis-associated ALI. While miR-153 overexpression increased AP severity. Mechanistic study showed that miR-153 exerts its effects via inhibiting TRAF3, a valid miR-153 target and consequently activating the p38 MAPK/JNK cascade. We next identified that during HTG-AP, SREBP1c, as a miR-153 upstream transcription factor, was markedly down-expressed, resulting in loss of its feedback inhibitory effect on miR-153 expression. In HTG mice, SREBP1c overexpression restored its inhibition of miR-153 expression, thus protected against AP. Finally, we found that insulin exert its protective effect on HTG-AP partially through restoring SREBP1c.

Conclusions: We demonstrated a novel SREBP1c/miR-153 signaling that is dysregulated during HTG induced by LPL inhibition/deficiency is the key mechanism that worsens AP. This study provides a promising therapeutic target for the prevention and treatment of HTG-AP.

Early Drain Removal After Major Pancreatectomy Reduces Postoperative Complications: A Prospective, Randomized, Single-Center Trial

M.H. Dai,1,2 Q.F. Liu,1,2 C. Xing,1,2 J. Kleeff,3 Q. Liao,1,2 J.C. Guo,1,2 X.L Han,1,2 Q. Xu,1,2 S.D. Wang,1,2 Y.P. Zhao.1,21Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China; 2National Translational Medicine of China, Beijing, China; 3Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.

Background: The timing of drain removal and its effects on complications after major pancreatectomy remain controversial. The aim of this study was to assess whether early drain removal after major pancreatectomy influences the incidence of complications in patients with low and intermediate risk of postoperative pancreatic fistula (POPF).

Methods: This study is a prospective randomized single center trial. A total of 144 patients undergoing major pancreatectomy who met our criteria were randomly assigned to early (POD 3) drain removal (group A, n = 72) or standard (POD 5 or later) drain removal (group B, n = 72). The incidence of postoperative complications, in-hospital stay and total medical costs within 3 months were analyzed.

Results: Five patients in group A had at least one Clavien-Dindo grade 2-4 complication, compared to 15 patients in group B (P = 0.028). The occurrence of grade 2-4 intra-abdominal complications in group A was also significantly lower than those in group B (10 versus 22, P = 0.026). The incidence of grade B/C pancreatic fistula was not significantly different between two groups (2.8% versus 0%). There was also no significant difference in postoperative stay and total medical costs. Multivariate analysis demonstrated that early drain removal was an independent factor associated with a reduced risk of grade 2-4 complications (odds ratio, 0.314; 95% CI, 0.105–0.943, P = 0.039).

Conclusions: Early drain removal on POD 3 is safe and reduces the incidence of grade 2-4 complications in patients with low and intermediate risk of POPF after major pancreatectomy.

Morphogenesis of the Ventral Pancreas Anlagen Is Associated With Branching Variation of the SMA

Y. Dai,1 K. Kurosawa,1 K. Ren,2 Y. Miwa,3 I. Sato,1 T. Liu,4 X. Lu,4 S.Q. Yi.11Department of Frontier Health Sciences and 2Project Division for Healthcare Innovation, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan; 3Department of Anatomy, School of Life Dentistry at Tokyo, The Nippon Dental University, Tokyo, Japan; 4Department of Gastrointestinal Surgery, Huazhong University of Science and Technology, Wuhan, China.S

Background: Developmentally, uncinate process of the pancreas derives from the ventral pancreatic anlagen, supplied by the superior mesenteric artery (SMA), and distributing pancreatic polypeptide (PP) cells-rich islets of Langerhans. By contrast, the other parts of the pancreas originate from the dorsal one, supplied by the celiac trunk, with PP cells-poor islets. The purpose of this study is to confirm whether the morphogenesis of ventral pancreas anlagen is associated with the topographical features of the SMA.

Methods: 44 cadavers were employed to dissect the branches of the SMA, divided into two groups, SMA group and General group which the SMA gives off with or without any branches to the pancreatic body, respectively. In SMA group, the size ratio of the branch which originating from the SMA to the pancreatic body vs the SMA were calculated. After the gross dissection completed, the all pancreatic tissues were collected to perform HE stain and immunohistochemical experiment with PP and insulin antibodies.

Results: General group and SMA group were 25 cases and 19 cases, respectively. In SMA group, appearing PP cells-rich islets in the pancreatic body were confirmed in 10 out of 25 cases, while the size ratio of the branch vs the SMA in PP cells-poor cases (in 9 out of 25 cases) was significantly smaller than the PP cells-rich cases (P < 0.001). In General group, 3 out of 25 cases were confirmed there were PP cells-rich islets or PP cells group were scattered in the exocrine region of the pancreatic body.

Conclusions: Accompanying to the SMA supplied the pancreatic body, the distribution of PP cells appeared in Langerhans islet of the region, while the pancreas ventral anlagen also expanded to the region. It was suggested that morphogenesis of the ventral pancreas anlagen may be associated with the branching variation of the SMA.

Malignant Melanoma Associated With Type 1 Autoimmune Pancreatitis

K. Dainaka, Y. Koyama, Y. Sawai, K. Takemura, T. Takada, K. Suwa, Y. Sogame, H. Yasuda, J. Sakagami, Y. Ito.

Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan.

Background: Malignant melanoma is rare malignancy about 2 in 100,000 in Japan. Recent year, it has been discussed that type1 autoimmune pancreatitis (type1 AIP) is associated with malignant melanoma. However it has not been clarified.

Methods: We analyzed that 41cases of type1 AIP with or without malignant melanoma, between 2001 and 2019 in our hospital. We examined association of background factor between both group. The patients of type1 AIP defined definite diagnosis or probable diagnosis by Clinical Diagnostic Criteria for Autoimmune Pancreatitis 2011.

Results: There are 3 cases of malignant melanoma with type1 AIP. Other malignancy is 11 cases (gastric cancer in 3 cases, malignant lymphoma in 2 cases, esophagitis cancer, colon cancer, pancreatic cancer, prostate cancer, bladder cancer, uterine cancer) with type1 AIP. Referring to the data of Cancer Registry and Statistics in Japan, the poisson probability of malignant melanoma with AIP is only 6.2*10-7. According to the univariate analysis using Logistic-regression analysis and Fischer’s exact test, only “sex” (P = 0.02) is found to be a risk factor. However, it is difficult to find statistical significance of both group by the multivariate analysis.

Conclusions: Although there is not statistical risk factor of malignant melanoma among the cases of AIP, there is clearly higher incidence of malignant melanoma with AIP than without AIP.

A Novel Link Between Chronic Inflammation and Pancreatic Cancer

J. Davis,1 B. Cheng,1 Q. Yu,1 M. Younes,2 T.C. Ko,1 Y. Cao.1Department of 1Surgery and 2Pathology & Laboratory Medicine, UTHealth, Houston, TX.

Background: Chronic pancreatitis (CP) is a major risk factor of pancreatic ductal adenocarcinoma (PDAC). How CP promotes pancreatic oncogenesis is unclear. A characteristic feature of PDAC is a prominent desmoplasia in the tumor microenvironment, composed of activated fibroblasts and macrophages. Macrophages can be characterized as M1 or M2, with tumor inhibiting and promoting functions, respectively. We reported that Gremlin1 (Grem1), a key pro-fibrogenic factor, is upregulated in the stroma of CP. We hypothesize that within the pancreatic tumor microenvironment, inflammation-induced expression of Grem1 by fibroblasts stimulates M2 activation and promotes tumorigenesis.

Methods: Three commercial human pancreatic tissue microarrays were used, containing 11 cases of CP, 9 cases of pancreatic intraepithelial neoplasia (PanIN), and 98 cases of PDAC with pathological tumor stages 1-4. Grem1 RNA in situ hybridization was performed and scored 0-4. Immunohistochemistry was performed using α-smooth muscle actin (SMA), CD68, and CD163 as markers of fibroblasts, total macrophages (MCD68+), and M2 macrophages (M2CD163+), respectively. The most densely stained area per case was imaged and quantified by investigators blinded to case identities.

Results: Grem1 RNA expression overlaps with α-SMA, indicating an exclusive expression of Grem1 by fibroblasts. The FibroblastsGrem1+ increase from CP to PanIN to PDAC (1.09±0.56, 2.67 ± 0.47, 2.04 ± 0.14, P = 0.047), increase with PDAC pathological tumor stages (P = 0.032), and positively correlate with MCD68+ (Pearson r = 0.370, P = 0.0002) and M2CD163+ (Pearson r = 0.234, P = 0.020) cells in PDAC.

Conclusions: The progressive increase of FibroblastsGrem1+ from CP to PanIN to PDAC, and with PDAC pathological tumor stages, suggests that Grem1 may have biomarker potential for PDAC progression. The positive correlation of FibroblastsGrem1+ and MCD68+ and M2CD163+ in PDAC indicates that Grem1 may promote M2CD163+ activation during PDAC development.

Taken together, Grem1 may act as a novel link between chronic inflammation and PDAC. Further investigation on how FibroblastsGrem1+ activate M2CD163+ is warranted, with aim of therapeutic development.

Treatment With Reltecimod Significantly Reduces Inflammation in Mouse Model of Acute Pancreatitis

R. Dawra,1 Z. Yuan,1 V. Dudeja,1 R. Edgar,2 A. Shirvan,3 A. Saluja.11Department of Surgery and 2Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL; 3Atox Bio, Weizmann Science Park, Ness Ziona, Israel.

Background: Injury to pancreatic exocrine cells initiates both local and systemic inflammation. Systemic inflammation contributes significantly to distant organs damage resulting in complications associated with acute pancreatitis. Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) frequently occur in severely affected acute pancreatitis patients. Therapeutic interventions, which can dampen systemic inflammatory response and in turn protect distant organs, are desired. Reltecimod is a rationally designed synthetic decapeptide acting as a CD28 co-stimulatory receptor antagonist, attenuating the host’s inflammatory response. This study was designed to evaluate efficacy of reltecimod in cerulein (CER)-induced acute pancreatitis in mice.

Methods: Cerulein-induced acute pancreatitis was triggered by hourly injections of cerulein (50 μg/kg, i.p. ×12) in BALB/c mice. In treatment groups, reltecimod was administered i.v. either as single dose (of 5 or 10 mg/kg) or as double dose (of 5+5 or 10+5 mg/kg) at the time of initiation of injury, concomitantly with first cerulein injection. In double dose groups, second dose was administered at 3 h. Control group was administered saline (vehicle). Animal were euthanized 23 hours after first cerulein injection (12 hours after the last CER injection). Severity of pancreatitis was evaluated in the pancreas as well as in a distant organ, (lung).

Results: All animals survived to the scheduled termination time point. Treatment with reltecimod only (no CER) showed no effects on the clinical and histopathologic parameters tested. All measures were significantly higher in the CER treated mice, as compared to vehicle (saline) control, manifesting pancreatitis. Mice treated with reltecimod showed a substantial and statistically significant (P < 0.05) dose dependent improvement of inflammation, 12 hours after the last CER injection, as judged by (i) Reduced MPO activity in both the pancreas and the lung (up to 3-fold reduction) (ii) Reduced recruitment of lymphocytes to injured organs (observed in tissue histology), (iii) Decrease in the number of specific inflammatory cells (neutrophils and PMN).

Conclusions: Reltecimod treatment resulted in substantial reduction of inflammation in cerulein-induced acute pancreatitis in both pancreas and lung. This promising drug candidate should be investigated further in pre-clinical models and clinical set up of the disease.

When Should We Operate on Pancreatic Cysts Detected in High Risk Individuals (HRI)? Validating Proposed Criteria for Resection Using International Consensus Guidelines (ICG) and International Cancer of the Pancreas Screening (CAPS) Consortium Statements

M.H. Dbouk,1 O.I. Brewer Gutierrez,2 M. Goggins,1,2 A.M. Lennon,2 R. Hruban,1 M.I. Canto.2Departments of 1Pathology and 2Medicine (Gastroenterology), Johns Hopkins Hospital, Baltimore, MD.

Background: Pancreatic cysts are frequently detected in HRI undergoing surveillance. The management of these cysts can be challenging because of the risks of pancreatectomy and high-risk lesions (IPMN-HGD, PanIN-3, and early pancreatic ductal adenocarcinoma (PDAC)) may be difficult to diagnose. The International CAPS Consortium developed consensus recommendations for surgical resection of pancreatic cysts in HRI, based upon Fukuoka ICG for management of cysts in non-HRI, but with differences in main duct criteria. This study aimed to compare the accuracy of ICG and CAPS criteria for prediction of HGD or PDAC in HRI with pancreatic cysts.

Methods: Using prospectively collected data from CAPS1-5 cohort studies from 1998-2019, we identified, patients who underwent pancreatic resection for pancreatic cysts following multidisciplinary review. We determined for each patient whether the ICG or the CAPS criteria recommended surgery and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these criteria using surgical pathology as the reference standard.

Results: In total, 732 HRI were enrolled; 62 patients had surgery and 23 (56.5% females, mean age 63.2, 21.7% genetic mutation carriers) of these were for surveillance-detected cysts. Of the 23 HRI, 7 and 8 patients had features that required surgery per ICG and CAPS criteria, respectively. The sensitivity, specificity, PPV, NPV of the ICG for target lesions were 50%, 73%, 50%, and 73% and those of the CAPS criteria were 62%, 80%, 62%, 80%, respectively. Expanding the ICG to also recommend surgery for worrisome features increased the sensitivity to 90% but decreased the specificity to 15.3%. The PPV and NPV also decreased to 45% and 67%, respectively.

Conclusions: In a highly selected population of HRI, the CAPS criteria appear to minimize unnecessary surgery, but may miss HGD/PDAC. Refinement of criteria for surgical treatment of detected lesions is critical for patient management.

Endosonographic Changes in Asymptomatic Subjects With Diabetes Mellitus Mimic Those Seen in Chronic Pancreatitis: A Case-Control Study

J. de la Fuente,1 M.J. Levy,2 W.R. Bamlet,3 H. Kandlakunta,2 N. Takahashi,4 J.G. Fletcher,4 S.T. Chari,2 S. Majumder.2Departments of 1Internal Medicine, 2Gastroenterology and Hepatology, 3Health Sciences Research, and 4Diagnostic Radiology; Mayo Clinic, Rochester, MN.

Background: Diabetic exocrine pancreatopathy (DEP) is a term used to describe asymptomatic exocrine pancreatic fibrosis that is associated with diabetes mellitus (DM). Previously, we have demonstrated that endoscopic ultrasound (EUS) findings in DEP can overlap with those of chronic pancreatitis (CP). It is unclear if similar EUS changes are present in subjects without DM.

Methods: In non-DM patients (fasting glucose <126 mg/dl and/or HbA1c <6.5%) above age 50 years and without known pancreatic disease, undergoing a clinically indicated EUS, pancreatic findings were collected using standardized study forms. Patient demographics and EUS findings were compared to a case group of subjects with DM from a study aimed at examining the pancreas in patients of similar age with new onset diabetes and no known pancreatic disease (EXPAND study). Chi-Squared and Wilcoxon Rank Sum tests were performed for categorical and continuous variables, respectively.

Results: Twenty patients with DM and 20 non-DM controls had their pancreatic EUS findings recorded. Cases and controls were similar for age, sex, race, smoking status, and alcohol use. DM subjects had a significantly higher median BMI (33.3 vs 23.9, P = 0.0005). Based on Rosemont criteria, presence of EUS findings consistent with or suggestive of CP was significantly higher in cases vs controls (60% vs 5%; P = 0.002). EUS findings that were more common in DM included dilated side branches (P = 0.02), hyperechoic duct margin (P = 0.0004), and cysts (P = 0.04). Hyperechoic foci were present in all cases and controls and stranding was present in 79% (15/19) of patients in the DM group and 70% (14/20) of patients in the non-DM group (P = 0.5).

Conclusions: In asymptomatic individuals, EUS criteria for CP are more commonly present in patients with DM when compared to non-DM controls of similar age, likely due to DEP. In the absence of symptoms, EUS should not be used to make a diagnosis of CP.

Alcohol Worsens Organ Failure in Severe Acute Pancreatitis (AP) by Increasing Fatty Acid Bioavailability

C. de Oliveira,1 B. Khatua,1 S. Kostenko,1 M. Belohlavek,2 Stacie Vela,3 V.P. Singh.1Departments of 1Medicine and 2Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ; 3Division of Gastroenterology, Carl T. Hayden VA Medical Center, Phoenix AZ.

Background: Alcohol consumption is a major risk factor for severe acute pancreatitis (SAP) related multisystem organ failure and mortality. Non-esterified fatty acids (NEFA) are increased systemically in patients with SAP. However, the role of alcohol in lipotoxic AP is unclear. In this study, we measured the impact of alcohol on NEFA bioavailability in two mechanistically distinct AP models.

Methods: Mild AP was induced in Wistar male rats (120–180 gm) with cerulein (CER; 20 mcg/kg I.P., 2×/day, 3 days) or duct ligation (DL), alone or with ethanol (EtOH; 3 ml/kg as10% solution in saline I.P., once). SAP was induced by combining these with the triglyceride of the high prevalence NEFA oleic acid - glyceryl trioleate (GTO; at 3% body weight I.P., once). Untreated, EtOH and GTO controls were used for comparison. Animals were followed with daily vitals till 72 hours or moribund requiring euthanasia, which ever came first.

Results: The CER+GTO+EtOH (CGE) and DL+GTO+EtOH (DGE) groups had the worst outcomes with average survival of 35h and 11h, respectively vs the CER+GTO and DL+GTO groups with survival of 63 h and 33 h (P < 0.05). Just EtOH, GTO, CER±EtOH and DL±EtOH did not cause any mortality. CGE and DGE respectively caused shock, reducing carotid pulse distention from ~600 ± 59 μm to 369 ± 43 and 216 ± 40 μm after 8 h of AP (P < 0.05) which were lower than without EtOH (458 ± 40 and 251 ± 45 μm). Plasma NEFA increased from 121 ± 22 μM in controls to 756 ± 43 and 3643 ± 394 μM with EtOH (P < 0.005) vs 572 ± 75 and 2762 ± 115 μM without ethanol. Similarly, BUN increased from 12 ± 1.6 mg/dl to 72 ± 18 and 128 ± 33 mg/dl with EtOH vs without EtOH to 35 ± 7 and 81 ± 11 mg/dl. The worst outcome in the EtOH groups was followed by increase in amylase and pancreatic necrosis (10× and 2×).

Conclusions: Alcohol increases the systemic bioavailability of free fatty acids generated from visceral fat lipolysis, which causes multisystem organ failure thus converting AP to SAP.

Comparing the Efficacy of Nab-paclitaxel Plus S-1 With Gemcitabine-based Chemotherapy as First-line Strategy for Advanced Pancreatic Cancer

G.C. Deng, S.S. Guan, H. Yan, Q.L. Han, L. Yao, D.C. Sun, G.H. Dai.

Department of the General Hospital of the People’s Liberation Army, Beijing, China.

Background: Our phase II clinical trial (NPSPAC) showed that nab-paclitaxel plus S-1 as first-line treatment in advanced pancreatic cancer had encouraging objective response rate (ORR). In this study, we aim to retrospectively analyze the efficacy between the nab-paclitaxel plus S-1 and gemcitabine-based chemotherapy.

Methods: The 254 patients with advanced pancreatic cancer received at least 2 cycles chemotherapy with nab-paclitaxel plus S-1 or gemcitabine-based treated at PLA General Hospital from Jan. 2010 to Dec. 2017. We collected the information of patients’ general situation, baseline characteristics and chemotherapy regimens. Kaplan-Meier was applied to perform univariate analysis. Cox model was used to compute hazard ratio [HR] and 95% confidence interval [CI].

Results: In the 254 patients, the overall survival time from 0.7 months to 43.7 months, and 1-year survival is 30.4%.The medium overall survival (OS) of all patients is 10.9 months. In the nab-paclitaxel plus S-1 arm, there are 158 patients, and the medium OS is 11.6 months, the ORR is 50.7%. In the gemcitabine-based arm, the medium OS is 9.7 months; the ORR is 29.1%. In the gemcitabine-based arm, there are 37 patients with gemcitabine monotherapy, 5 patients with gemcitabine plus oxaliplatin, 7 patients with gemcitabine plus cisplatin, 28 patients with gemcitabine plus S-1 and 19 patients with gemcitabine plus nab-paclitaxel and the medium OS was statistically significantly longer for nab-paclitaxel plus S-1 vs gemcitabine monotherapy (11.5 vs 6.3 months; ORR, 50.7% vs 11.0%; HR, 0.70; 95% CI, 0.58–0.84; P < 0.001).Compared nab-paclitaxel plus S-1 with gemcitabine plus nab-paclitaxel, the medium OS was 11.5 vs 10.7 months; ORR, 50.7% vs 15.8%; HR, 1.15; 95% CI, 0.68–1.95, P = 0.598. And we also combined the four chemotherapy regimens (gemcitabine, gemcitabine plus, oxaliplatin gemcitabine plus cisplatin, and gemcitabine plus S1) to compare with nab-paclitaxel plus S1, the result showed that the medium OS was 9.3 vs 11.6 months, respectively and ORR, 22.8% vs 50.7%; HR, 0.75; 95% CI, 0.55–1.01; P = 0.061.

Conclusions: These data confirmed that the superior efficacy of nab-paclitaxel plus S-1 over gemcitabine alone. Also that nab-paclitaxel plus S-1 had better ORR than gemcitabine-based chemotherapy.

Challenges of the Current Precision Medicine Approach for Pancreatic Cancer: A Single Institution Retrospective Analysis

D. Ding, D. Laheru, C.L. Wolfgang, L. Zheng.

The Pancreatic Cancer Precision Medicine Center of Excellence Program, the Johns Hopkins University School of Medicine, Baltimore, MD.

Background: Recent researches on genomic profiling of pancreatic ductal carcinoma (PDAC) have identified some actionable alterations. However, genomic profiling is still not a clinical standard for PDAC patients. The feasibility and efficiency of using genomic profiling in real world to guide clinical decision making for PDAC patients are still unclear.

Method: We retrospectively reviewed PDAC patients who underwent treatment and clinical next-generation sequencing(NGS) tests between October 2013 and December 2017 at the Johns Hopkins Medical Institute. Potential actionable alteration, the clinical treatment and response were analyzed. Based on the problems we found in the study, a real-time clinical genomic testing system with potential actionable alteration flagging was explored to assist clinical decision making.

Results: We included 92 patients with 93 tumor samples. A majority (78.3%) were tested through Foundation Medicine. Fourty-eight (52.2) patients had curative surgery. A majority of 64.5% of the samples were from primary tumors (42 from surgery samples and 18 from EUS-FNA). The median time from sample obtained to genomic test ordered was 229 days (IQR, 62–415 days), and 12 (IQR, 10–13 days) from genomic test ordered to test result reported. There were 17 (18.5%) patients had BRCA1 or BRCA2 mutations, 15/17 (88.2%) patients were treated with platin-based chemotherapy. Within 12 evaluable patients, 5 (41.7%) patients had progressive response, 6 (50%) had stable disease. Four (23.5%) patients were given PARP2 inhibitor (3 in clinical trial and 2 with off-label use) and 2/4 (50%) had progressive response.

Conclusions: The genomic profiling guided personalized treatment for PDAC patients is feasible, but percentage of patients who benefited is still low. Some of the manageable issues are the long turn-around time from sample obtained to genomic results available, lack of real-time and evidence based system to help with potential targetable alteration based treatment. A real-time genomic test ordering and evidence based potential targetable alteration notification system is intensely needed.

2-HF Sensitizes Human Pancreatic Cancer Cells to EGFR Inhibitors by Inhibiting STAT3 Pathway

S.B. Dong, Y.Y. Yue, Q.Y. Ma, Z. Wu, Z. Wang.

Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancy and chemotherapy is still an important treatment. It is urgent to develop new medicine because of the restricted and side effect of chemotherapy. 2-Hydroxyflavanone (2-HF) is a citrus-bioflavonoid that is considered has anti-cancer efficacy.

Methods: We choose the human pancreatic ductal epithelial cell line hTERT-HPNE, cancer cell lines BxPC-3, MIA PaCa-2 and KPC mice as models to study the 2-HF. Cell lines were treated with 2-HF (0-90 μM) and cell viability was determined by MTT assay. The potent antiproliferation and proapoptotic effects were tested by colony formation assays, Hoechst 33258 staining, cell flow cytometric analysis. The potent anti-metastatic effects were detected by wound healing, transwell migration and invasion assays. The western blot analysis, immunohistochemical and immunoflurescence assay were applied to reveal the inhibition of the IL6/STAT3 signaling and change of molecular markers.

Results: Compared to hTERT-HPNE, more significant growth- inhibitory effects were seen in PDAC cell lines. Treatment with 2-HF induced apoptosis and caused cell cycle arrested in a dose-dependent manner. The expression of molecular proteins cleaved PARP, cleaved caspase3, BAX, BCL2, CyclinD1, P27 changed correspondingly, on the other side, we observed the anti-metastatic effects and the change of MMP9, E-cadherin, N-cadherin, Vimentin if cells were treated by low dose of 2-HF. Suppression of the phosphorylation of STAT3 and EGFR were also identified as a result of the treatment with a combination of 2-HF and EGFR inhibitors. The in vivo anti-tumor effects of KPC mice was consistent with in vitro.

Conclusions: 2-HF has impactful anti-cancer efficacy and sensitizes human pancreatic cancer cells to EGFR inhibitors through inhibition of STAT3.

Overcoming Therapeutic Resistance in Pancreatic Cancer Through Inhibition of Interleukin-1α

A.R. Dosch, X. Dai, S. Mehra, B. Willobee, F. Messaggio, S. Srinivasan, N. Nagathihalli, N. Merchant.

Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.

Background: Pancreatic ductal adenocarcinoma (PDAC) has dismal overall survival rates due to innate and acquired therapeutic resistance. The desmoplastic stroma of PDAC not only impairs drug delivery and effector immune cell infiltration, but engages in tumor-stromal crosstalk through soluble cytokines which can promote chemoresistance. We have recently identified interleukin-1α (IL-1) as an inflammatory mediator in PDAC which promotes therapeutic resistance, however the mechanisms underlying this process remain unknown. The purpose of this study was to investigate the molecular mechanisms of IL-1-mediated chemoresistance and explore the therapeutic potential of targeting IL-1 to improve response to chemotherapy in PDAC.

Methods: Murine K8484 PDAC cells were utilized for these experiments. Cytokine profile in cancer-associated fibroblasts (CAFs) treated with IL-1 was examined by cytokine array. K8484 cells overexpressing IL-1 (IL1AORF) were cocultured with CAFs and pluripotency gene expression (NANOG, OCT4, and MYC) were characterized. Changes in cancer stem cell (CSC) surface marker CD133+ and EdU proliferation were delineated by flow cytometry. To explore the in vivo potential of inhibition IL-1, Ptf1acre/+;LSL-KrasG12D/+;Tgfbr2flox/flox (PKT) mice were treated with IL-1 receptor antagonist (IL-1ra, 25 mg/kg QD) +/- gemcitabine (GEM, 10 mg/kg QOD). Tumor size/weight were characterized at the conclusion of treatment and histologic analysis performed on resected tumors.

Results: IL-1 exposure in murine CAFs resulted in a marked increase in IL-6 secretion. CAF coculture with IL1AORF clones resulted in STAT3 activation in tumor cells, increased pluripotent gene expression, enhanced proliferation, and promoted the expression of CD133. These effects were abrogated by pretreatment with neutralizing IL-6 antibody. PKT mice treated with GEM and IL-1ra exhibited reduction in CD133+ cells, reduced circulating IL-6 levels, and had significantly reduced tumor size and weight.

Conclusions: These data suggest that IL-1 promotes a chemoresistant phenotype in PDAC through the induction of stromal-derived IL-6 and demonstrate the therapeutic potential of targeting IL-1 to improve outcomes in PDAC.

Molecular Mechanisms Underlying Crosstalk Between Fibroblasts and Macrophages in Pancreatic Tumorigenesis

M. Drake,1 B. Yang,1 J. Davis,1 M. Younes,2 Y. Cao,1 T.C. Ko.1Departments of 1Surgery and 2Pathology & Laboratory Medicine, UTHealth, Houston, TX.

Background: Pancreatic ductal adenocarcinoma (PDAC) is known for its desmoplastic microenvironment containing activated fibroblasts and macrophages. We reported that activated pancreatic fibroblasts secrete Gremlin1 (Grem1), a key pro-fibrogenic factor in chronic pancreatitis. Grem1 has been shown as an endogenous inhibitor of macrophage migration inhibitory factor (MIF) in atherosclerotic disease. MIF stimulates classical activation of macrophages (M1) which are tumor-inhibiting. In contrast, alternatively activated macrophages (M2) are tumor-promoting. We reported that M2 positively correlate with Grem1 in PDAC (Abstract #3647). We hypothesize that upregulation of Grem1 during chronic pancreatitis blocks MIF, promoting M2 activation and pancreatic tumorigenesis. As a first step to test this hypothesis, we profiled expression patterns of these interrelated molecules in human PDAC.

Methods: A commercial human pancreatic tissue microarray containing 70 PDAC cases with pathological tumor stages 1-4 underwent Grem1 RNA in situ hybridization, and immunohistochemistry (IHC) staining of α-smooth muscle actin (activated fibroblasts), MIF, CD68 (total macrophages), and CD163 (M2). The most densely stained area per case was imaged and quantified by two investigators blinded to case identities. MIF/CD163 co-staining was further performed and multiple images per case were quantified. Data analysis was performed to identify correlations.

Results: MIF is mainly expressed in tumor cells, and Grem1 in activated fibroblasts. MIF is positively correlated with Grem1 in PDAC (r = 0.32, P < 0.01), but not correlated with CD68 or pathologic tumor stage. MIF showed an inverse trend with CD163, but was not significant. The subsequent MIF/CD163 co-staining confirmed a negative correlation between MIF and CD163 (r = -0.29, P < 0.001).

Conclusions: The contrasting correlations, negative for MIF vs CD163, but positive for Grem1 vs CD163, suggest Grem1 may block MIF activity to promote M2 activation in PDAC. Further investigation is warranted into the interaction between Grem1 and MIF, and its impact on M2 activation and pancreatic tumorigenesis.

Canine Pancreatic Acinar Cell Butyrylcholinesterase (Pseudocholinesterase, BCHE) and Basolateral Exocytosis of Pancreatic Enzymes Inhibit Digestive Protein Synthesis in Response to Cholinergic Stimuli

T.D. Dressel.

Department of Surgery, University of Minnesota, MN.

Background: Lampel reported acute interstitial pancreatitis and acinar cell vacuolization in rats induced by excessive doses of pancreatic secretagogue. Scheele reported in rats, a secretagogue dose dependent decrease in the release of amylase into the pancreatic duct, a concomitant increase in acinar cell vacuolization and basolateral exocytosis of enzymes into the interstitial space. Butyrylcholinesterase is synthesized, stored, and secreted by the canine acinar cells in an active form. Canine pancreatic juice BCHE activity is 15 times greater than serum BCHE activity. Unlike Acetylcholinesterase, which is membrane bound, Butyrylcholinesterase is water soluble, and on that basis, is transportable into the interstitial space via basolateral exocytosis.

Methods: The principals of modern control theory were applied to a model of the acinar cell that incorporates the basolateral transport of pancreatic enzymes, along with BCHE, into the interstitial space.

Results: The gross acinar cell vacuolization and basolateral exocytosis seen under the conditions of supramaximal stimulation occurs, to a less obvious extent, under physiologic levels of stimulation. The mechanism of transporting BCHE into the interstitial space acts as a closed loop, negative feedback inhibitor of secretagogue induced pancreatic digestive protein synthesis. In fact, a canine model of anticholinesterase induced pancreatitis was developed with increased serum amylase and lipase levels, gross pancreatic edema, and acinar cell vacuolization. This occurs two hours after administration of the anticholinesterase insecticide Diazinon 50 mg/kg. That dose results in the complete inhibition of acinar cell BCHE activity.

Conclusions: The human pancreas does not synthesize BCHE, but acute pancreatitis occurred in a woman poisoned by Diazinon, a serine protease inhibiter. This suggests that the human pancreas synthesizes different secretagogue specific inhibitory enzymes, (CCKase, Gastrinase). If such secretagogue specific inhibitory enzymes exist in the human pancreas, they will be: serine proteases, water soluble and synthesized in an active form.

Malignant Insulinoma: A Retrospective Study Analyzing the Distinct Clinicopathological and Prognostic Features

B.Q. Du, X. Wang, Q.Q. Tan, X.B. Liu.

Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China.

Background: Malignant insulinoma is extremely rare and accounts for 4%-14% of total insulinoma cases, the rarity of which limits reports on therapeutic strategies and outcome. This study aimed to verify the distinct clinicopathological and prognostic features of malignant insulinoma.

Methods: In this retrospective analysis, we collected data pertaining to malignant insulinoma diagnosed in 110 patients with insulinoma at our institution from January 2000 to January 2015. We analyzed the demographic characteristics, clinical presentations, operative strategies, follow-up outcomes and differences between benign and malignant diseases.

Results: Malignant insulinomas were found in 13 patients (11.8%) included four males and nine females (vs benign: P = 0.513) with a mean age of 43 (30–53) years (vs benign: P = 0.347). 10 patients (76.9%) had developed metastases at diagnosis, 3 patients (23.1%) developed tumor recurrence during the follow-up. All patients had symptoms of neuroglycopenic (100%). Of the 13 patients, 7 (53.9%) underwent distal pancreatectomy, 2 (15.4%) underwent enucleations, and the rest (30.7%) underwent pancreaticoduodenectomy. A total of 87.5% of the patients had one primary pancreatic lesion that was in the head (38.5%), body and tail (61.5%) of the pancreas (vs benign: P = 0.089) with diameters ranging between 0.8 and 6.1 cm (mean diameters was 3.4 ± 1.7 cm; vs benign: P = 0.017). Median survival was 47 months (mean survival was 58.3 ± 51.1 months; vs benign: P < 0.0001). Most patient (80%) displayed total or partial relieved of hypoglycemia after surgery with a 5-year survival of 46.1% (vs benign: P < 0.0001) and 10-year survival of 7.6% (vs benign: P < 0.0001).

Conclusions: Surgical resection can significantly alleviate the symptoms of patients with malignant insulinoma, while the prognosis is worse than benign insulinoma, which requires long-term postoperative follow-up and comprehensive therapies to alleviate hypoglycemic symptoms and extend patients’ survival.

Epidermal Growth Factor Receptor Targeting Peptide Nanoparticles Simultaneously Deliver Gemcitabine and Olaparib to Treat Pancreatic Cancer With Breast Cancer 2 (BRCA2) Mutation

C. Du,1,2 Y. Wang,2 X. Tian,2 G. Nie,3 Y. Yang.21Department of Oncology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China; 2Department of General Surgery, Peking University First Hospital, Beijing, China; 3CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, National Center for Nanoscience and Technology, Beijing, China.

Background: The current treatment regiments for pancreatic cancer (PCa) have a low response rate in unselected patients. However, the subgroup of PCa patients with BRCA mutations could benefit from poly-ADP-ribose polymerase inhibitors (PARPi) due to their biological properties in DNA repair. Dose-limiting toxicity in normal tissues is frequently observed when PARPi are combined with other chemotherapies, and the co-delivery of two drugs to tumor sites at an adequate concentration is challenging.

Methods: An epidermal growth factor receptor (EGFR) targeting (with GE11 peptide) self-assembly amphiphilic peptide nanoparticle (GENP) was engineered to co-deliver gemcitabine and the PARPi olaparib to treat BRCA mutant PCa. Transmission electron microscopy, dynamic light scattering and high performance liquid chromatography were used to characterize the GENP. Cell targeting ability was determined by flow cytometer and confocal microscopy. DNA double-strand breaks were examined via immunofluorescence and western blot analysis of γ-H2AX. Pharmacokinetics and drug concentration in tumor tissue were investigated in the PCa-bearing mice. Anti-tumor effect was evaluated in both subcutaneous and orthotopic PCa mouse models.

Results: The GENP was relatively stable, exhibited high encapsulation efficiency, and could coordinately release the two drugs in tumor milieu. Gemcitabine and olaparib showed strong synergistic actions in optimized conditions in vitro. The nanoparticle prolonged the half-life of both drugs and resulted in their tumor accumulation at the optimal therapeutic ratio in vivo. The drug-loaded nanoparticles were able to significantly suppress tumor growth in murine PCa models with minimal side effects.

Conclusions: Drug co-delivery of DNA damaging agents and PARP inhibitors via the GENP represents a promising approach for treatment of pancreatic cancers with molecular defects at DNA repair pathway.

Efficacy of Recombinant Human Soluble Thrombomodulin (rTM) in Preventing WON in Severe Acute Pancreatitis Patients Using Inverse Probability of Treatment Weighting (IPTW) Method

T. Eguchi,1 Y. Tsuji,2 S. Ikeoka,1 A. Okadai.11Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan; 2Shiga University of Medical Science Japan, Otsu, Japan.

Background: We previously reported that rTM suppressed WON in severe acute pancreatitis (SAP) patients with disseminated intravascular coagulation (DIC). However, it has been compared in two groups of SAP patients with different degrees of severity. Therefore, we adjustment the patient background by the IPTW method to examine whether rTM administration leads to depress WON.

Methods: We retrospectively analysed 91 SAP patients treated from January 2006 to January 2016 at Osaka Saiseikai Nakatsu Hospital. The 91 SAP patients were divided into two groups: SAP patients with DIC treated with rTM (the rTM group, 53 patients) and without DIC and without rTM (Control group, 38 patients). The propensity score is measured based on the background factors which had a significant difference, the background adjustment by the IPTW method. The relationship between rTM administration and WON was examined by univariate analysis.

Results: rTM group was significantly more severe than that of those in Control group on admission day; (CRP, APACHEII, SIRS, ratio of SAP on JPN criteria, Extrapancreatic progression of inflammation score, DIC score, P < 0.05). Although the rTM group was more severe than Control group, the rate of development of WON was no different between the two groups (49.1% [26/53] vs 52.6% [20/38]). Regarding the relationship between rTM administration and WON, in the original data, the odd ratio (95% CI) was 0.867 (0.361–2.082) and there was no significant difference. However, when examined in the group with the patient background aligned with IPTW, the odd ratio was 0.243 (0.066–0.896) and the rTM was significantly different in leading to suppression of WON (P < 0.05).

Conclusions: rTM administration may be contribute to suppression of WON.

Acute Pancreatitis CT Severity Index (CTSI) Versus Modified CT Severity Index (MCTSI) for the Prediction of Severe Acute Pancreatitis: A Systematic Review and Meta-analysis

B. El Kurdi,1 S. Babar,1 M. El Iskandarani,1 I. Haddad,1 M. Alomari,1 M. Young.2Departments of 1Internal Medicine and 2Gastroenterology and Hepatology, East Tennessee State University, Johnson City, TN.

Introduction: In 1994, Balthazar et al introduced CTSI to stratify acute pancreatitis (AP) according to severity. Due to the inability of CTSI to correlate with extrapancreatic complications, a modified CTSI was introduced in 2004. We found multiple studies comparing CTSI to MCTSI for the prediction of AP outcomes. We therefore conducted a systematic review and meta-analysis to evaluate the predictive ability of CTSI/MCTSI for AP outcomes.

Methods: A computerized search was conducted in Pubmed, EMBASE, and Cochrane databases from inception through March 2019 for studies comparing CTSI to MCTSI for the prediction of AP severity. Relevant data was extracted and analyzed using open meta-analysis software. Random-effects model was used. No publication bias found on Egger’s test.

Results: Five studies examining 422 patients were included. A “severe” classification in either CTSI or MCTSI carried an increased risk for AP complications with OR (95% CI), 12.2 (6.1–24.6) for mortality, compared to 15.4 (8.2–29) for pancreatic infection and 16.2 (10–26.4) for organ failure. While the sensitivity (Sn) of CTSI and MCTSI for prediction of mortality was similar; 70.9% (0.36–0.91), 74.6% (0.54–0.88), respectively. Specificity (Sp) of CTSI was higher 87.6% (0.78–0.93) compared to 72.6% (0.59–0.83) for MCTSI. For the prediction of organ failure, MCTSI’s Sn was 74.5% (0.55–0.88) compared to 44.4% (0.30–0.60) for CTSI. However, CSTI showed better Sp 92.8% (0.77–0.98) compared to 82.7% (0.66–0.92) for MCTSI. As a predictor of pancreatic infection, MCTSI showed higher Sn 82.4% (0.46–0.96) compared to 52.8% (0.24–0.80) for CTSI. However, CTSI had superior Sp 89.9% (0.79–0.96) compared to 78.8% (0.67–0.87) for MCTSI.

Conclusions: Both severity indices conferred increased risk of mortality, pancreatic infection and organ failure. MCTSI showed a pattern for higher Sn while CTSI showed better Sp across the board. While MCTSI might decrease missed complications (low false negatives), it is associated with higher false positive results. CTSI however, might be associated with missed complications due to false negatives but a more reliable positive result.

Dietary Fat Composition and Male-sex Rather Than Obesity May Be Associated With Increased Acute Pancreatitis (AP) Severity

B. El Kurdi,1 B. Khatua,2 K. Patel,2 D. Faigel,2 V.P. Singh.2Department of 1Internal Medicine, East Tennessee State University, Johnson City, TN; 2Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ.

Introduction: The association between obesity and severe acute pancreatitis (SAP) is controversial. We found several references studying this association with marked heterogeneity in obesity definition and conflicting results. Therefore, we performed a meta-regression to determine the confounders resulting in this heterogeneity.

Methods: We searched PubMed form inception through January 2017 for studies correlating obesity to SAP. Relevant data was extracted and analyzed using comprehensive meta-analysis software. Random-effects model was used. Heterogeneity was assessed using the I2. Publication bias was assessed using Egger’s test. Meta regression considering age, sex, AP etiology, per-capita-GDP, unsaturated fat proportion of dietary fat (%UFA) and absolute saturated fat (SFA) consumed in respective countries.

Results: In 20 studies evaluating 3956 patients, SAP prevalence was 20% (16–25%) (I2 = 90%). The BMI cut-off used to define obesity (>25 vs >30) did not significantly alter the OR of SAP; 2.9 (1.5–5.5), 2.6 (1.7–3.9), respectively. Meta-regression of SAP rate reported in studies showed a positive correlation with male sex (P = 0.01) and %UFA (P = 0.004). Correlation with male-sex and %UFA were able to explain 21% and 33% of the heterogeneity in SAP rate, respectively. Neither age, AP etiology, or per-capita-GDP correlated with SAP. Multivariate meta-regression showed largely independent effects of male-sex and dietary fat consumption on SAP rate; a model of combined %UFA and male-sex was able to explain 44% of heterogeneity between studies with less than 4.5% overlap between the two covariates. SFA was negatively correlated to SAP (P = 0.01) and able to explain 28% of heterogeneity, and up to 40% when combined with male-sex with less than 5% overlap.

Conclusions: We note based on international data from 20 studies, that male-sex and dietary fat composition were independently associated with SAP and were able to explain 40-44% of the heterogeneity in SAP rate noted between studies. This might indicate that visceral fat composition rather than amount might be responsible for AP severity.

Outcomes of Total Pancreatectomy With Islet Autotransplantation (TPIAT): A Systematic Review and Meta-analysis

B. El Kurdi,1 S. Babar,1 M. El Iskandarani,1 M. Young.2Departments of 1Internal Medicine and 2Gastroenterology and Hepatology, East Tennessee State University, Johnson City, TN.

Background: TPIAT is a last resort procedure for the management of chronic pancreatitis pain uncontrolled by medical or endoscopic means. Despite its increased use over the past decade, systematic evidence on its outcomes remains limited. We therefore, conducted a systematic review and meta-analysis to evaluate the outcomes of TPIAT.

Methods: We searched the Pubmed, EMBASE, and Cochrane databases from inception through March 2019 for studies on the outcomes of TPIAT. Relevant data was extracted and analyzed using comprehensive meta-analysis software. Random-effects model was used for all variables. Heterogeneity was assessed using the I2 measure and Cochrane Q-statistic. Publication bias was assessed using Egger’s test.

Results: Twenty-one studies published between (1980-2017) examining 1011 patients were included; 18 studied adult while three studied pediatric populations. Insulin-independence post procedure was achieved in 31.8% (95% CI, 26%–38%) of adults with considerable heterogeneity (I2 = 64%) compared to 47.7% (95% CI, 20%–77%) in children (I2 = 82%). Narcotic-independence was achieved in 53.5% (95% CI, 45%–62%) of adults (I2 = 81%) compared to 51.9% (95% CI, 17%–85%) in children (I2 = 84%). HbA1c 12 months post-surgery was reported in four studies evaluating adult populations with a pooled value of 6.76% (standard error, 0.27). Neither stratification by age of studied population nor meta-regression analysis considering (publication date) or (islet-cell-equivalent/kg weight) were able to explain the marked heterogeneity between studies.

Conclusions: We found 31.8% of adults were insulin-independent post procedure compared to 47.7% of children. About half the patients in both age-groups achieved narcotic-independence post procedure. HbA1c was 6.76% 12 months post-surgery. These results indicate acceptable success for TPIAT. While our meta-analysis spanned 37 years, and a vast number of publications, data on TPIAT outcomes remain sparse. Future studies should evaluate the discussed measures before and after surgery for comparison. Clear definitions of patient populations, surgical procedures as well as post-surgical care are needed to limit heterogeneity in outcomes.

Pancreatitis Related Pseudoaneurysms: Systematic Review on Causes, Diagnosis, and Management

M. Elkhouly,1 C.R. Simons-Linares,2 P. Chahal.2

1Internal Medicine Department, John Stroger Hospital of Cook County, Chicago, IL; 2Gastroenterology and Hepatology Fepartment, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Background: Pancreatitis related pseudoaneurysm (PSA) formation results from autodigestion of arterial walls caused by the release of pancreatic enzymes during pancreatitis. In this review, we analyzed the data collected from published case reports and series, on common presentation of pancreatitis related PSA, affected vessels, management and outcomes.

Methods: A MEDLINE search (1955-2019) of the English literature was performed looking for all human case reports and series with a pancreatitis related PSA. All published cases were reviewed by 2 physicians. Patients were divided into 2 groups: 1) acute/recurrent pancreatitis and 2) chronic pancreatitis, according to the type of pancreatitis preceding the development of PSA. Both groups were compared for the cause of pancreatitis, vessel involvement, symptoms, treatment and outcomes.

Results: Total of 457 PSA in 438 patients were included in the review. Most of the patients had chronic pancreatitis (260 patients, 59.4%). Alcohol was the most common etiology of pancreatitis (257 patients, 58.7%). Splenic artery (33.7%) was the most common vessel involved, followed by gastroduodenal artery (20.1%). Total of 68.3% had a bleeding PSA. Most common site of bleeding was into the pancreatic duct causing hemosuccus pancreaticus (60.8%). Mortality in group 1 was 11.8% vs 5.4% in group 2. Overall mortality was 8%. Causes of death were sepsis (33.3%), multiorgan failure (19%) and bleeding (19%) in group 1; compared to bleeding (42.9%), PE (21.4%), and multiorgan failure (21.4%) in group 2. Angioembolization was performed in 55% of patients as initial therapy, while surgical intervention was necessary in 23.7%. Favorable outcome was reported in 92% at mean follow up of 7.3 months.

Conclusions: Mortality in patients with PSA is significantly higher in acute or recurrent pancreatitis compared to chronic pancreatitis. This review summarizes the published data on pancreatitis related pseudoaneurysms, providing clinicians with guide towards clinical presentation, management and outcomes of PSA.

Complex Interactions Between GGT1, UBR1, and Moderately Severe Risk Pancreatitis Variants

M. Ellison,1 D. Spagnolo,1 C. Shelton,1 E. Orlova,2 J. LaRusch,1 D.C. Whitcomb,3 M. Haupt.1

1Ariel Precision Medicine, Pittsburgh, PA; 2Department of Human Genetics and 3Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA.

Background: Chronic pancreatitis (CP) is the end stage of a pathologic chronic inflammatory syndrome of multiple genetic, metabolic, and environmental factors. The genetic etiology of a large proportion of CP is complex. Multiple mechanistic pathways linked to genetic variants are known. We hypothesized CP requires injury initiation and failure of compensatory mechanisms in stress response genes.

Methods: One hundred consecutive idiopathic pancreatitis patients undergoing clinical genetic testing with a deep sequencing pancreatitis panel (PRSS1, PRSS2, PRSS1-2 risk haplotype, CPA1, CEL, CFTR, SPINK1, CTRC, UBR1 and GGT1) were evaluated. Variants were classified according to ACMG guidelines and allele frequencies were compared to those of healthy populations, such as gnomAD and 1000 Genomes. Variants observed in at least 2% of patients were tested for co-occurrence within genetic loci and between genes using Fisher’s exact test. Variant interaction networks were organized by gene, haplotype, cell type, and biological mechanisms. Gene-gene interactions were further evaluated using single cell RNA-sequencing (scRNA-Seq) data from the GEO repository.

Results: Co-occurrence analysis revealed genetic interactions between CFTR and GGT1 variants, and PRSS1-2 and UBR1 variants. Unique CFTR-GGT1 (n = 11; P < 0.05) and PRSS1-2-UBR1 interactions were detected (n = 4; P < 0.05). Common co-occurrences included the CFTR p.Trp1282X with an intronic variant in GGT1. PRSS1-2 variants co-occurred with intronic variants in UBR1 regulatory elements. ScRNA-Seq data demonstrated GGT1 expression was generally limited to pancreatic duct cells, with noted co-expression of GGT1 and CFTR within the duct cells. Similarly, PRSS1-2 and UBR1 were co-expressed.

Conclusions: CP is a complex disorder caused by genetic interactions across multiple genes and cell types. Altered GGT1 expression appears to be associated with CFTR-related disorders while altered UBR1 expression may be linked with pancreatic cell stress responses. Continuing efforts are ongoing to better understand and replicate these findings in additional populations.

Hepatic Arterial Infusion Chemotherapy for Liver Metastases in Pancreatic Cancer Following the Standard Chemotherapy: A Case Report

S. Endo,1 S. Kawaguchi,1 S. Terada,1 N. Shirane,1 H. Kanemoto.2Departments of 1Gastroenterology and 2Surgery, Shizuoka General Hospital, Shizuoka, Japan.

Background: Recurrent pancreatic cancer (RPC) is generally well known to have a poor prognosis. Chemotherapy is the standard therapy for RPC, but it has limited efficacy, and has serious adverse effects. Hepatic arterial infusion chemotherapy (HAIC) is a treatment strategy that involves local delivery of anticancer drugs into the nutrient vessel of a tumor directly through an implantable port, aimed at increasing the concentrations of drugs locally in order to reduce the systemic adverse effects. We report a case of HAIC for RPC that was limited to liver metastases following the standard chemotherapy.

Case: A 65-year-old Japanese man initially diagnosed with locally advanced pancreatic cancer underwent distal pancreatectomy and combined portal vein resection following neoadjuvant chemoradiation (30Gy/10Fr+ S-1 for 10 days) in September 2017. A month after surgery, contrast-enhanced magnetic resonance imaging revealed multiple liver metastases. Initially, we administered two courses of GEM plus nab-PTX; however, there was no response, and we could not continue treatment because of grade 3 neutropenia. Thereafter, we administered 17 courses of modified FOLFIRINOX. However, as grade 3 neutropenia recurred, we had to administer G-CSF concomitantly. In addition, renal dysfunction, neuralgia, and dysgeusia (grade 1 each) were observed. As the residual tumor was limited to liver metastases, we administered HAIC using GEM plus 5-FU after obtaining approval from the ethical review board in October 2018. We administered a total of 14 courses of the regimen. Progression-free-survival was 7 months, and no drug-related adverse effects were noted during treatment. The overall status of the patients was quite good until May 2019.

Conclusions: HAIC may be a useful technique for administration of chemotherapy for RPC that is limited to liver metastases.

Very High Rates of Pancreatic Fluid Collections in Patients With the Triad of Hypertriglyceridemia-induced Acute Pancreatitis and Diabetes Ketoacidosis

J. Estevez, C.R. Simons-Linares, T. Stevens, P. Chahal.

Gastroenterology and Hepatology Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Background: The triad of hypertriglyceridemia (HTG) induced acute pancreatitis (AP) coexisting with diabetes ketoacidosis (DKA) has been reported. Outcomes of pancreatic fluid collections (PFCs) in this population has not yet been studied.

Methods: Cohort study of a prospectively maintained AP database. Study groups were: AP-only vs HTG-AP + DKA, AP + DKA, and HTG-AP. Primary outcome was inpatient mortality, morbidity (SIRS, ICU, AKI, ARDS), severity of AP and complication of AP. Multivariable logistic regression models were constructed.

Results: Over two thousand patients were reviewed, of whom 124 patients had the triad (HTG-AP, DKA), 100 had HTG-AP only (triglyceride levels >1000 mg/dL), 67 had AP +DKA and we included 101 with AP-only (control) for the analysis. Patients with HTG-AP +DKA had higher rates of PFCs 59% compared to AP-only 22%, HTG-AP 29% and AP +DKA 20% (P < 0.001). HTG-AP +DKA were more likely to have acute peripancreatic fluid collections (APFC) 46% compared to AP-only 17%, HTG-AP 19%, and AP +DKA 13% (P < 0.001). HTG-AP were more likely to have pseudocysts 11% compared to AP-only 4%, HTG-AP +DKA 4%, and AP +DKA 2% (P = 0.06). No difference in PFC drainage was found (P = 0.97). Patients with AP+DKA were more likely to develop AKI 63% compared to AP-only 8%, HTG-AP +DKA 34%, and HTG-AP 33% (P < 0.001). HTG-AP patients were more likely to have ARDS 25% compared to AP-only 2%, AP+DKA 10% and HTG-AP+DKA 17% (P < 0.001). HTG-AP were more likely to require enteral tube feeding and total parenteral nutrition. No difference inpatient mortality was found.

Conclusions: Patients with the triad of HTG-AP + DKA have significantly higher rates of pancreatic fluid collections. But PFCs seems to resolve in its own as there was not difference in interventions for the PFCs. Less aggressive strategy for PFCs management in this patient population can be followed.

Nutritional Status Assessment Using Bioelectrical Impedance Vector Analysis (BIVA) and Body Mass Index in Chronic Pancreatitis After Introduction of an Individualized Nutritional Therapy.

P. Estrada-Arzate,1 C. De Luna-Fregoso,1 P. Alarcon-Murra,1 A. Soriano-Ríos,1 M. Peláez-Luna,1,2 L. Uscanga Domínguez,1 J. Hernández-Calleros.11Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; 2Research división, Department of Experimental Medicine, Universidad Autónoma de México, Mexico City, Mexico.

Background: CP patients usually present malnutrition; nutritional evaluation is challenging, frequently determined by Body Mass Index (BMI). However it is not an objective method considering that it does not measure skeletal or fat mass and hydration status. The aim of our study is to compare BMI and BIVA to evaluate nutritional status in CP patients before and after nutritional intervention.

Methods: We prospectively included 70 patients with CP diagnosed between 1985-2018 at the pancreas unit. Fifty seven percent were men; mean age was 52.6 ± 14.7 years. BMI and body composition with BIVA were calculated. All patients were started on an individualized nutritional therapy. Diet compliance was assessed by 24-hour dietary recall. So far 35 patients have come back for follow up (FU) (3.2 ± 4.5 months) and have been included in final analysis.

Results: At baseline and FU: BMI was normal (18.5–24.9 kg/m2) 57.1% vs 60% (P = 0.674), underweight (<18.5 kg/m2) 11.4% vs 5.7% (P = 0.601) and overweight-obesity I (>25 kg/m2) 31.4% vs 34.4% (P = 0.437). BIVA at baseline and FU showed normal body composition in 40% vs 57.1% (P = 0.005), depletion of skeletal muscle mass 45.7% vs 31.4% (P = 0.030); no change in water overload before and after the intervention occurred (14.3%). In 20 patients with normal BMI the initial BIVA was normal in 8, water overload in 2, and low skeletal muscle mass in 10. At FU in 21 patients with normal BMI the BIVA was normal in 11, 4 water overload, and 6 depletion of skeletal muscle mass. Differences between initial and FU BIVA were statistically significant (P = 0.002).

Conclusions: BMI is not effective to evaluate nutritional status. BIVA is an effective and reliable nutritional assessment tool. Nutritional therapy improves body composition in CP.

Risk Factors and Outcome of Patients With Pancreatic Ductal Adenocarcinoma and Thromboembolism

A. Eurola,1 N. Mattila,1 R. Lassila,2,3 H. Mustonen,1 C. Haglund,1,4 H. Seppänen,1,4Departments of 1Surgery and 2Coagulation Disorders, Helsinki University Hospital, Helsinki, Finland; 3HUSLAB Laboratory Services, Clinical Chemistry, Helsinki, Finland; 4Translational Cancer Medicine Research Program, University of Helsinki, Helsinki, Finland.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most thrombogenic cancers and PDAC-patients are at 12-15% risk of venous thromboembolism (VTE). Chemotherapy is one of the risk factors for VTE. The purpose of this study was to investigate risk factors for thromboembolism in PDAC and to clarify the association between neoadjuvant treatment (NAT) and VTE.

Methods: PDAC-patients surgically treated in Helsinki University Hospital 2006-2016 were identified. Following data was collected: venous- and arterial thromboembolic events, BMI, neoadjuvant and adjuvant treatment, medication, resection marginal, tumor size, positive lymph node ratio, perivascular- and perineural invasion, surgical method, vascular reconstruction, other cancers, and postoperative stay in hospital. The follow-up was at least 2 years or until death. Patients with another cancer (n = 29), stage IV and inoperable disease (n = 54), lack of monitoring data (n = 2), or coagulation disorders (n = 1) were excluded.

Results: 313 patients were analyzed. 76 (24%) had NAT. 92 (29%) patients had a thromboembolic event (52 venous, 31 arterial, 21 multiple). Median disease-specific survival (DSS) for patients with VTE was 2.1 (95% CI, 1.5–2.7) vs 2.5 (2.1–3.0) years (P = 0.003). Median disease-free survival (DFS) with VTE was 0.9 (0.4–1.3) vs 1.1 (0.8–1.3) years (P = 0.001). In the NAT group median DSS with VTE was 1.7 (0.4–3.0) vs 3.6 (2.2–4.9) years (P = 0.001). Median DFS with VTE was 1.0 (0.4–1.6) vs 1.4 (0.9–1.9) years (P = 0.022). In the NAT vs the upfront surgery group 28% vs 22% had VTEs (P = 0.192). On multivariate analysis risk factors for VTE were BMI ≥25 (HR, 2.1; 95% CI, 1.20–3.68, P = 0.009) and disease progression (HR, 3.78; 95% CI, 1.43–9.93; P = 0.007).

Conclusions: VTE is associated with higher mortality and morbidity in local PDAC also when treated with neoadjuvant treatment. Disease progression and obesity are risk factors for VTE. Neoadjuvant treatment did not significantly increase the risk of postoperative thromboembolic event.

Clinical Outcomes of Patients With Acute Pancreatitis and Co-Existing Cirrhosis

N. Evans,1 J. Yeh,1 L. Hilson,1 B. Hiramoto,1 E. Baral,1 M. Quezada,2 J. Buxbaum.2Departments of 1Internal Medicine and 2Gastrointestinal and Liver Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA.

Background: The aim of this study was to define the clinical features and outcomes of patients with liver cirrhosis who develop acute pancreatitis.

Methods: The analysis included patients hospitalized at Los Angeles County Hospital from 2016-2018 for acute pancreatitis defined by epigastric pain and lipase>3× ULN and/or consistent imaging. The cohort was divided based upon the presence or absence of liver cirrhosis determined by the real time clinical assessment of the treating providers. Primary outcomes included hospital duration, ICU admission, ICU interventions, and death. Univariate and multivariate regression models were used to investigate the association between cirrhosis and the main clinical outcomes. The baseline demographic and clinical features of these groups were also compared.

Results: Among 844 patients admitted for acute pancreatitis, 46 had concomitant cirrhosis and 798 did not. Among cirrhotics, 62% had ascites and the average MELD score was 18 (7–37). Comparison of baseline features revealed that cirrhotic patients were more likely to be male (70% vs 51%), older (mean age 53 years [95% CI, 48–60] vs 45 [44–46]), and hypoalbuminemic (mean albumin 3.3 mg/dL [3.1–3.6] vs 4.2 [4.1–4.2]). There were no significant differences for cirrhotics versus noncirrhotics in the length of hospitalization (5.8 [95% CI, 3.3–8.7] days vs 5.7 [95% CI, 5.0–6.3] days), need for ICU admission (OR, 1.1; 95% CI, 0.5–2.5), ICU interventions (OR, 1.4; 95% CI, 0.3–6.1) or mortality (OR, 2.5; 95% CI, 0.3–20.9). Multivariate adjustment for age, albumin, and sex did not materially impact these results. Additionally, stratification for hospitalization <24 hours vs >24 hours and by MELD <17 or >17 did not materially impact these findings.

Conclusions: Patients with acute pancreatitis and cirrhosis are more likely to be older, male, and hypoalbuminemic compared to those without advanced liver disease. The presence of cirrhosis did not appear to impact the length of hospitalization, ICU stay, ICU interventions, or mortality.

Calcifications and Moderate to Marked Ductal Changes are Only Seen in Patients With Imaging Documented Acute Recurrent Pancreatitis

M. Faghih,1 N. Yahyapourjalaly,1 T. Boortalary,1 C. Fan,1 M. Gurkar,1 M.A. Makary,3 A.N. Kalloo,1 E. Afghani,1,2 M.A. Khashab,1 A. Zaheer,4 V.K. Singh,1,21Division of Gastroenterology, 2Pancreatitis Center, Department of Medicine, 3Division of Surgical Oncology Department of Surgery, 4 Division of Abdominal Imaging, Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD.

Background: Acute pancreatitis (AP) is often diagnosed on the basis of abdominal pain and elevations in pancreatic enzymes without abdominal imaging. However, neither pain nor enzyme elevations are specific for AP and recurrent presentations without confirmatory imaging may lead to a misdiagnosis of acute recurrent pancreatitis (ARP) and/or chronic pancreatitis (CP). Aim: To evaluate for findings consistent with definite CP among patients with definite, probable and possible ARP.

Methods: Adult patients referred with a diagnosis of ARP and/or CP between 2010-2019 were evaluated. Definite ARP was defined as ≥2 episodes of abdominal pain, elevated serum amylase and/or lipase ≥3× upper limit normal (ULN) and abdominal imaging showing changes or sequelae of AP. Probable ARP was defined as above but without any evidence of AP on abdominal imaging. Possible ARP was defined as ≥2 episodes of abdominal pain either with serum amylase and/or lipase levels that were normal or <3× ULN and without AP on abdominal imaging. This was included as a category as referring physicians had diagnosed and managed these patients as ARP. Definite CP was defined using the M-ANNHEIM criteria. Any patients with definite CP without a history of ARP were excluded.

Results: There were a total of 854 patients with ARP and/or CP with a mean age of 51.2 ± 14 years; 54.9% female; 75% white. There were 489 (57.2%) definite ARP, 162 (19%) probable ARP and 202 (23.7%) possible ARP with a similar mean duration of disease. Pancreatic calcification(s) and moderate to marked ductal changes were only seen in definite ARP. There were higher rates of exocrine insufficiency in definite ARP compared to probable (P = 0.02) and possible ARP (P = 0.005). Chronic opioid use was higher among the probable ARP compared to definite ARP (P = 0.0005) and possible ARP (P = 0.0002). All other characteristics including demographics, rates of alcohol use and smoking, diabetes, and BMI were similar between the 3 groups.

Conclusions: This study highlights the nonspecific nature of abdominal pain and enzyme elevations for the diagnosis of AP and suggests that current diagnostic criteria for AP may require revision.

Pain Modulatory Phenotypes Differentiate Chronic Pancreatitis Patients With Distinct Clinical Pain Profiles

M. Faghih,1 A.E. Phillips,2 I.M. Larsen,3 A.M. Drewes,3 V.K. Singh,1 D. Yadav,2 S.S. Olesen,31Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; 2Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 3Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.

Background and Aims: Pain is a common problem in patients with chronic pancreatitis (CP) and effective therapy remains a considerable challenge. Methods based on quantitative sensory testing (QST) provide information on pain modulation and have demonstrated promise in predicting future pain status and the efficacy of analgesics. The aims of this study were to evaluate the existence of CP subgroups with different pain modulatory phenotypes and to investigate associations with patients’ clinical pain and psychological profiles.

Methods: This was a cross-sectional, multicentre study of CP patients. Patients completed a number of questionnaires including the quality of life (QOL; PROMIS Global Health Scale and EORTC-QLQ-C30), modified Brief Pain Inventory short form, the Hospital Anxiety and Depression Score as well as measures of conditional and situational Pain Catastrophizing. All subjects underwent standardized QST assessments including a cold pressor test, a conditioned pain modulation paradigm, repetitive pin prick stimuli (temporal summation) and pressure stimulation of the upper abdominal (pancreatic) and control dermatomes. Patients were grouped based on normative QST reference values and questionnaire scores were compared across subgroups.

Results: A total of 91 patients were enrolled in the study. The mean age was 53.1 ± 12.7 y, 62% were men, and 65% had toxic etiology. Three distinct pain modulatory phenotypes were found: group 1 (n = 31) had normal pain modulation; group 2 (n = 17) had segmental sensitization; group 3 (n = 43) had widespread sensitization. Patients with widespread sensitization had higher pain score (P < 0.01) and lower QOL (P < 0.05) in comparison to segmental and normal. In contrast, psychological features were comparable across subgroups.

Conclusions: CP patients with widespread sensitization have significantly higher levels of pain and lower QOL. QST characterizes the sensory profiles independently of the patient’s psychological status and provides an unbiased proxy of pain processing. This information can be used for prognostication and tailoring of management strategies.

Pancreatic Atrophy Does Not Correlate With Fibrosis in Patients Undergoing Total Pancreatectomy With Islet Autotransplantation for Acute Recurrent and Chronic Pancreatitis

M. Faghih,1 M. Noe,2 R. Mannan,3 E. Afghani,1 A. Zaheer,4 I. Kamel,4 R. Kalyani,5 E. Hall,5 D. Warren,6 N. Desai,6 Z. Sun,6 C. Walsh,7 M. Makary,7 J. He,7 V.K. Singh,1,81Division of Gastroenterology and 2Sidney Kimmel Comprehensive Cancer Center, Department of Oncology, Johns Hopkins Medical Institutions, Baltimore, MD; 3Division of Gastrointestinal, Liver and Pancreatic Pathology, Department of Pathology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA; 4Division of Abdominal Imaging, Department of Radiology, 5Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, 6Division of Transplant Surgery, and 7Division of Surgical Oncology, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; 8Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.

Background: Atrophy is often used to describe reductions in the volume of the pancreas and is reported as an imaging feature of chronic pancreatitis (CP). However, there is no objective definition of atrophy in patients with CP and it is not known whether there is a correlation with fibrosis.

Aim: To evaluate the relationship between pancreatic atrophy and fibrosis in patients undergoing total pancreatectomy with islet autotransplantation (TPIAT) for acute recurrent pancreatitis (ARP) and CP.

Method: All adult patients who underwent TPIAT between 2010-2019 were evaluated. Patients were classified into 3 groups: definite CP (n = 29), probable CP (n = 16) and ARP (n = 15). 3D CT imaging of the abdomen was used to calculate pancreatic volume by summing up the volume from each thin section of the pancreas. Normal pancreas volume was defined as 85.2 ± 26.9 cc for males and 63.0 ± 20.5 cc for females based on a prior large study utilizing a similar method for volume assessment (Saisho Y et al. Clin Anat 2007). Pancreatic atrophy was defined as the volume below the normal limit (mean-1 standard deviation). Excisional biopsies of the pancreatic head as well as body/tail region were obtained at the time of the TPIAT. Fibrosis scores were determined as per Amman criteria. Pericelluar fibrosis, interlobular fibrosis, collagen content, sublobular atrophy and lobular atrophy were scored separately.

Results: A total of 60 patients underwent TPIAT. The mean pancreatic volume for definite ARP, definite CP and probable CP were 61.9 ± 23.6 cc, 54.7 ± 23.6 cc and 86.5 ± 25 cc (P =0.08). There were 20 patients with and 40 patients without pancreatic atrophy. There were no significant differences regarding age, sex, BMI, and etiology between patients with and without pancreatic atrophy.

Conclusions: Pancreatic atrophy is commonly seen in patients with CP; however, there is no correlation between pancreatic atrophy and fibrosis.

Preceding Acute Pancreatitis is Found in the Majority of Patients With Definite Chronic Pancreatitis by The M-ANNHIEM Diagnostic Criteria

M. Faghih,1 N. Yahyapourjalaly,1 T. Boortalary,1 C. Fan,1 M. Gurkar,1 M.A. Makary,2 A.N. Kalloo,1 E. Afghani,1,3 M.A. Khashab,1 A. Zaheer,4 V.K. Singh,1,31Division of Gastroenterology, Department of Medicine, 2Division of Surgical Oncology, Department of Surgery, 3Pancreatitis Center, Department of Medicine, and 4Division of Abdominal Imaging, Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD.

Background: A recent study questioned the ‘SAPE’ hypothesis of chronic pancreatitis (CP) reporting that only 50% of patients with CP had a history of acute/recurrent acute pancreatitis (AP/RAP). However, it is not clear how many patients had definite CP as calcifications and/or advanced ductal changes were not reported.

Aim: To determine the prevalence of preceding AP/RAP in patients with definite CP evaluated in a large specialty referral clinic.

Methods: Adult patients referred with a diagnosis of CP between 2010-2019 were evaluated. All medical records and imaging studies from prior AP admissions were prospectively obtained and reviewed at our institution prior to clinic consultation. Definite CP was defined as the presence of calcification(s) on CT imaging and/or moderate to marked ductal changes on MRCP/ERCP (M-ANNHEIM diagnostic criteria). Exocrine insufficiency and/or typical histology were only found in patients with either of the aforementioned criteria. AP was defined as upper abdominal pain, serum amylase and/or lipase ≥3× upper limit normal and abdominal imaging showing changes and/or sequelae of AP (e.g. pseudocyst) if imaging was obtained after hospital discharge. ARP was defined as 2 or more episodes of AP.

Results: There were 355 patients with definite CP among whom 114 (32%) had calcification(s) only, 126 (35.4%) had moderate to marked ductal changes only and 115 (32%) had both. The mean age was 50 ± 13 years; 54% male; 70% white; and 44.7% had an alcohol and/or smoking etiology. AP/ARP was found in 300 (84.5%) patients with definite CP. All patients were followed for a mean of 5.7 ± 2 years. Among the 55 (15.5%) definite CP patients with no prior history of AP/ARP, 15 (34%) patients had a history abdominal pain for which they were not hospitalized and 9 (16%) had diabetes.

Conclusions: Approximately 85% of patients with definite CP by the M-ANNHEIM diagnostic criteria have preceding AP/RAP.

The CRP/Alb Ratio Predicts Survival and Monitors Chemotherapeutic Effectiveness in Patients With Advanced Pancreatic Cancer

Z.Y. Fan,1,2,3,4 X.Y. Yu,1,2,3,4 C. Liu,1,2,3,4 G.P. Luo,1,2,3,41Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; 2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; 3Shanghai Pancreatic Cancer Institute, Shanghai, China; 4Pancreatic Cancer Institute, Fudan University, Shanghai, China.

Background: The CRP/Alb ratio, a recently reported predictor, has shown value for prognosis in various human cancers. However, for patients with advanced pancreatic cancer, the role of the CRP/Alb ratio in predicting survival and monitoring chemotherapy responses has not yet been elucidated.

Methods: Five hundred and ninety-five patients diagnosed with locally advanced or metastatic adenocarcinoma of the pancreas were enrolled. Cut-off Finder was used to calculate the best cut-off value for baseline CRP/Alb. The primary endpoint was overall survival, which was analyzed by Kaplan-Meier survival curves with 95% confidence intervals. The log-rank test and Cox proportional hazard model were used to evaluate the univariate and multivariate analyses.

Results: The optimal cut-off value for baseline CRP/Alb was determined to be 0.18. Both the baseline CRP/Alb (CRP/Alb ≥0.18 vs CRP/Alb <0.18; hazard ratio [HR], 2.506; P < 0.001) and post-chemotherapy CRP/Alb (CRP/Alb ≥0.18 vs CRP/Alb <0.18; HR, 1.854; P = 0.002) were significant predictors of overall survival according to multivariate analysis and were independent of other factors. Patients with a baseline and post-chemotherapy CRP/Alb ≥0.18 had the worst prognosis.

Conclusions: CRP/Alb is a strong and useful indicator of prognosis for advanced pancreatic cancer. Both baseline and post-chemotherapy CRP/Alb can be used in predicting the survival of patients and monitoring the effectiveness of chemotherapy in clinical practice.

COPII Dependent ER Export and Its Regulation in ZG Biogenesis and Acinar ER Homeostasis

J. Fang, H. Pang, X. Chen.

Department of Physiology, Wayne State University, Detroit, MI.

Background: Zymogen granule (ZG) proteins are produced in the endoplasmic reticulum (ER), exported to the Golgi and then packaged into ZGs. The molecular mechanisms by which ZG proteins exit ER and how this process is regulated are poorly understood.

Methods: Adenovirus expressing human chymotrypsin C (CTRC)-mCherry was used to monitor ZG protein processing/trafficking. Wild type (wt) and dominant negative Sar1 mutant adenoviruses were used to study COPII (coat protein complex II) dependent ER exit. An in vitro COPII vesicle budding assay was developed using permeabilized AR42J cells. Experimental acute pancreatitis was induced by i.p. injections of cerulein and pancreatic sections were immunostained with anti-COPII antibodies.

Results: Confocal microscopy and CCK-stimulated secretion assay indicated CTRC- mCherry targeted to ZGs. Dominant negative, but not wt, Sar1 caused cellular CTRC- mCherry accumulation; abolished CCK-stimulated CTRC-mCherry secretion; and reduced its glycosylation. In vitro COPII budding assay showed that amylase and CTRC- mCherry were packaged into COPII vesicles. Defective COPII dependent ER export induced ER stress in acinar cells. In tissue immunostaining, COPII proteins displayed a punctate localization throughout acinar cytoplasm consistent with their assembly on the ER exit sites (ERES). In addition, COPII proteins were also found on vesicular tubular clusters adjacent to the cis-Golgi network. Importantly, at the onset of cerulein-induced acute pancreatitis, localization of COPII on ERES was significantly reduced and the vesicular tubular staining of COPII was abolished. Instead, COPII was found redistributed to the cytosol by immunostaining and was confirmed by Western blotting on membrane/cytosol fractions.

Conclusions: CTRC-mCherry can monitor soluble ZG protein trafficking and secretion. COPII dependent ER export is required for ZG biogenesis and is a critical component of acinar ER homeostasis. Supramaximal stimulation with cerulein disrupts COPII coat assembly on the acinar ER membrane and COPII vesicle transport between ER and cis- Golgi.

Severe Diabetes-related Complications and Pancreatic Cancer Incidence in the Multiethnic Cohort

A.J. Farias,1,2 J. Porcel,1 K.R. Monroe,1 S.J. Pandol,3 V.W. Setiawan,1,21Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA; 2Norris Comprehensive Cancer Center, Los Angeles, CA; 3Division of Gastroenterology, Departments of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: Individuals with diabetes are at an increased risk of developing pancreatic cancer. However, it is unclear whether those who experience worsening diabetes are at an even greater risk. Our objective was to investigate the association between severe diabetes-related complications and risk of pancreatic cancer.

Methods: A nested case-control analysis was conducted among the fee-for-service Medicare participants of the prospective Multiethnic Cohort (n ≈ 123,000). Between 2001-2014 we identified 433 incident cases of pancreatic cancer and 1728 individually matched controls based on birth year, sex, race/ethnicity, and age at cohort entry. We used information from baseline questionnaires with linked data from the California and Hawaii SEER cancer registries and Medicare claims. We calculated the diabetes complications severity index (DCSI) using ICD-9-CM codes for the presence of 7 diabetes-related complications within two-years of diagnosis date of the index case. Multivariable conditional logistic regression was used to examine the association of DCSI with pancreatic cancer incidence adjusting for demographic, lifestyle, and other comorbid characteristics.

Results: There were 45.4% of cases and 34.1% of controls with diabetes. The most prevalent diabetes-related complications for cases were cardiovascular disease (61.2%), nephropathy (31.2%), and cerebrovascular disease (21.7%). Of the cases, 32.8% had a DCSI score of ≥4 compared to 21.2% for controls. In the multivariable analyses, individuals with diabetes (OR, 1.51; 95% CI, 1.16–1.95), nephropathy (1.72, 1.29–2.27), cardiovascular disease (1.92, 1.49–2.48), and metabolic disease (6.63, 2.51–17.51) were at increased risk of pancreatic cancer. For every 1-unit increase in DCSI score, participants had a 19% greater risk of pancreatic cancer (1.19, 1.12–1.26).

Conclusions: The results suggest that Medicare participants with a combination of diabetes-related complications have an elevated risk of pancreatic cancer than those with diabetes alone or no complications. The role of diabetes-related complications in the etiology of pancreatic cancer deserves further investigation.

Mastl, a Novel Therapeutic Target for Pancreatic Cancer Progression

I. Fatima,1 S. Barman,1 S. Chauhan,1 J.P. Uppada,1 G. Talmon,2 A.B. Singh,1,3,4 S.K. Batra,1,4 P. Dhawan,1,3,4Departments of 1Biochemistry and Molecular Biology and 2Pathology, University of Nebraska Medical Center, Omaha, NE; 3VA Nebraska-Western Iowa Health Care System, Omaha, NE; 4Buffet Cancer Center, University of Nebraska Medical Center, Omaha, NE.

Background: Anti-cancer treatments act primarily by damaging the DNA of cancer cells. Upon DNA damage, cells stop proliferation at cell cycle checkpoints, which provides them time for DNA repair. Hence, pharmacological inhibition of checkpoint kinases in combination with the DNA damaging anti-cancer therapies (chemotherapy or radiotherapy) is now emerging as promising cancer treatment strategy. In this regard, pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal malignancies with a frightening resistance to chemotherapeutic and targeted approaches. Here, along with a key role of KRAS-dependent signaling, receptor tyrosine kinases especially the EGF receptor (EGFR) signaling is strongly upregulated in PDAC. Importantly, Greatwall (Mastl in human; Microtubule-associated serine/threonine-protein kinase-like) promotes normal G2-mitosis transition and is highly upregulated in multiple cancer types and demonstrated to associate with therapy resistance. However, status of Mastl expression in PDAC and its potential role in pancreatic cancer progression and/or therapy resistance remains unknown. Our central hypothesis is that MASTL expression is (a) involved in cancer progression and intrinsic drug resistance and (b) constitutes a potential therapeutic target for PDAC.

Methods: We used immunoblotting, immunohistochemistry and TCGA database analysis to examine Mastl expression and its association with pancreatic cancer progression, and patient survival. Normal and pancreatic cancer cells were used. Genetic and pharmacological manipulations for Mastl expression were performed. ERB family members expression, tumorigenic and invasive activity were determined.

Results: A robust increase in Mastl expression was found in pancreatic cancer cells compared with the non-transformed pancreatic cells. A similar upregulated expression of Mastl was noted in samples originating from KPC mouse model of PDAC (immunoblotting and the IHC). Analysis of the human pancreatic cancer samples and the TCGA database strongly supported these outcome and suggested a positive association of the Mastl expression with cancer progression and patient mortality. Additional, the shRNA silencing of MASTL expression as well as the GKI treatment (MASTL inhibitor) in pancreatic cancer cells induced cell cycle arrest and apoptosis in vitro and inhibited xenograft-tumor growth in vivo. Interestingly, genetic inhibition of Mastl expression in pancreatic cancer cells not only inhibited the ability of these cells to proliferate and invade through the matrix but also inhibited EGFR activation. Further studies revealed that overexpressing K-ras/mutant p53 pathway in HPNE cells (untransformed pancreatic cells) modulates Mastl expression thus suggested a causal correlation with K-Ras/EGFR signaling in pancreatic cancer cells.

Conclusions: Our results suggest a cross talk of Mastl with K-ras/EGFR signaling pathway in pancreatic cancer progression. We hypothesize that combinatorial therapy targeting Mastl along with Gemcitabine would overcome the drug resistance in the PDAC. Thus, this study identifies a novel approach for the treatment of tumors resistant to traditional EGFR inhibitors.

Improving Diagnostics of Pancreatic Ductal Adenocarcinoma Via Tumor Targeted Wormhole Silica Particles With Optoacoustic Tomography

B.L. Fouts,1,2 M.W. McNally,1,2 P. Chuong,3 L.R. McNally,1,21Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC; 2Department of Biomedical Engineering, University of Oklahoma, Norman, OK; 3Department of Medicine, University of Louisville, Louisville, KY.

Purpose: Advanced pancreatic ductal adenocarcinoma (PDAC) suffers from inadequate early detection, inoperability, and available chemotherapeutics and contrast agents which are inefficacious. Nanoparticles may be used as tunable and targetable therapeutic vehicles treating and detecting such cancers. We hypothesize that pH-sensitive mesoporous silica nanoparticles functionalized with pancreatic tumor targeting ligand (V7) and near-infrared dye can prove to be effective as an exogenous contrast agent for detection of pancreatic cancer via multispectral optoacoustic tomography.

Methods: Wormhole pore architecture mesoporous silica particles were (W-MSN) synthesized by sol-gel chemistry and characterized by transmission electron microscopy (TEM) and dynamic light scattering (DLS). The surface of the W-MSN particle was cross-linked with the gatekeeper molecule chitosan, loaded with IR780 contrast agent, and targeted with V7 peptide to result in V7-CW-MSN dual acidic pH-targeted nanoparticle. Female athymic mice orthotopically implanted with S2VP10 or MIA PaCa-2 human pancreatic cancer cells (3 mm tumor size) were intravenously injected with V7-CW-MSN carrying IR780 dye and were imaged with MSOT using the in Vision 512TF.

Results: Wormhole particles (W-MSN) of 50 ± 10 nm delivered IR-780 contrast agent to pancreatic ductal adenocarcinoma in an orthotopically implanted S2VP10L human PDAC tumor in a murine model. V7-CW-MSN demonstrated 2x preferential dye release at pH 6.6 than 7.4 as well as excellent cellular uptake in terms of fluorescent and optoacoustic signal (14× and 7× signal increase at pH 6.6 than 7.4). In vivo bio-distribution confirmed that V7-CW-MSN could detect orthotopic pancreatic tumors (P < 0.0001, n = 5) which closely resemble human pancreatic ductal adenocarcinoma pathophysiology.

Conclusions: PDAC-targeted peptide and polymer functionalization of a wormhole silica nanoparticle enabled specific binding to PDAC cells and pH dependent release of internalized IR-780 contrast agent for detection by the MSOT imaging modality. These results inform design principles for clinical nanovehicles and aid development of high impact clinical treatment options for pancreatic adenocarcinoma patients.

ASAP2, a Downstream of Src Pathway is a Brand New Molecular Target of Pancreatic Cancer

A. Fujii,1,2 T. Masuda,1 S. Kuramitsu,1 A. Kitagawa,1 M. Noda,1 Y. Tsuruda,1 Y. Matsumoto,1 H. Ohtsu,1 H. Uchida,1 T. Ohtsuka,2 M. Nakamura,2 K. Mimori.1

1Department of Surgery, Kyushu University Beppu Hospital, Beppu, Japan; 2Department of Surgical Oncology, Kyushu University, Fukuoka, Japan.

Background: ASAP2 is a type of ADP-ribosylation factor GTPase-activating protein, which forms a stable complex with Src and functions as a downstream target of Src pathway that promotes proliferation and invasion of cancer cells. Here we investigated how ASAP2 affects the malignant phenotype of PC.

Methods: We examined the ASAP2 expression in 176 cases of PC using TCGA dataset and immunostaining. To explore biological effect of ASAP2, proliferation, cell cycle, and migration assay were performed in vitro. We further examined which pathway ASAP2 affects in development of pancreatic cancer.

Results:ASAP2 expression is higher in PC compared to normal tissue and the high expression group showed poorer prognosis significantly. Immunostaining showed high expression of ASAP2 in PC cells. Depletion of ASAP2 by siRNA and knockout using a CRISPR/Cas9 showed a significant decrease of colony formation ability, cell proliferation, cell cycle progression, migration activity, and phosphorylation of Epidermal Growth Factor Receptor (EGFR) of PC cells.

Conclusions:ASAP2 contributes to malignant phenotype of PC by activating migration activity and proliferation through promotion of cell cycle progression possibly via activation of EGFR.

Comparison of Pancreatic Exocrine Status Between Patients With Cystic Fibrosis in Pediatric and Adult Age in Japan

K. Fujiki,1 S. Kondo,2 M. Nakakuki,3 Y. Kozawa,3 A. Yamamoto,3 Y. Takeyama,4 S. Naruse,5 H. Ishiguro,31Department of Nutrition, Nagoya University of Arts and Sciences, Nisshin, Japan; 2Department of Health and Science, Nagoya Women’s University, Nagoya, Japan; 3Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan; 4Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan; 5Miyoshi Municipal Hospital, Miyoshi, Japan.

Background and Aim: Cystic fibrosis (CF) is the most common autosomal recessive disease in Europeans. It’s very rare in Asian population including in Japanese. Although the median survival for CF patients is ~23 years in Japan, a small group of patients survive longer. Since the relationship between pancreatic exocrine status and survival is not clear in CF patients in Japan, in this study, we have compared the clinical features of pediatric and adult patients.

Subjects and Methods: Twenty-nine patients (14 male and 15 female; mean age 14 years) with definite CF were evaluated. Fecal pancreatic elastase (PE) was measured by ELISA.

Results: 20 of 23 pediatric (<18 years of age) patients was pancreatic insufficient (PI) (fecal PE <200 μg/g,) and 3 pediatric patients was pancreatic sufficient (PS) (fecal PE ≥200 μg/g). 1 of 6 adult (≥18 years of age) patients was PI and 5 adult patients was PS. These 5 adult PS patients had chronic pulmonary disease or sweat [Cl-] was high. The ratio of PI and PS was significantly different between pediatric and adult patients (P < 0.01).

Conclusions: These data suggest that the existence of PI is one of the risk factors for mortality in CF patients in Japan.

Effectiveness of MRSA Active Surveillance for Pancreatic Resection

N. Fujimoto, J. Shimizu, K. Noguchi, K. Dono.

Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan.

Background: Although there is relatively little MRSA infection in post-pancreatectomy infections, when combined with a pseudoaneurysm, it is fatal and a major problem. In our hospital, all cases of nasal MRSA carriage have been investigated using PCR immediately after pancreatic resection for 10 years. We report the relationship between MRSA nasal carriage and postoperative MRSA infection.

Methods: The subjects were 212 cases of pancreatectomy (154 cases of pancreatoduodenectomy, 58 cases of distal pancreatectomy) performed at our hospital from 2011 to 2019. The incidence of surgical site infection and the frequency of MRSA postoperative infection were examined.

Results: MRSA nasal carriage positive was observed in 12 cases (5.7%, Group M). The incidence of SSI in group M and MRSA nasal carriage negative cases (Group N) did not differ significantly between 50.0% and 47.5% (P = 0.90). However, the frequency of MRSA infection in patients with SSI was 66.7% and 2.1%, respectively, with a statistically significant difference (P < 0.01).

Conclusions: The incidence of SSI in MRSA nasal carriage patients during pancreatectomy is similar to that in negative patients, the frequency of MRSA infections in SSI patients in group M is higher than in group N.

Analysis of Change in Size of Pancreatic Cystic Lesion Less Than 10 mm in Diameter

T. Fujimoto, O. Inatomi, S. Shintani, Y. Takeda, A. Andoh.

Department of Gastroenterology, Shiga University of Medical Science, Otsu, Japan.

Background: As aging progressed, opportunities for imaging examinations increased. As a result, pancreatic cystic lesions are often found by chance. Among the cystic lesions, there are various disease states such as those with risk of malignant transformation such as IPMN, and benign lesions such as simple cysts that do not require follow-up. Differential diagnosis of small asymptomatic cystic lesions is not always easy, and follow-up varies depending on the guidelines. We retrospectively analyzed cases that were diagnosed with a pancreatic cyst of 10 mm or less at our hospital and were able to follow the course.

Methods: We analyzed the patient's background, lesion site, diagnosis, and size transition, for patients diagnosed with a pancreatic cyst of 10 mm or less at our hospital and able to follow for more than 12 months.

Results: There were 83 cases with a mean age at diagnosis of 68 years and a mean follow-up of 40 months. At the time of diagnosis, the average diameter of the cyst was 7.4 mm. Thirty-six patients (43%) were diagnosed with IPMN by CT, MRCP, and EUS. An increase was seen in 5 cases (6%) of all cases, and 4 cases were diagnosed with IPMN. There were no indications for surgery or death due to a pancreatic cyst.

Conclusions: Although there were some cases in which cysts with a diameter of 10 mm or less at the time of diagnosis increased over time, there were no cases of death due to pancreatic cysts. Although follow-up was necessary, it was suggested that it might not be necessary to repeat short-term detailed examinations, especially in cases where simple cysts are suspected. In the future, it is necessary to examine the course of cases that do not satisfy the diagnosis of IPMN and to establish an appropriate surveillance method.

Usefulness of Continuous Glucose Monitoring for the Patients With Pancreatic Diabetes Mellitus

T. Fujita,1 M. Yanagimachi,1 H. Nakayama,1 M. Yamaichi,1 E. Sato,1 A. Matsumoto,1 Y. Matsuhashi,1 Y. Tando,2 M. Daimon,1 N. Teruo,31Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; 2Division of Medical Life Science, Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan; 3Health Care Center, Hirosaki Medical Association, Hirosaki, Japan.

Background: In patients with pancreatic diabetes mellitus (PDM) it’s difficult to maintain a high quality glycemic control and good nutritional status because of pancreatic endocrine and exocrine insufficiency. In this study, we performed a retrospective evaluation of glycemic control and nutritional status in patients with PDM after the total pancreatectomy.

Methods: We intended for eight patients with PDM after the total pancreatectomy that evaluated glucose profile using CGM (Continuous Glucose Monitoring). We evaluated the dose of pancreatic enzyme and insulin, HbA1c, body mass index (BMI), serum albumin, total cholesterol, Hounsfield Unit (HU) attenuation of liver and area of the psoas major muscle (PMMA) as measured on a CT scan.

Results: From the data of CGM, the mean blood glucose level was 161.5 ± 56.2 mg/dl. The hypoglycemic frequency was higher in the nighttime (6 pm-6 am) than in the daytime (6 am-6 pm) (1.7% vs 0.7%, P < 0.05). The frequency of nocturnal hypoglycemia more than 5% was observed in 3 cases, those showed higher diurnal variation in blood glucose and mean of daily differences, on the other hand HbA1c levels controlled less than 7.5%. Postoperative BMI was slightly declined, but other clinical nutrition data was not getting worse as compared with preoperative data.

Conclusions: To avoid hypoglycemia and maintenance of good nutritional status, it is important to provide insulin replacement therapy after sufficient caloric intake and the administration of the pancreatic enzyme in patients with PDM. Also, it is necessary to regulate the insulin dose and quantity of snack using blood glucose monitoring.

Intraductal Papillary Mucinous Neoplasm of Pyloric Gland Type: It Significantly Differs From Gastric Foveolar Type

Y. Fukumura,1 J. Nakahodo,1 Y. Maimaitiaili,1 S. Kishikawa,1 T. Fujisawa,2 H. Isayama,2 A. Saiura,3 M. Takase,4 T. Yao.

1Departments of 1Human Pathology, 2Gastroenterology, and 3Hepatobiliary Pancreatic Surgery, Juntendo University, Tokyo, Japan; 4Department of Pathology of Koshigaya Municipal Hospital, Saitama, Japan.

Background: Clinicopathological features of pancreatic intraductal papillary mucinous neoplasm (IPMN) are diverse and depend much on histological subtypes. We recently reported that gastric pyloric gland (PG)-type IPMN, i.e. IPMN of gastric subtype in which pyloric-type tumor glands predominantly proliferate) is often over treated since benign PG-IPMN frequently shows high risk stigmata according to IPMN guideline (IAPCG2017), such as marked dilatation of main pancreatic duct (MPD) and high tumor papilla. In this study, to help overtreatment of benign PG-IPMN and to lead to the correct diagnosis of PG-IPMN, we aimed to clarify clinicopathological features of PG-IPMN.

Methods: Surgically resected, serial 80 cases of IPMNs, including 17 GP-, 36 gastric foveolar (GF)-, 17 intestinal (INT)-, 5 oncocytic (ONC)-, and 6 pancreatobiliary (PB)-subtypes were used. (i) Imaging features, including duct type, enhanced mural nodule, (ii) histological data, including concomitant IPMN subtypes, association of malignancy, upstream pancreatic atrophy, (iii) immunohistochemically data, including MUCs, CDX2, smad4, and p53, (iv) mutational status of KRAS and GNAS were collected. These data were compared between PG-IPMNs and other-IPMNs, and benign PG-IPMNs and malignant PG-IPMNs.

Results: (i) Mean age of PG-IPMN patients was 70.9 y (range, 34–80), and male/female was 10/7. Surgical procedure for PG-IPMN were pancreatoduodenectomy for 14 cases and distal pancreatectomy for 3 cases. Two cases were MPD-type, 4 were branch duct type, and 11 were combined duct type. (ii) Thirteen, two, and two PG-IPMNs were low grade, high grade, and high grade with invasive adenocarcinoma. Seven cases contained area of GF-IPMN and 4 cases had INT-IPMN. (iii) GNAS/KRAS mutation were detected in 77.3%/66.7% of GP-IPMNs. (iv) malignant PG-IPMNs often showed wider distribution and harbored markedly atrophic upstream pancreas compared to benign PG-IPMNs.

Conclusions: PG-IPMNs should be regarded as a distinct subtype from other 4 IPMN subtypes, since high risk stigmata for malignancy is different for PG-IPMN from others.

CFTR Expression and Activity in Fetal Pancreatic Ducts

G. Fűr,1 L. Kiss,1 Z. Balla,1 E.R. Bálint,1 E.S. Kormányos,1 B. Czira,1 P. Pallagi,2 N. Pásztor,3 L. Kaizer,4 V. Venglovecz,5 J. Maléth,2 P. Hegyi,6,7 Z. Kozinszky,8 Z. Rakonczay, Jr.11Department of Pathophysiology, 2First Department of Medicine, Departments of 3Obstetrics and Gynecology, 4Pathology, and 5Pharmacology and Pharmacotherapy, and 6MTA-SZTE Momentum Research Group, University of Szeged, Szeged, Hungary; 7Institute for Translational Medicine, University of Pécs, Pécs, Hungary; 8Department of Obstetrics and Gynecology, Blekinge Hospital, Karlskrona, Sweden.

Background: Our possibilities for investigating the function of human pancreatic ducts and their regulation by CFTR are limited. Basically, we can only obtain pancreatic tissue samples from transplant patients or from patients with pancreatic diseases. Our aim was to study CFTR expression and activity in fetal pancreatic ducts.

Methods: Aborted human fetal pancreata were collected at 14-23 gestational weeks (GW). Tissue samples were taken for pancreatic duct isolation and for immunohistochemistry of ductal proteins (CFTR, SLC26A6, and CK-19). Staining of proteins was analyzed with ImageJ software. Functional measurements were performed on duct cells using intracellular pH measurement and whole-cell patch clamp technique.

Results: Immunohistochemical staining showed that CFTR and CK-19 protein expression was co-localized in human fetal pancreata from 14 GW. CFTR expression was significantly lower at 14-15 GW than at 22-23 GW. In the case of CK-19 expression, there was no significant difference between any of the GW. SLC26A6 staining did not show co-localization with the CK-19 protein. In functional measurements, the slope (ΔpH/min) of intracellular pH recovery from alkali load was significantly lower at 15-16 GW than at 20-22 GW. We also found that cAMP-dependent stimulation of CFTR channels was dependent on the fetal GW. Patch clamp measurement on duct cells derived from a 19-GW fetus demonstrated cAMP-agonist-stimulated CFTR Cl- currents.

Conclusions: CFTR expression was observed in human fetal pancreata from 14 GW. Ductal CFTR activity could be detected and stimulated with cAMP activation. The results obtained so far provide a good basis for the use of human fetal pancreatic tissues for further studies.

Study on the Validity and Long-term Prognosis of Elective Surgery for Chronic Pancreatitis

Y. Futagawa,1 T. Okamoto,1 K. Abe,1 M. Kanehira,1 K. Yanaga.2

1Department of Surgery, The Jikei University Daisan Hospital, Tokyo, Japan; 2Division of Digestive Surgery, The Jikei University School of Medicine, Tokyo, Japan.

Background: The first-line treatment for chronic pancreatitis includes non-surgical treatment. However, there are a certain number of cases with resistance to conservative treatment. This study investigates the effectiveness of surgery as well as issues related to postoperative management in such cases.

Methods: The subjects were seventeen patients (aged from 40 to 80 years with the median age of 62 years; the male-to-female ratio 14:3) who were given the final diagnosis of chronic pancreatitis, including autoimmune pancreatitis (AIP) through clinical and pathological diagnosis in Jikei Daisan Hospital since 2003. Postoperative complications and long-term outcomes were investigated.

Results: Preoperative diagnoses were chronic pancreatitis in twelve and pancreatic tumor in five cases. Surgical technique pancreaticoduodenectomy in two, distal pancreatectomy in 12, pancreaticojejunostomy in three and partial resection in one case without mortality. Postoperative complications were observed in five cases (29%), consisting of pancreatic fistula in two pancreatic pseudocyst in two and pneumonia in one case. Among eleven cases that presented with repeated pancreatitis preoperatively, none developed postoperative relapse of pancreatitis. Among the 6 cases with difficulty in differentiation from malignant tumor, two were diagnosed with AIP and steroids were administered postoperatively. During the median observation period of 7 years (1–15 years), three cases developed pancreatic cancer at 3, 6, and 3.5 years following surgery, respectively. Additionally, one case developed gastric cancer, and another case colon cancer. Among the nine cases with preoperative diagnosis with alcohol-related chronic pancreatitis, five continued to drink postoperatively. Particularly, three cases with pancreaticojejunostomy developed cirrhosis and esophageal varices.

Conclusions: Surgery for chronic pancreatitis was effective in suppressing repeated pancreatitis and helped to obtain definitive diagnosis and to determine subsequent treatment plan. Since as high as 29% of the patients developed gastrointestinal cancer including pancreatic cancer during the postoperative observation period, postoperative strict observation and abstinence from alcohol is important.

A Novel in situ Approach to Studying Pancreatic Ducts in Mice

E. Gál,1 J. Dolenšek,2,3 A. Stožer,2 V. Pohorec,2 A. Ébert,1 V. Venglovecz.1

1Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary; 2Faculty of Medicine and 3Faculty of Natural Sciences and Mathematics, University of Maribor, Maribor, Slovenia.

Background: The tissue slice technique offers several benefits compared to isolated cells and cell clusters that help us understand the (patho) physiology of several organs in situ. The most prominent features are preserved architecture and function, with intact homotypic and heterotypic interactions between cells in slices. In the pancreas, this technique has been utilized successfully to study acinar and endocrine islet cells. However, it has never been used to investigate ductal function. Our aim was to use this technique to study PDEC structure and function in situ.

Methods: C57BL/6 mice were used for preparation of pancreas tissue slices. Low melting point agarose was injected into the common bile duct and the whole organ was extracted. For morphological studies, the tissues were embedded in agarose and cryosectioned to obtain 15 μm thick slices. To visualize pancreatic ducts, (i) the Giemsa dye was added to the agarose and visualized using light microscopy or (ii) immunostaining for the cystic fibrosis transmembrane conductance regulator (CFTR) was performed. For functional characterization, agarose-embedded tissue was immediately cut to 140 μm thick tissue slices that were loaded with the Oregon Green 488 BAPTA-1 AM dye and used for confocal calcium imaging.

Results: Giemsa staining has shown that the injected agarose reaches the head and body of the pancreas to a greater extent than the tail, without disrupting the tissue architecture. Strong CFTR expression was detected at the apical membranes of PDECs and acinar cells, whereas islet cells were completely negative for CFTR. Stimulation with chenodeoxycholic acid (CDCA, 1mM) resulted in a robust transient increase in intracellular calcium concentration that was readily visible in >40 ductal cells per slice.

Conclusions: Our results confirm that the acute pancreas tissue slice technique is suitable for structural and functional investigation of PDECs and their relationship with other cell types, such as acini and endocrine cells in situ.

Relationship Between Obstructive Jaundice and the Outcome of Pancreatic Cancer

E. Gál,1 Z. Veréb,2 E. Becskeházi,1 L. Kemény,2 L. Tiszlavicz,3 V. Venglovecz.1

1Department of Pharmacology and Pharmacotherapy, 2Regenerative Medicine and CellularPharmacology Research Laboratory, Department of Dermatology and Allergology, and 3Department of Pathology, University of Szeged, Szeged, Hungary.

Background: Pancreatic cancer (PC) is usually associated with obstructive jaundice (OJ), although the effect of bile acids (BAs) on tumour progression is less studied. MUC4 is an oncogenic muci that upregulated in PC however, it’s interaction with BAs is not completely clear. Therefore,our aim was to characterize the effect of BAs on tumour progression and to study the possible role of mucins in it.

Methods: Mucin expressions were studied in normal and pancreatic ductal adenocarcinoma cell lines(PDAC) and in human samples, using real-time PCR and immunostainings. Silencing of mucins was performed using specific siRNAs for MUC4 and -17. The effects of BAs of tumour progression were investigated using different assays. Expression of epithelialmesenchymal transition (EMT) markers was investigated by flow cytometry.

Results: BAs treatment highly increased the expression of MUC4 and -17 in PDAC. Most of the BAs enhanced the rate of proliferation, migration, adhesion, colony forming and the expression of EMT markers in PDAC, whereas decreased the viability of normal cells. In patients, where PC is associated with OJ, strong MUC4 and -17 positivity were detected. Silencing of MUC4 decreased, whereas knock-down of MUC17 increased the proliferation of PDACs. Normal cells respond by cell death to BAs treatment, that probably a protective mechanism inorder to avoid malignant transformation. In PDAC, BAs promote tumour progression and MT, in which the increased expression of MUC4 probably plays an important role.

Conclusions: Our data indicate that in PC patients with OJ, the early treatment of biliary obstruction may improve life expectancy.

pH Homeostasis as a Novel Therapeutic Target in Pancreatic Cancer

K. Galenkamp, M. Jung, C. Commisso.

Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA.

Background: Pancreatic ductal adenocarcinoma (PDAC) cells reprogram their metabolism in order to meet elevated energy demands and sustain tumor growth. As an aspect of what is commonly referred to as the “Warburg effect,” cancer cells tend to favor glycolysis for energy production. This boost in glycolytic flux serves to support proliferation of tumor cells, but also generates acid in the form of hydrogen ions (H+) that must be eliminated from the cytoplasm to maintain the alkaline intracellular pH (pHi) associated with cellular transformation. To cope with acid production, tumor cells employ ion transport systems, including the family of sodium-hydrogen exchangers (NHEs).

Methods and Results: Here, we identify NHE7 as a novel regulator of pHi in PDAC. We find that high expression levels of NHE7 strongly correlate with poor overall survival in PDAC patients. NHE7 knockdown suppresses proliferative capacity and significantly enhances cell death in PDAC cells but not normal cells. We determine that NHE7 localizes to the trans-Golgi network (TGN), where it regulates luminal pH. Interestingly, the inability to acidify the TGN results in a concomitant accumulation of cytosolic acid. This decrease in pHi leads to cell death through the dysregulation of actin stress fibers, which are critical to normal cellular contraction and cytokinesis. Using mouse models of PDAC, we find that the suppression of NHE7 in vivo leads to the abrogation of tumor initiation and a blockade in the growth of established tumors.

Conclusions: These results identify Golgi acidification as a mechanism by which cancer cells can control pHi and point to the therapeutic potential of targeting this process in PDAC.

Clinical Study of Different Surgical Approaches in Laparoscopic Debridement for Patients With Infected Pancreatic Necrosis

C. Gao, F. Li, F. Cao, X. Wang, A. Li.

Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.

Background: Laparoscopic debridement is widely used in patients with infective pancreatic necrosis (IPN). This study is to investigate the indications and effects of different surgical approaches in laparoscopic debridement for IPN patients.

Methods: The clinical data of 213 IPN patients treated by laparoscopic debridement in Xuanwu Hospital, Capital Medical University from June 2012 to February 2019 were retrospectively analyzed. The therapeutic effects were summarized and analyzed according to different surgical approaches. There were 123 cases in retroperitoneal approach group, 73 males and 50 females, ageing of (51.3 ± 12.4) years old; 59 cases in omental sac approach group, 32 males and 27 females, aging of (48.3 ± 14.2) years old; 23 cases in combined approach group, 13 males and 10 females, aging of (54.3 ± 19.7) years old; 8 cases in digestive tract approach group, 5 males and 3 females, aging of (50.2 ± 12.5) years old.

Results: The operation time in retroperitoneal, omental sac, combined and digestive tract approach groups was (52.3 ± 26.4), (64.3 ± 29.2), (82.8 ± 24.7), (78.2 ± 38.1) minutes respectively; the median bleeding volume was 18, 33, 42, and 30 ml, respectively; and the first time to eat after operation was (2.5 ± 1.6), (3.8 ± 1.8),(3.7 ± 2.0),(8.4 ± 3.9) days respectively. The incidence of complications (Clavien-Dindo grade III and above) was 10.6% (13/123), 10.2% (6/59), 17.4% (4/23), 25% (1/8) and the mortality was 4.9% (6/123), 3.4% (2/59), 4.3% (1/23), and 0%, respectively. The mortality was 4.2%. The levels of inflammatory factors were significantly lower 7 days after operation than before, and no patients were converted to open surgery.

Conclusions: Individualized selection of the optimal laparoscopic debridement approach of pancreatic necrosis plays an important role in improving the efficacy and prognosis of IPN patients.

Exploration of the Indication for Removal of the Abscess Cavity Drainage Tube of Infectious Pancreatic Necrosis

C. Gao, F. Li, X. Wang, F. Cao, A. Li.

Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.

Background: There is no explicit regulation on tube extubation in patiens with infected pancreatic necrosis (IPN) in guidelines, and there is no relevant report. This study is to investigate the indication for removal of abscess cavity drainage tube of IPN.

Methods: The data of 169 IPN patients who underwent debridement and drainage and removed the drainage tube according to original standard in general surgery department of Xuanwu Hospital, Capital Medical University from February 2014 to October 2018 were retrospectively analyzed. The risk factors of local infection after extubation were analyzed.

Results: Of the 169 patients, 156 patients recovered smoothly after extubation, and 13 patients had abnormal symptoms after extubation (8 got fever and 5 suffered abdominal pain). The median time for the above symptoms was 7 (4–10) days after extubation, and the infection rate was 7.7%. The types of bacteria were Enterococcus faecium in 4 cases, Escherichia coli in 4 cases, Staphylococcus in 3 cases, Acinetobacter baumannii in 1 case and Klebsiella pneumoniae in 1 case. 10 cases recovered after antiinfection and puncture, and 3 cases recovered after replacement of sputum suction tube. Univariate analysis showed that White blood cell, C-reactive protein, Interleukin-6, Procalcitonin, average number of operations, length of drainage tube in vivo measured by CT were risk factors for local infection after extubation. Multivariate analysis showed that White blood cells, Procalcitonin and length of drainage tube in vivo measured by CT were independent risk factors for local infection after extubation.

Conclusions: IPN patients with WBC ≥10 ×109/L, PCT ≥0.05 ng/ml and length of drainage tube in vivo measured by CT ≥10 cm are prone to suffer local infection after extubation. Therefore, in addition to previous criteria, these three indicators should also be considered before extubation.

Central Pancreatectomy for Early-stage Pancreatic Ductal Adenocarcinoma: A Single-Center Case–control Study

H. Gao,1,2 T.T. Liu,1,2 G.F. Wang,1,2 Y. Gao,1,2 L.D. Yin,1,2 Y.P. Peng,1,2 N. Lyu,1,2 K. Zhang,1,2 W.T. Gao,1,2 J.L. Wu,1,2 K.R. Jiang,1,2 J.S. Wei,1,2 Y. Miao,1,21Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China; 2Pancreas Institute of Nanjing Medical University, Nanjing, China.

Background: Central pancreatectomy (CP) has been applied for treating benign and low-grade malignant tumors in pancreatic neck, but studies regarding CP for pancreatic ductal adenocarcinoma (PDAC) are quite limited. We aimed to investigate the role of central pancreatectomy in the treatment of PDAC in the neck of the pancreas.

Methods: Patients who underwent CP at our hospital between 2009 and 2016 were identified. Patients treated by distal pancreatectomy (DP) were matched according to the tumor size, location, and staging. The surgical and survival outcomes were compared between the CP and DP groups.

Results: Nine patients had CP. Five (56%) had postoperative complications and three (33%) had clinically significant (grade B+C) fistula. No significant difference was found between CP and DP group for the rate of overall morbidity, pancreatic fistula, reoperation, and readmission. Tumor size was smaller in the CP group compared to DP group. The mortality of both groups was zero. The median postoperative survival was similar between the two groups (20.4 months for CP vs 19.4 months for DP, P = 0.842).

Conclusions: CP is safe for patients with small PDAC at the neck of the pancreas. Considering the good preservation of pancreatic endocrine and exocrine functions, CP could be considered as an alternative procedure for single small PDAC in pancreatic neck.

The Critical Role of Inflammasome Induced GSDMD-Dependent Pyroptosis for Acinar Cell Death in Acute Pancreatitis

L. Gao,1 W. Huang,2 J. Xue,3 L. Ke,1 X. Gao,4 Z. Tong,1 G. Lu,1 W. Li.1

1Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, Nanjing, China; 2Department of Integrated Traditional Chinese and Western Medicine, West China Hospital/West China Medical School, Sichuan University, Chengdu, China; 3State Key Laboratory of Oncogenes and Related Genes, Stem Cell Research Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; 4Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University, Nanjing, China.

Background: Acute pancreatitis (AP), as a sterile inflammation, is triggered by the death of acinar cells. Pyroptosis, as a new programmed form of cell death, is characterized by its dependence on Caspase-1 and canonical NLRP3 inflammasome induced Gasdermin D (GSDMD) activation. In this study, we aimed to verify the contribution of pyroptosis to acinar cell death, driving AP pathogenesis and systemic inflammation.

Methods: Both in vivo and in vitro AP model were adopted. AP was induced in mice by repetitive supramaximal cerulein or retrograde bile duct injection of sodium taurocholate. 266-6 cell, as a mouse pancreatic acinar carcinoma cell strain, was used to establish AP model in vitro induced by cholecystokinin or taurocholate. Apart from this, human pancreatic samples were also collected. Pyroptosis associated gene knockout mice, as well as pyroptosis inhibitors were used to investigate the effects of pyroptosis on AP pathogenesis.

Results: GSDMD and NLRP3 inflammasome activation were observed in injured acinar cells both in mice and patient with pancreatitis. Besides, the acinar cells were proven to be pyroptotic upon AP-relevant insults in vitro. By adopting Caspase-1, NLRP3 and GSDMD knockout mice respectively, we verified that pyroptosis associated protein deficiency could protect mice from acinar cell death and pancreatic injury. In addition, loss of GSDMD could reduce pancreatic acinar cell death upon AP related stimulation in vitro. Furthermore, pyroptosis inhibitors were shown to alleviate.

Conclusions: Here we showed that pyroptosis, mediated by NLRP3 inflammasome induced GSDMD activation, existed in injured pancreatic acinar cells during AP. Our results suggest that therapeutic strategies to target pyroptosis may protect acinar cell from injury and have potential for clinical application.

HIF-1α/RNF139 Axis is Involved in Nab-paclitaxel Resistance in PDAC by Inducing Endoplasmic Reticulum Stress

S. Gao, S. Yuan, B.D. Zhou, J. Xu, J.H. Hao.

Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.

Background: Nab-paclitaxel is the first-line chemotherapeutic that showed promising effect in pancreatic ductal adenocarcinoma (PDAC). The response rate of Nab-paclitaxel in PDAC is about 30%. Little is known about the mechanisms underlying nab-paclitaxel (n-PTX) resistance. Hypoxia plays a key role in chemoresistance in PDAC. The purpose of this study is to investigate the HIF-1α drived Nab-paclitaxel resistance in PDAC.

Methods: Expression of certain protein including HIF-1α were exhbited in tumor tissue from patients received Nab-paclitaxel chemotherapy by Immunohistochemistry staining. The corelation between protein expression and Nab-paclitaxel response was analyzed. Molecular assay was adopted to reveal the reciprocal regulation of HIF-1α and downstream target. Specific markers of endoplasmic reticulum stress were checked. Animal model was used to verify the HIF-1α induced ER stress may lead to Nab-paclitaxel resistance in vivo.

Results: HIF-1α expression was negatively correlated with Nab-paclitaxel response (n = 179, rs = -0.471, P < 0.001). RNF139 expression showed a similar result (n = 179, rs = -0.558, P < 0.001). The expression of RNF139 and HIF-1α was positively correlated (n = 179, rs = 0.358, P < 0.001). Increased expression of HIF-1α in tumor cell led to augment expression of RNF139, vice versa. HIF-1α may bind with HRE element on RNF139 promoter to facilitate its transcriptional expression. RNF139 diminished VHL expression to stablize HIF-1α. HIF-1/RNF139 axis activated endoplasmic reticulum stress in tumor cell, which consquently lowered the sensitivity of tumor cell to Nab-paclitaxel in vivo.

Conclusions: HIF-1α transcriptionally regulated RNF139, which affected VHL to stablize HIF-1α. The positive regulation circle between HIF-1α and RNF139 may lead to endoplasmic reticulum stress in tumor cell, which facilitated the Nab-paclitaxel resistance in PDAC.

Anterior Versus Posterior Radical Antegrade Modular Pancreatosplenectomy for Patients With Adenocarcinoma of Body and Tail of Pancreas: A Propensity Score Matching Study

S.Z. Gao, S.W. Guo, G. Li, T.L. He, Y.Q. Zhou, X.Y. Zhou, Y.J. Zhang, X.G. Hu, G. Jin.

Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China.

Background: Radical antegrade Modular pancreatosplenectomy (RAMPS) was designed to improve on the surgical radicality of the conventional distal pancreatosplenectomy for adenocarcinoma of body and tail of pancreas. The posterior RAMPS increases the posterior extent of resection, but it involves a more extensive resection than the anterior RAMPS. There have been few comparative studies comparing these two procedures.

Methods: Patients underwent RAMPS for the treatment of pancreas body and tail adenocarcinoma between 2011 and 2016 in Changhai Hospital were included in the original data. Propensity score matching (PSM) analysis was taken for more balanced data in this study. We compared surgical and survival outcomes between anterior RAMPS and posterior RAMPS.

Results: 328 patients with pancreatic cancer underwent RAMPS were included in the original data and after PSM analysis 244 patients were brought into the further study. Among the original dataset, significant differences were found between the two groups in AJCC stage, perineural invasion, and vessel tumor embolus. In matched data set, the baseline data showed no difference between two groups. In the original data set, posterior RAMPS revealed more intraoperative bleeding (300.0 [IQR, 200.0–500.0] vs 200.0 [IQR, 100.0–400.0] ml, P = 0.000), more dissected lymph nodes (19.4 ± 2.8 vs 16.8 ± 3.0, P = 0.000), but no more complications and post-operative days. There were no significant differences in OS and DFS between the two groups in the original data set. However, in the matched data set, the median OS and DFS was longer in the posterior RAMPS group (OS: 19.9 months vs 15.0 months, P = 0.034; DFS: 11.6 months vs 8.0 months, P = 0.022). In the multivariate analysis, symptom occurrence, tumor differentiation, pathologic T stage, pathologic N stage, adjuvant chemotherapy were independent factors for overall survival.

Conclusions: Posterior RAMPS was as safe as anterior RAMPS and could prolong the overall survival time of patients with pancreatic adenocarcinoma.

Insulin Promotes the Invasion and Migration of Pancreatic Cancer Through the Epithelial-mesenchymal Transition Pathway

Y. Gao, H. Gao, G.F. Wang, L.D. Yin, B.B. Cai, Z.P. Lu, Yi Miao.

Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most deadly cancers in the world. Hyperinsulinemia has been considered to be associated with the risk of pancreatic cancer. Our study is to explore the effect of insulin on the migration and invasion of pancreatic cancer cells and possible mechanism.

Methods: Transwell assay was used to evaluate the effect of insulin on the migration and invasion of pancreatic cancer cells. Western Blot was used to detect the expression of functional proteins related to epithelial-mesenchymal transformation (E-cadherin, N-cadherin, Vimentin). All the above experiments were repeated 3 times. T test was used for comparison between the two groups.

Results: The results of Transwell assay showed that the migration ability of CFPAC and Capan-2 cells co-cultured with insulin at 20 nM was significantly improved after 48 hours (CFPACins vs CFPACctrl: 354.0 ± 13.5 vs 158.3 ± 9.4, P < 0.05; CAPAN-2ins vs CAPAN-2ctrl: 261.0 ± 13.9 vs 127.7 ± 17.2, P < 0.05). The invasion ability of CFPAC and Capan-2 cells co-cultured with insulin at 20 nM was also significantly improved after 48 hours (CFPACins vs CFPACctrl: 229.0 ± 11.0 vs 93.0 ± 11.6, P < 0.05; CAPAN-2ins vs CAPAN-2ctrl: 135.7 ± 10.3 vs 98.7 ± 10.9, P < 0.05). The results of Western Blot showed that the expression of E-cadherin decreased at protein level after 20nM insulin stimulation of CFPAC or Capan-2, while the expression of N-cadherin and Vimentin were up-regulated. Western Blot also found that insulin stimulation could up-regulate the expression level of Snail protein.

Conclusions: Transwell assay showed that insulin significantly enhanced the ability of pancreatic cancer cells to migrate and invade. The results Western Blot showed that insulin increased the expression of E-cadherin, decreased the expression of N-cadherin and Vimentin in pancreatic cancer cells, that is, the migration and invasion ability of pancreatic cancer cells were increased through the EMT pathway. Western Blot results suggest that insulin may further affect the expression of E-cadherin by inducing activation of Snail.

Chronic Pancreatitis Prognosis Score (COPPS): Preliminary Results From a Prospective Multicenter, International Validation Study

A. Garbe,1 U.M. Mahajan,1 T. Kohlmann,2 E. Goni,1 C. Budde,3 E. Martinez-Moneo,4 T. Shimosegawa,5 C. Forsmark,6 P. Garg,7 A. Gomes,8 S. Stigliano,9 D.L. Conwell,10 M.M. Lerch,3 J. Mayerle,1 G. Beyer.1

1University Hospital, LMU Munich, Medical Department II, Munich, Germany; 2University Medicine Greifswald, Institute of Community Medicine, Greifswald, Germany; 3University Medicine Greifswald, Department of Medicine A, Greifswald, Germany; 4Hospital Universitario de Cruces, Bilbao, Spain; 5Tohoku University, Sendai, Japan; 6University of Florida, Gainsville, FL; 7All India Institute Of Medical Sciences, New Delhi, India; 8Hospital Prof. Dr. Fernando Fonseca, Servico de Cirurgia B, Amadora, Portugal; 9II Medical School, University La Sapienza, Digestive and Liver Disease Unit, Rome, Italy; 10The Ohio State University, Wexner Medical Center, Columbus, OH.

Background: We recently developed a multivariate scoring system for chronic pancreatitis using BMI, pain, CRP, platelets and HbA1c. COPPS allowed objective monitoring of disease severity, determining risk for readmission to hospital and length of hospital stay in a prospective development cohort and retrospective validation cohort, recruited in Germany and Denmark (Beyer et al. Gastroenterology. 2017). The predictive performance of COPPS in a diverse population is unknown. Here we validate COPPS in an international cohort of chronic pancreatitis patients.

Methods: We prospectively recruited 252 patients between 04/2016 and 01/2018 with chronic pancreatitis from 8 centers in Europe, Japan, India and North America. At baseline COPPS, demographics and etiological factors were recorded. Patients were followed for one year. The primary end-point was number of readmissions to hospital and the combined length of all hospital stays during that period. The study was approved by IRB of all centers.

Results: Of 252 included patients 220 had full data available for analysis (26.4% female, median age at diagnosis 50 years, alcohol and idiopathic most common etiology). Mean COPPS was 8.06 points (SD ± 1.84), with 46, 122, and 52 patients in the respective COPPS category A, B, C. Mean number of hospital admissions during follow-up was 1.07 (SD ± 1.60) with a mean number of 9.63 days (SD ± 23.35) spent in hospital. COPPS correlated with both primary endpoints (P < 0.01). Patients with COPPS category B, C had a significantly higher risk for readmission (P < 0.05). Regular bootstrapping with 1000 repeats excluded significant bias.

Conclusions: Chronic Pancreatitis Prognosis Score (COPPS) reliably predicts the risk for readmission in a large, prospective, international cohort of patients with chronic pancreatitis. This supports the potential value of COPPS as a reliable tool for severity grading of chronic pancreatitis. Recruitment to this cohort will continue until a final number of 500 subjects is reached.

Early Detection of Familial Pancreatic Cancer Leads to Improved Survival: Retrospective Comparison of Clinically Versus Early Detected Familial Pancreatic Cancer

S.K. Garg, B. Ravella, D. Singh, H. Kandlakunta, S.S. Nagpal, A. Sharma, S.T. Chari.

Gastroenterology and Hepatology Division, Mayo Clinic, Rochester, MN.

Background: Current guidelines recommend pancreatic cancer (PC) screening in individuals with 2 or more first degree relatives with PC, but there is scant evidence that early detection leads to better survival in familial pancreatic cancer (FPC). Typically, symptoms (severe abdominal/back pain, anorexia, fatigue and weight loss) lead to clinical diagnosis of familial pancreatic cancer (FPC-CD). Infrequently, FPC is diagnosed before the onset of these symptoms, i.e. detected early (FPC-ED), as an incidental finding on imaging or due to isolated symptom of painless jaundice. We tested the hypothesis that FPC-ED would have better survival than FPC-CD.

Methods: A total of 374 subjects with FPC, who were not part of FPC surveillance program, were identified from the Mayo Clinic pancreatic tumor registry per the following criteria: biopsy proven pancreatic cancer and a reported family history of pancreatic cancer in a first degree relative. We abstracted detailed clinical symptoms at diagnosis in 372 FPC patients (2 patients did not have symptom data).

Results: We classified 326 (87.6%) patients as FPC-CD and the remaining 46 (12.4) as FPC-ED. Mean age at diagnosis was similar in FPC-CD and FPC-ED (68.5 ± 12.0 and 67.3 ± 10.9; P = 0.5). FPC-ED, compared to FPC-CD, had better median survival (527 days vs 306 days, P = 0.006) and higher proportion with 1-year survival (60.9 % vs 42.3%, P = 0.018) and 3-year survival (26.1% vs 12.3%, P = 0.011). Rate of surgical resection of familial pancreatic cancer was 41.3% in FPC-ED compared to 28% in FPC-CD (P = 0.064).

Conclusions: Early detection of PC in FPC is associated with higher median, 1- and 3-year survival compared to clinically detected tumors

Familial Pancreatic Cancer Patients Have Higher Surgical Resection and Survival Compared Sporadic Pancreatic Cancer Patient

S.K. Garg, B. Ravella, D. Singh, H. Kandlakunta, S.S. Nagpal, A. Sharma, S.T. Chari.

Gastroenterology and Hepatology Division, Mayo Clinic, Rochester, MN.

Background: While majority of pancreatic cancers (PC) are sporadic (SPC), 7% of patients report a family history of PC. Due to its rarity, the prognosis and survival of familial PC (FPC) (subjects with at least 2 first degree relatives [FDRs] with PC) is largely unknown.

Methods: From the Mayo Clinic tumor registry from 2000-2017 we identified 374 subjects who met the following criteria: had biopsy proven PC and reported a family history of PC in an FDR. These patients were not a part of any FPC surveillance program. For each FPC case, we identified SPC control (n = 371) matched for age, sex, and year of diagnosis from Mayo tumor registry and compared the key outcomes between the 2 groups.

Results: FPC patients were more likely to undergo surgical resection compared to SPC (29.5% vs 15.1%, P ≤ 0.001). The proportion of resected tumors that were well to moderately differentiated was significantly higher in FPC patients than SPC (41.6% vs 24.5%, P = 0.04). FPC patients had higher median survival than SPC (317 days vs 279 days, P < 0.004), 2-year survival (23 % vs 16.7 %, P = 0.03) and 5-year survival (4.8% vs 2.2%, P = 0.04). The subset of subjects without cancer-specific symptoms (abdominal/back pain, anorexia, fatigue) at diagnosis were higher in FPC compared to SPC (12.4% vs 6.5%, P < 0.05); symptomatic FPC patients had higher median survival compared to symptomatic SPC (306 days vs 276 days, P = 0.06).

Conclusions: For similar age patients, FPC presents more often without cancer-specific symptoms, have higher resection rates and higher proportion of well to moderately differentiated tumors compared to SPC. All these factors likely contribute to increase median survival for FPC patients.

Glycemic Profile of Subjects With Familial Pancreatic Cancer Compared to Sporadic Pancreatic Cancer

S.K. Garg, B. Ravella, D. Singh, H. Kandlakunta, S.S. Nagpal, A. Sharma, S.T. Chari.

Gastroenterology and Hepatology Division, Mayo Clinic, Rochester, MN.

Background: More than half of sporadic pancreatic cancer (SPC) patients have diabetes mellitus (DM) at cancer diagnosis, with majority having either new-onset DM or significant recent worsening of long-standing DM. Whether Familial Pancreatic cancer patients (FPC) patients also have a similar glycemic profile is not known.

Methods: From the Mayo Clinic tumor registry we identified 374 subjects with biopsy proven pancreatic cancer who reported a family history of pancreatic cancer in a first degree relative. For comparison, 371 sporadic pancreatic cancer (SPC) patients matched for sex, age, and year of diagnosis were identified. All patients were glycemically typed (based on fasting blood glucose [FBG] levels, A1c and anti-diabetic medications) at cancer diagnosis and baseline (3-5 year prior to cancer diagnosis). We also ascertained weight, BMI at baseline (3-5 year prior to cancer diagnosis) and at cancer diagnosis.

Results: Comparing the glycemic profiles of FPC to SPC at cancer diagnosis, there was no difference (P = ns) in the prevalence of DM (56% vs 51.6%), pre-DM (28% vs 34.5%), and normoglycemia (15.9% vs 14%) between the 2 groups. Mean FBG levels in FPC and SPC at diagnosis was 134 ± 4.2 vs 140 ± 4.7, P = 0.3 and at baseline was 115 ± 4.2 vs 106 ± 3, P = 0.14. Mean BMI at diagnosis was also comparable between FPC and SPC (26.9 ± 0.3 vs 6.1 ± 0.3, P = 0.9). FPC patients had 11% weight loss from baseline weight which was similar to SPC patients who had 10.3% weight loss from there baseline weigh; P = 0.5.

Conclusions: This is the first study to show that glycemic profile of FPC patients mimic that of SPC patients. The sporadic PC-DM paradox (i.e. rise in blood glucose in face of weight loss) is also seen in FPC patients. These findings, if validated, suggest the usefulness of temporal assessment of FBG levels and body weight in surveillance program for FPC kindred.

Poorly Differentiated Pancreatic Ductal Adenocarcinoma is Associated With Hyperglycemia at Diagnosis

S.K. Garg, B. Ravella, D. Singh, H. Kandlakunta, S.S. Nagpal, A. Sharma, S.T. Chari.

Gastroenterology and Hepatology Division, Mayo Clinic, Rochester, MN.

Introduction: There is strong epidemiological evidence to suggest pancreatic cancer (PDAC) causes hyperglycemia and diabetes; however, whether PDAC tumor biology is associated with this glycemic disturbance is unknown. We hypothesized that poorly differentiated tumors, to cope with the harsh tumor microenvironment, are more likely to cause hyperglycemia/diabetes compared to well-moderately differentiated tumors.

Methods: We used Mayo Clinic pancreatic cancer tumor registry to identify all PDAC patients who underwent surgical resection for curative purposes from 1976-2017. Only resected patients were used to determine the grade of the tumor. For each patient we abstracted grade at resection and fasting blood glucose (FBG) levels prior to surgery. FBG level at PDAC diagnosis was used to ascertain the glycemic status: normoglycemia (<100 mg/dl), impaired tolerance (100-125 mg/dl) and hyperglycemia (>125 mg/dl). Patients in whom the grade or glycemic status was unknown were excluded from the study (13.2%).

Results: We identified 1192 patients who met our study inclusion criteria. At cancer surgery, the mean age (± SD) was 65.4 ± 0.3, 326 (54.6%) were males, and 1055 (88.5%) were white. Prior to cancer surgery, 43.3% patients were classified as having DM, 36.2% as impaired fasting glucose and 20.6% as normoglycemia. Of 1192, 50.9% had poorly differentiated tumors, 27.2% had well to moderately differentiated tumors [well, 2.6% and moderate, 24.6%] and 9.6% had undifferentiated tumors. Conversely, 81.5% of poorly differentiated tumors had either impaired fasting glucose or DM. At resection, the tumor differentiation for normoglycemic patients were more likely to be well-moderate than poor (24.3% vs 18.6%; P = 0.03). The median survival of well to moderately differentiated tumors was significantly higher than poorly differentiated tumors (865 days vs 660 days, P < 0.001).

Conclusions: Poorly differentiated tumors are more likely to cause hyperglycemia compared to well-moderately differentiated tumors.

Transmissible ER Stress (TERS) Response Between Different Cell Types in Pancreatic Adenocarcinoma Contributes to Quiescence in Cancer Cells

V.T. Garrido,1,2 B.C. Durden,1,2 N.S. Sharma,1,2 V.K. Gupta,1,2 R. Haddad,1,2 K. Kesh,1,2 A.K. Saluja,1,2 S. Banerjee,1,21Department of Surgery, Miller School of Medicine, and 2 Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL.

Background: Endoplasmic reticulum (ER) stress in solid tumors results from cell-intrinsic and cell-extrinsic conditions. To thrive under these challenges, malignant cells activate the unfolded protein response (UPR) to maintain cell homeostasis. Persistent activation of ER stress sensors increases cell survival, chemoresistance, immunosuppression, and metastasis. Recent studies show that ER stress response can be transferred from one cell to another resulting in “transmissible” ER stress (TERS). In this study, we investigated the stroma-tumor as well as tumor-tumor transfer of ER stress response in pancreatic cancer.

Methods: MIA PaCa-2 and pancreatic stellate cells were treated with Thapsigargin or DMSO for 2 hours, washed twice with PBS and then incubated in fresh medium for 16 hours to generate the TERS-conditioned medium (TCM). Multiplex cytokine profiling of the CM was performed using LEGENDplex bead-based immunoassay. The expression of UPR and inflammation related genes was analyzed by RT-PCR. Cell proliferation was measured by ECIS. Western blotting was used for protein expression analysis.

Results: Data shows that MIA PaCa-2 cultured in cancer-TCM upregulate the expression of spliced-XBP1, GRP78, and CHOP. Inflammatory pathways were also activated, as observed by an increase in the gene expression of IL6. Similarly, stroma-TCM triggered a global UPR induction in MIA PaCa-2, demonstrating a transfer of ER stress response from stromal cells to tumor cells. There was no difference between the cytokine profile of TCM and CM from DMSO-treated cells after the 16 hour rest period. Interestingly, tumor and stroma-TCM were associated with the enrichment of quiescence in MIA PaCa-2 cells. Additionally, these cells demonstrated improved survival over DMSO CM-primed cells when challenged with cytotoxic compounds, suggesting an acquired adaptive fitness.

Conclusions: Cells undergoing ER stress release soluble factors that can trigger the UPR pathway in recipient pancreatic cancer cells and this intercellular communication endows tumor with improved capacity to adapt to stressful environments.

Cancer Exposed Dendritic Cells Mount a Dysfunctional Immune Response Dependent on Heat Shock Protein 70

B. Giri, P. Sharma, A. Ferrantella, V. Sethi, S. Modi, Z. Malchiodi, B. Garg, S. Ramakrishnan, S. Lavania, S. Banerjee, A.K. Saluja, V. Dudeja.

Department of Surgery, University of Miami, FL.

Introduction: Dendritic cells (DCs), by antigen processing, form one of the main defense mechanisms against tumorigenesis but cancer cells develop despite presence of a mounting immune system. Heat shock protein 70 is known to modulate antigen presentation in adaptive immune cells. We sought to find the role of HSP70 in dendritic cells exposed to tumors.

Methods: Dendritic cells from mice from either WT or HSP70-/- mice were selected by pan dendritic cell isolation kit. Then they were incubated with KPC cancer cells in vitro and their expression of anti-tumorigenic molecules were measured. In another experiment, WT or HSP70-/- dendritic cells were exposed to tumor cell lysates derived from the mouse pancreatic cancer cell line, KPC, in vitro.

Results: Tumors that were formed in WT mice receiving HSP70-/- DC were smaller than those receiving WT Dendritic cells. Overall vaccination with DC decreased tumor formation rate in both WT and KO mice but the decrease in tumor size was greater when HSP70-/- DC were implanted. Similarly, HSP70-/- dendritic cells had greater expression of anti-tumorigenic MHCII peptide on their surface when they were exposed to tumor lysates from KPC cells suggesting that HSP70 deficient DCs were more adept at mounting an anti-tumor immune effect.

Conclusions: HSP70 modulates dendritic cell function in the immune response against cancer.

Complications After Resection of the Pancreas

S. Głuszek,1,2 M. Kot,1,2 Ł. Nawacki,1,2 I. Wawrzycka,1,2 M. Kołomańska,1,2 G. Markowska,1,2 M. Głuszek-Osuch,1 J. Bicki,1,2 J. Matykiewicz,1,2 M. Wawszczak,1 D. Kozieł.11Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, Poland; 2Clinic of General, Oncological and Endocrine Surgery, Regional Polyclinical Hospital, Kielce, Poland.

Background: Pancreatic resections belong to the most difficult surgical procedures and are still burdened with a high percentage of complications. The aim of the study was to analyze both the medical records of patients qualified for surgical treatment and the postoperative course after procedures of radical resection of the pancreas, with consideration of the most severe complications.

Methods: Postoperative courses were analyzed in 100 patients with pancreatic resection.

Results: The most frequent indications for pancreatic resection were: cancer of the ampulla of Vater (30), pancreatic cancer (24), inflammatory tumors (16), and benign cystic tumors (12). In 8 cases, pancreatic resection (distal) was an element of the surgery due to advanced gastric cancer, while the remaining were: lymphoma (2), neuroendocrine tumors (2), adenoma with high-grade dysplasia involving the ampulla of Vater (2), GIST (1), IPMN (1), fibromatosis (1), and injury (1). The most frequent surgery was partial resection of the organ (73: proximal resection – 35, distal resection – 38). Total pancreatectomy was performed in 20 patients, and in 3 patients the surgery was limited to resection of the tumors. The dominant postoperative complications were pancreatic fistulas (9%) and hemorrhages (5%). Only one case of fistula was surgically treated. Surgical intervention was necessary in all cases of hemorrhagic complications (in 2 patients). During the postoperative period 5 deaths were registered (5%).

Conclusions: Pancreatic surgery remains a very difficult discipline, which requires not only excellent surgical technique, but also skill in the management of postoperative complications.

NADPH Oxidase 1-derived ROS Promote NF-ĸB-dependent Kinases Msk1/IKKα Production in Pancreatic Stellate Cells in Presence of Pancreatic Cancer Cells

C. Godoy,1 A. Chakraborty,1 B. Singla,2 B. Halder,1 H. Kashif,1 E. Thomas,1 G. Csanyi,2 M.E. Sabbatini.1Departments of 1Biological Sciences and 2Pharmacology and Toxicology, Augusta University, Augusta, GA.

Background: Chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) are characterized by a stroma produced by pancreatic stellate cells (PaSCs). A communication between pancreatic cancer cells and PaSCs results in an increased expression of stromal proinflammatory and fibrotic genes, which promote the progression of the disease. NADPH oxidase (Nox) is a family of enzymes that catalyze the transfer of an electron from NADPH to oxygen to generate reactive oxygen species (ROS). We previously found that Nox1 mediates cerulein-induced pancreatic fibrogenesis in CP. Because CP predisposes to PDAC, the objective was to assess the extent to which Nox1in PaSCs co-cultured with pancreatic cancer cells facilitates the expression of stromal proinflammatory and fibrotic genes.

Methods: PaSCs from WT (C57BL/6) and Nox1 KO mice were isolated. PANC-1 cells were plated onto transwell inserts in serum-free media and co-cultured with PaSCs overnight. Intracellular ROS levels were tested using flow cytometry by the H2DCFDA probe. Activation of NF-ĸB was evaluated by immunohistochemistry (IHC) and Western-blotting. Total RNA was isolated from PaSCs using RNeasy® Mini kit. The analysis of relative NF-ĸB dependent gene expression data was carried out using the 2-ΔΔCT method and confirmed by Western-blotting.

Results: By using light microscopy and IHC for desmin and α-SMA, no difference in cell morphology or activation could be detected between PaSCs from WT or Nox1 KO mice. The lack of Nox1 abolished cerulein-induced ROS generation and nuclear translocation of NF-ĸB in PaSCs. The NF-ĸB-activated proinflammatory factor TGF-β and histone H3 kinases Msk1 and IKKα RNA and protein levels were higher in PaSCs from WT mice co-cultured with PANC-1 cells. The lack of Nox1 abolished the up-regulation of these genes.

Conclusions: In presence of PANC-1 cells, Nox1-evoked ROS caused the activation of NF-ĸB in PaSCs, which through the histone H3 kinases Msk1 and IKKα, up-regulated the transcription of pro-inflammatory and fibrotic genes.

Olaparib as Maintenance Treatment Following First-line Platinum-based Chemotherapy (PBC) in Patients With a Germline BRCA Mutation and Metastatic Pancreatic Cancer (mPC): Phase III POLO Trial

T. Golan,1 P. Hammel,2 M. Reni,3 E. Van Cutsem,4 T. Macarulla,5 M.J. Hall,6 J.O. Park,7 D. Hochhauser,8 D. Arnold,9 D.Y. Oh,10 A. Reinacher-Schick,11 G. Tortora,12 H. Algül,13 E. M O'Reilly,14 D. McGuinness,15 K.Y. Cui,16 K. Schlienger,17 G.Y. Locker,16 H.L. Kindler,181The Oncology Institute, Sheba Medical Center at Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel; 2Hôpital Beaujon (AP-HP), Clichy, and University Paris VII, Paris, France; 3IRCCS Ospedale, San Raffaele Scientific Institute, Milan, Italy; 4University Hospitals Gasthuisberg, Leuven and KU Leuven, Leuven, Belgium; 5Vall d’Hebron University Hospital and Vall d’Hebron Institute of Oncology, Barcelona, Spain; 6Fox Chase Cancer Center, Philadelphia, PA; 7Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; 8University College London Cancer Institute, London, UK; 9Asklepios Tumorzentrum Hamburg AK Altona, Hamburg, Germany; 10Seoul National University Hospital, Seoul, South Korea; 11St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany; 12Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy; 13Klinikum rechts der Isar, Dept. of Internal Medicine II, Technische Universität München, Munich, Germany; 14Memorial Sloan Kettering Cancer Center, New York, NY; 15AstraZeneca, Cambridge, UK; 16AstraZeneca, Gaithersburg, MD; 17Merck & Co., Inc., Kenilworth, NJ; 18The University of Chicago, Chicago, IL.

Background: PC patients with a germline BRCA1 and/or BRCA2 mutation (gBRCAm) have shown response to the PARP inhibitor olaparib (Kaufman 2015). POLO (NCT02184195) is the first Phase III trial to evaluate efficacy of maintenance treatment with a PARP inhibitor in mPC.

Methods: POLO is an international, randomized, double-blind, placebo-controlled trial of patients with a gBRCAm and pancreatic adenocarcinoma who had received ≥16 weeks of first-line PBC for metastatic disease without progression. Patients were randomized 3:2 to maintenance olaparib tablets (300 mg bid) or placebo. Treatment began 4–8 weeks after last PBC dose, continuing until investigator-assessed progression or unacceptable toxicity. The primary endpoint was progression-free survival (PFS) by blinded independent central review (modified RECIST 1.1).

Results: We screened 3315 patients, identified 247 with a gBRCAm, randomized 154 (olaparib 92, placebo 62), and treated 151 (olaparib 90, placebo 61). Patient characteristics (olaparib/placebo): age, median (range) 57 (37–84)/57 (36–75); male, 58%/50%; ECOG performance status 0, 71%/61%. With 104 events, PFS was significantly improved with olaparib versus placebo (HR, 0.53; 95% CI, 0.35–0.82; P = 0.0038; median 7.4 vs 3.8 months) and consistent irrespective of response to prior PBC (complete/partial HR 0.62; stable disease HR, 0.50). At 2 years, 22.1% of olaparib-arm patients versus 9.6% of placebo-arm patients were free from disease progression. At the interim overall survival analysis (46% maturity), HR was 0.91 (95% CI, 0.56–1.46; P = 0.68). Grade ≥3 adverse events occurred in 40% of olaparib- and 23% of placebo-treated patients; 5.5% and 1.7%, respectively, discontinued treatment due to an adverse event.

Conclusions: Maintenance olaparib provided a statistically significant and clinically meaningful improvement in PFS in mPC patients with a gBRCAm who had not progressed on PBC. Safety was consistent with the known profile for olaparib. POLO is the first Phase III trial to validate a biomarker-driven treatment in PC.

Pancreatic Adenocarcinoma With Inferior Vena Cava Invasion: Report of a Case

T. Goto,1 T. Yamazaki,2 R. Kawashima,1 T. Koide,1 T. Yasuda,1 H. Sendo,1 S. Muramatsu,1 M. Miyashita,1 Y. Ku.1Department of 1Surgery and 2Pathology, Konan Hospital, Kobe, Japan.

Case: We report a case of pancreatic adenocarcinoma with inferior vena cava (IVC) and portal vein (PV) invasion. A 66-year old Japanese woman was admitted to our hospital for jaundice. Abdominal Computed tomography (CT) imaging demonstrated dilatation of intra and extrahepatic bile duct, and a hypovascular lesion that measured 30 mm in diameter in the head of the pancreas. This tumor was in contact with the PV and IVC, but signs of obvious invasion were not detected. Upper gastrointestinal endoscopy showed obstruction of the SDA of the duodenum. We choose upfront surgery considering the patient’s general condition being stable and the difficulty of endoscopic biliary drainage. Pancreaticoduodenectomy was performed. During surgery, stiff attachment between the tumor and the IVC was identified and wedge resection of the IVC wall was performed. PV resection and end-to-end reconstruction was also carried out. Pathological studies of the surgical specimen revealed direct invasion by the pancreatic adenocarcinoma to the adventitia of the IVC. The postoperative course was uneventful, the patient was discharged from the hospital on the 27th post-operative day. She underwent adjuvant chemotherapy (S-1; 100 mg/day) and is still alive without tumor recurrence 18 months after surgery.

Conclusions: Pancreatic adenocarcinoma often involves adjacent major vasculatures, such as PV or superior mesenteric vein. However, direct invasion to the IVC is uncommon. Resected case of pancreatic adenocarcinoma directly invading the IVC is rare. In our case, pancreaticoduodenectomy along with wedge resection of the IVC wall could safely be performed and no complication was observed. The prognostic impact of concomitant IVC resection for patients with pancreatic adenocarcinoma is unclear. There is a need for further accumulation of cases.

Carboxyl Ester Lipase (CEL) in Pancreatic Disease: The Position of Single-base Deletions in the Last Exon of the Gene may Predict Pathogenicity

A. Gravdal,1,2,3 X. Xiao,4 M. Cnop,5 M.E. Lowe,4 B.B. Johansson,3,6 A. Molven,1,3,7 K. Fjeld,2,31Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Bergen, Norway; 2Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway; 3Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway; 4Department of Pediatrics, Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO; 5ULB Center for Diabetes Research, Universite Libre de Bruxelles, Division of Endocrinology, Erasmus Hospital, Brussels, Belgium; 6Department of Pediatrics, Haukeland University Hospital, Bergen, Norway; 7Department of Pathology, Haukeland University Hospital, Bergen, Norway.

Background: We have previously identified disease-associated CEL mutations localized in a variable number of tandem repeats (VNTR) region of the gene. Single-base deletion in VNTR repeat 1 (DEL1) or repeat 4 (DEL4) cause a syndrome of diabetes and exocrine pancreatic dysfunction. DEL variants of unknown pathogenicity including deletions in repeat 9 (DEL9) or repeat 13 (DEL13) have been observed in control materials. All deletion variants lead to frameshifts and altered C-terminal sequences of the protein. Our aim was to evaluate the pathogenicity of single-base deletions within the CEL VNTR by testing various DEL variants in a cellular system.

Methods: HEK293 cells were transfected with constructs encoding CEL wild-type (WT), DEL variants (DEL1, DEL4, DEL9, DEL13) or TRUNC (a variant lacking the VNTR). To investigate the expression of CEL proteins and ER-stress markers, cellular fractions were assessed by Western blotting. Quantitative real-time PCR was performed to validate ER-stress at the transcriptional level. CEL enzyme activity was measured in conditioned media from transfected cells.

Results: Compared to CEL-WT, DEL9 and DEL13, the disease-causing CEL variants (DEL1, DEL4) as well as TRUNC showed reduced secretion, intracellular protein accumulation and increased levels of the ER-stress marker BIP. In addition, DEL1 and DEL4 showed significantly lower enzyme activity than all other variants. In Western blotting, the DEL variants migrated with various sizes despite having the same theoretical molecular mass, suggesting different patterns of post-translational modification of the VNTR.

Conclusions: The CEL protein is highly influenced by length, composition and post-translational modification of the VNTR region. Our results suggest that proximal single-base deletions (DEL1, DEL4) lead to an extended aberrant protein tail that makes CEL prone to misfolding and aggregation. This induces ER-stress as an initial cellular reaction to cytotoxicity. The distal deletions (DEL9, DEL13) behave more like the normal CEL protein.

Iron Levels and Lipocalin 2 Expression Modulate Responses of Cells in the Tumor Micro-environment of Pancreatic Ductal Adenocarcinoma

V. Grisanti,1,2,3 A.W. Dangel,1,2 A. Ludwig,1,2 O. Ueltschi,1,2 X. Mo,4 M. Pietrzak,4 A. Hite,4 R.F. Hwang,5 M. Traczek,1,2 N. Badi,1,2 Z. Cruz-Monserrate,1,21Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2The Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH; 3Interdisciplinary Nutrition Program and 4Department of Biomedical Informatics, The Ohio State University, Columbus, OH; 5Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX.

Background: Pancreatic Ductal Adenocarcinoma (PDAC) is the third leading cause of cancer- related death in the US. Cancer cells uptake high iron levels that could induce an epithelial-to- mesenchymal transition (EMT). Intracellular iron levels can be regulated by lipocalin-2 (LCN2), a secreted protein that chelates iron in the tumor microenvironment (TME) and promotes PDAC by modulating pro-inflammatory responses in pancreatic stellate cells (PSCs). The objective of this study was to determine how iron levels and LCN2 expression affected PDAC cell proliferation and metastasis.

Methods: Human PDAC cell lines BXPC3 (KRAS-wild-type) and PANC-1 (KRAS-mutant), and PSCs were treated with various iron levels. Cell proliferation was measured via MTT assays, and changes in the expression of pro-inflammatory cytokines and the LCN2 receptor SLC22A17 were measured via RT-qPCR. Invasion assays were performed to assess the migratory potential. The expression of EMT markers and the anti-metastatic gene N-myc downregulated gene-1 (NDRG1) were quantified. Moreover, the Lcn2 gene was deleted via CRISPR in mouse PDAC cells, and RNA sequencing analyses were done to assess the effects. The expression of NDRG1 and LCN2 were measured after iron treatments in the parental and Lcn2-KO cell lines via RT-qPCR.

Results: Iron regulation of cell proliferation depended on KRAS-mutation status. Increased iron treatments upregulated the expression of pro-inflammatory cytokines, EMT markers and invasion in BXPC-3 compared to PANC-1 cell lines, and reduced NDRG1 expression. Deletion of Lcn2 in mouse PDAC cells modified the expression of extracellular matrix (ECM) genes, and increased the expression of NDRG1, which was downregulated after iron treatments. Furthermore, iron chelation increased Ndrg1 and Lcn2 expression at high doses in parental mouse PDAC cells.

Conclusions: Iron responses in PDAC cells are dependent on KRAS mutation status. Further studies will determine the role of iron intake modulation and Lcn2 blockade in PDAC.

Circulating Tumor DNA in Prediction of Prognosis and Response to Nab-paclitaxel Based First-line Chemotherapy in Metastatic Pancreatic Cancer

S. Guan,1 Q. Han,1 J. Li,2 Y. Lv,1 H. Yan,1 L. Han,1 Y. Chen,1 N. Qian,1 Z. Wang,1 H. Shi,2 Y. Shi,1 G. Dai

1Departments of 1Medical Oncology and 2Pathology, the First Medical Center, Chinese PLA General Hospital, Beijing, China.

Background: This study was to investigate the prognostic value of circulating tumor DNA (ctDNA) and the clinical implication of dynamic assessment ctDNA in metastatic pancreatic cancer (MPC).

Methods: From 2015 to 2018 in our center, 40 MPC patients treated with nab-paclitaxel based first-line chemotherapy were prospectively collected both tumor tissue and blood samples, in which the genomic profiling of 425 genes was identified by next-generation sequencing. 29 of them had at least 2 plasma samples which were collected at baseline and periodical follow-ups until progression or death. High mutation allelic frequency (MAF) was defined >30% and >5% in tumor tissue and blood, respectively. Progression of ctDNA was defined as increased mutation MAF of common mutant gene from baseline or nadir, or the presence of new gene alternations.

Results: Among 40 MPC patients, tumor tissue and blood samples were available in 34 and 38 patients, respectively. The most commonly mutant gene were KRAS (31/34 in tissue, median MAF 29.4%, 29/38 in ctDNA, mMAF 8.2%), and TP53 (28/34 in tissue, mMAF 31.1%, 25/38 in ctDNA, mMAF 7.4%). MTKRAS in tissue with high MAF was associated with poor OS (high 7.5 m vs low 10.1 m, P = 0.001) in univariate and multivariate analyses (HR, 3.87; 95% CI, 1.47–10.19). Univariate analyses showed mtKRAS and mtTP53 in ctDNA with high MAF were associated with poor PFS (KRAS and TP53: high 3.4 m and 3.0 m vs low 6.1 m and 5.7 m, P = 0.001 and P = 0.004, respectively) and OS (KRAS and TP53: high 5.3 m and 5.3 m vs low 12.6 m and 10.1 m, P < 0.001, respectively). Among 29 patients with dynamic assessment ctDNA, 24 achieved progressive disease (PD), including 9 found earlier progression of ctDNA with median time of 1.93 months compared to image findings.

Conclusions: Peripheral ctDNA was a potential reliable alternative biomarker for prognosis and efficacy prediction in MPC.

A Novel Target That Required for Autophagy, Associated With Activation of Pancreatic Stellate Cells, Promotes Pancreatic Cancer Progression

W.Y. Guan,1 K. Nakata,1 K. Ohuchida,1,2 A. Sagara,1 S. Endo,1 Y. Ando,1 Z.L. Yan,1 S. Matsumoto,1 T. Shinkawa,1 Y. Ohtsubo,1 C. Iwamoto,2 T. Moriyama,1 N. Ikenaga,1 K. Shindo,1 T. Ohtsuka,1 K. Mizumoto,3 M. Nakamura.1Departments of 1Surgery and Oncology and 2Advanced Medical Initiatives, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; 3Cancer Center, Kyushu University Hospital, Fukuoka, Japan.

Background: Pancreatic stellate cells (PSCs) transdifferentiate from quiescent into activated state in tumor microenvironment. Activated PSCs produce extracellular matrix (ECM), secrete cytokines and chemokines. Subsequently, increase the aggressiveness of pancreatic cancer cells (PCCs). We have previously reported autophagy contributes to PSCs activation, but the mechanism is still unclear. The aim of this study is to investigate the mechanism of activation of PSCs.

Methods: We investigated Gene expression between human origin autophagic activated PSCs and non-activated PSCs using microarray. To examine the effect of predicted genes on PSCs activation, PSCs were transfected with small interfering RNAs (siRNA) and analyzed by immunofluorescence staining, immunoblots, quantitative reverse transcription polymerase chain reaction, and in assays for proliferation, migration, invasion and lipid droplets. Target Protein was knocked out in immortalized PSCs by expression of small hairpin RNAs (shRNA), and transplanted into pancreatic tails of nude mice to analyze tumor growth and metastasis.

Results: Based on gene expression microarray, Endoplasmic reticulum aminopeptidase 2 (ERAP2) is the top-scoring expression gene in autophagic activated PSCs compared with corresponding non-activated PSCs. After knockdown of ERAP2, PSCs activation marker and autophagy marker expression were suppressed, production of ECM components and interleukin 6 were reduced, while lipid droplets accumulation increased in cytoplasm. As well, their promoting effect on invasiveness of pancreatic cancer cell lines were ablated by ERAP2 knockdown.

Conclusions: ERAP2 is related with PSCs activation through autophagy, associated with production of ECM components and interleukin 6, which promote PDAC cell aggressiveness. ERAP2 is a potential target for stroma-directed therapy in the treatment of PDAC.

Simultaneous Upregulation of Heat Shock Protein 70, 90: Potential Targets Against Acute Pancreatitis and Pancreatic Ductal Adenocarcinoma

A. Gulla,1,2,3 Q. Wanglong,4 K. Strupas,2,3 G.H. Su,41Department of Surgery, Georgetown University Hospital, Georgetown, Washington, DC; 2Department of Surgery, Gastroenterology, Nephrology, Vilnius University Hospital “Santaros Klinikos”, Vilnius, Lithuania; 3Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; 4Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY.

Introduction: Heat shock proteins are important in a variety of cellular processes that include early protection against cell stress and inflammation. The inducible heat shock proteins-70 and 90 are anti-oxidative, anti-inflammatory and cytoprotective enzymes and reported in both acute pancreatitis (AP) and pancreatic ductal adenocarcinoma (PDAC), however their upregulating role remains unknown in AP leading to PDAC.

Methods: Acute pancreatitis (n = 50) patients and age-and sex-matched pancreatic cancer patients (n =50) were studied. Peripheral blood samples from pancreatitis and pancreatic cancer patients were collected on admission. Plasma samples were stored -80C. Commercially available ELISA kits were used to measure the levels of HSP-70 and HSP-90.

Results: The results are currently being analyzed.

Conclusions: Further studies are now underway to analyze the pancreatic levels of HSP-70 and HSP-90 in acute pancreatitis and pancreatic cancer to determine whether the presence of simultaneous upregulation of these proteins are protective and play anti-tumor role.

Bone Morphogenetic Protein Receptor 2 Promotes Pancreatic Cancer Progression Via the GRB2-Mediated PI3K-Akt-mTOR Pathway

H. Guo, Y. Wang, Z. Zhang, M. Li, F. Wang, X. Tian, Y. Yang

Department of General Surgery, Peking University First Hospital, Beijing, China.

Background: Tumor microenvironment favors aberrant expression of tumor cells characterized by dysregulated release of cytokines, chemokines, and growth factors that the tumor exploits for survival and invasion. The crosstalk of bone morphogenetic proteins and its receptors between tumor and its surrounding stromal cells have been reported in breast cancer, but effects of the interaction in pancreatic cancer remain unclear.

Method: The enrichment of BMP pathway gene set was anlaysis by GSEA software in three database of GEO. BMPR2 were reduced in PDAC cells via specific shRNA-mediated knockdown. Quantitative proteomic analysis was performed to explore the mechanism of BMPR2 regulation. The cell growth rate was assessed by CCK-8, flow cytometry and colony formation assays. ChIP-sequence was performed to identify and characterize smad complexes target genes.

Results: Here we demonstrate that BMP pathway was hyperactived in pancreatic cancer.BMPR2 was overexpressed in human pancreatic cancer specimens and associated with the prognosis of pancreatic cancer patient. Down-regulated BMPR2 markedly inhibits the growth of pancreatic cancer cell lines MIA PaCa-2 and PANC-1 in vitro and in vivo. Mechanistically, disrupt the expression of BMPR2 suppresses the expression of GRB2 in a smad-independent manner, and then inactivates GRB2-associated signaling pathways, PI3K-Akt-mTOR pathway. In addition, LDN193189, a BMP pathway inhibitor, can also impair the expression of BMPR2 and inhibit the functions of pancreatic cancer cells by GRB2-mediated PI3K-Akt-mTOR pathway.

Conclusions: Thus, our results suggest that BMPR2 is an important mediator of pancreatic cancer cells and its surrounding microenvironment and offer insight into therapeutic applications for better survival of patients with this deadly disease.

CDCA3 Promote Pancreatic Cancer Proliferation and Metastasis by Inhibited P53 Signal Pathway

S. Guo, H. Wang

Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongching, China.

Background: Cell division cycle associated protein-3 (CDCA3) is required for mitosis entry. New evidence suggests CDCA3 plays a role in tumor promotion. However, its function and corresponding mechanisms involved in pancreatic cancer (PC) remains largely unknown.

Methods: Immunohistochemical was performed to evaluate associations between CDCA3 expression and clinical characteristics. The biologic function of CDCA3 was investigated by loss-of-function and gain-of-function assays in vitro. The downstream pathway and target of CDCA3 was studied by RNA-seq research and Ingenuity Pathway Analysis (IPA). The signal pathway and targets were validated by Western blot experiments. Furthermore, the rescue assay was performed to confirm the downstream targets. Xenograft mouse model was applied to study therapeutic value in vivo.

Results: CDCA3 was significantly over-expressed in pancreatic cancer tissues and positively associated with clinical stage and patient prognosis. Multivariate survival analysis showed that it was an independent protective factor in PADC patients. The result was also validated by TCGA data. CDCA3 knockdown markedly suppressed pancreatic cancer cell proliferation, affected cell cycle progression and inhibited cell invasion. Strikingly, high-throughput sequencing analysis after CDCA3 silencing highlighted alterations in cell proliferation and adhesion pathways. The IPA analysis revealed p53 signaling pathway was remarkably activated. Mechanistically, we found CDCA3 increased the phosphorylation level of p53 through up-regulating CITED2. Furthermore, rescued assay was conducted to confirm that CITED2 could abolished cancer-promoting ability of CDCA3 in vitro and in vivo.

Conclusions: Our data revealed the mechanism that CDCA3 promoted tumor progression by inactivating p53 and may act as a potential prognostic biomarker and therapeutic target for PADC.

Novel Parameters of Pancreatic Neuroendocrine Tumor Assessment Using DOTATATE PET-CT SCAN

S. Gupta,1 S. Elhanafi,1 N.J. Patel,1 P.T. Hangge,2 L. Chen,3 C.C. Stucky,2 M. Yang,4 R. Pannala.11Division of Gastroenterology and Hepatology and Departments of 2Surgery, 3Pathology and Laboratory Medicine, and 4Radiology, Mayo Clinic Arizona, Scottsdale, AZ.

Background/Aims: Gallium-DOTA-D-Phe1-Tyr3-Thr8-octreotide positron emission topography/computed topography (DOTATATE PET/CT) imaging is superior to Octreoscan for diagnosis and staging of somatostatin receptor-positive pancreatic neuroendocrine tumors (pNETs). In a retrospective study of patients with pNETs who underwent DOTATATE PET/CT, we compared the correlation between maximum standard uptake value (SUV) and novel parameters such as metabolic tumor volume (MTV) and Krenning score (pathological uptake grading).

Methods: All patients who had a DOTATATE PET/CT at our institution (September 2016-2018) and had a primary pancreatic lesion (n = 47) were identified through the radiology database and selected as the study sample. In patients who had multiple studies, data from the initial study was utilized. Demographic, clinical and radiological data were entered into a RedCap database. Wilcoxon rank-sum and Fisher’s exact tests were used to compare continuous and categorical variables, respectively. Pearson’s correlation coefficient was calculated among the various parameters. Statistical analyses were performed using STATA 14.2.

Results: Median age was 65 (IQR, 53–73) and 24/47 (51%) were female. Median size and SUV of the dominant pancreatic lesion were 19.5 mm (IQR, 13–45) and 22 (IQR, 9.8–44.8) respectively. Median MTV was 6.1 (1.2–24.1) and 27 (60%) of tumors were graded as Krenning Score 4 (scale 1–4). There was good or very good correlation between tumor size and maximum SUV (r = 0.67, P = 0.0013), MTV (r = 0.78, P < 0001). Very good correlation was noted between MTV and size on surgical pathology when available (r = 0.87, P = 0.0229). Tumors with high pathological uptake (Krenning score 4 vs <4) were significantly larger (P < 0.001) and had higher SUV (P < 0.001) and MTV (P = 0.008).

Conclusions: Use of novel parameters such as MTV and Krenning score may provide additional information, compared to SUV and size alone in DOTATATE PET/CT scans for pNETs. Prospective evaluation of these markers and correlation with tumor grade and survival outcomes in pNETs should be the focus of future studies.

L-2-Hydroxyglutarate Drive Self-Renewal in Pancreatic Cancer in a Hypoxic Tumor Microenvironment

V. Gupta,1 N. Sharma,1 V. Garrido,1 K. Kesh,1 B. Durden,1 R. Hadad,1 D. Edwards,1 V. Dudeja,1 P. Singh,2 A.K. Saluja,1 S. Banerjee.11Department of Surgery, University of Miami, Miami, FL; 2University of Nebraska Medical Center, Omaha, NE.

Introduction: Pancreatic cancer remains a significant health burden associated with very low 5-year patient survival and poses a major therapeutic challenge. Pancreatic cancer cells undergo extensive metabolic reprogramming to deal with high demand of metabolic nutrients to fuel their rapid proliferation, which is mainly driven by oncogene-mediated cell-autonomous pathways, tumor microenvironment, and interactions with non-cancer cells. This results in abnormal accumulation of various metabolites which causes both metabolic and nonmetabolic dysregulation and potential transformation to malignancy and therefore termed as “oncometabolites”. Hypoxia is a major hallmark of pancreatic tumors which associated with increase in self-renewal. Aim: The present study investigates the role of Hypoxia mediated altered oncometabolite in regulating self-renewal in pancreatic cancer.

Methods: Pancreatic cancer cells (MIA PaCa-2 and S2-VP10) cultured in hypoxic environment (1.0% Oxygen) for 24 hrs. Cell lysates and culture supernatant analyzed for metabolites using liquid chromatography-mass spectrometry (LC-MS). Chiral derivatization was done by DATAN to separate L-2HG and D-2HG enantiomers by LC-MS. Gene expression were analyzed in different cell lines and conditions by QPCR.

Results: Metabolic mass spectrometric analysis showed that pancreatic cancer cells produce 2-hydroxyglutarate (2-HG) when exposed to hypoxic environment. Further analysis showed Hypoxic cells selectively accumulate L- enantiomer form both in cells as well as culture supernatant. Self-renewal requires critical balance between stemness and differentiation. Current study showed for the first time that L-2-HG regulates self-renewal by increasing expression of genes associated with stemness (Sox-2, CD133) and by decreasing expression of differentiation genes (PdX-1, HB9, NKX6.1). Similar genes expression was observed in cells under hypoxic environment. Further analysis showed that L-2-HG mediated H3K9 methylation regulates this balance of self-renewal and pro differentiation gens in pancreatic cancer in hypoxic environment.

Conclusions: Our results indicated that hypoxia mediated accumulation of L-2-HG upregulate self-renewal by shifting critical balance of gene expression towards stemness in pancreatic cancer. This increase in stemness contribute to chemoresistance and highly metastatic tumors associated with pancreatic cancer.

hENT1 RNA and Protein in Combination May Act as Predictive Biomarkers for Survival for Patients Treated With Adjuvant Gemcitabine in Pancreatic Cancer

J. Hale,1 A. Evans,1 K. Aughton,1 N.O. Elander,1,2 P. Ghaneh,1 J.P. Neoptolemos,3 R. Jackson,1 T.F. Cox,1 F. Campbell,1 C.M. Halloran,1 J.R. Mackey,4 A.G. Scarfe,4 J.W. Valle,5 R. Carter,6 D. Cunningham,7 N.C. Tebbutt,8 D. Goldstein,9 J. Shannon,10 B. Glimelius,11 M. Deakin,12 R.M. Charnley,13 A. Anthoney,14 M.M. Lerch,15 J. Mayerle,15,16 E. Costello,1 D.H. Palmer,1 M.W. Büchler,3 W. Greenhalf,1 for the European Study Group for Pancreatic Cancer

1Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, United Kingdom; 2Department of Oncology, Linköping University, Linköping, Sweden; 3Department of Surgery, University of Heidelberg, Heidelberg, Germany; 4Cross Cancer Institute and University of Alberta, Canada; 5University of Manchester/The Christie NHS Foundation Trust, Manchester, United Kingdom; 6Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom; 7Royal Marsden National Health Service (NHS) Foundation Trust, London and Surrey, United Kingdom; 8Austin Health, Melbourne, Australia; 9Prince of Wales Hospital and Clinical School, University of New South Wales, Australia; 10Nepean Cancer Centre and University of Sydney, Australia; 11Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden; 12North Staffs University Hospital, Staffordshire, United Kingdom; 13Freeman Hospital, Newcastle upon Tyne, United Kingdom; 14St James's University Hospital, Leeds, United Kingdom; 15Department of Medicine A, University Medicine Greifswald, Greifswald, Germany; 16Medizinische Klinik und Poliklinik II, Klinikum der LMU München-Grosshadern, München, Germany.

Background: Gemcitabine is used alone or in combination, in adjuvant and palliative treatment of pancreatic cancer. Benefit is patient specific and a comprehensive, stratified approach is required in order to improve outcomes. Human equilibrative nucleoside transporter 1 (hENT1) protein is a predictive therapeutic biomarker for patients receiving adjuvant gemcitabine. The relationship between hENT1 RNA expression and gemcitabine sensitivity remains unclear. The aim of this study was to evaluate hENT RNA as a greater predictive marker and its interaction with protein levels.

Method: Tissue microarray sections with 434 ESPAC-3(v2) patients underwent in situ hybridisation with RNAscope® and immunohistochemistry with validated antibodies. The relationship between RNA and protein expression was investigated in patient cores where matched RNA and protein data were available. 277 patients were included in the final analysis. Overall survival from date of randomization was analyzed using the Kaplan Meier method and Cox Regression

Results: Overall hENT1 mRNA and hENT1 protein did not correlate. Patients with high hENT1 protein and low hENT1 mRNA levels survived the longest time in this study when receiving Gemcitabine (median OS [95% CI] 33 [24.2–undefined] months, n = 41). Survival for patients with high mRNA and high hENT1 protein was not significantly greater than survival of patients with low hENT1 protein (median OS [95% CI] 24.1 [16.6–30.2] months, n = 41 vs 17.2 [14.1– 29.5], n = 34; HR, 1.29 [95% CI, 0.802–2.066]; P = 0.296).

Conclusions: Although expression of hENT1 protein remains a significant predictor of survival when receiving treatment with Gemcitabine this is only true in patients with low levels of hENT1 mRNA. Post-transcriptional modifications or feedback mechanisms within PDAC tumour cells are likely to be important for hENT1 expression and require further mechanistic work to evaluate. hENT1 regulation at the transcriptional level in primary tumour does not seem to indicate a benefit when treating residual tumour burden and metastases.

Chaiqin Chengqi Decoction Ameliorates Pain Via Inhibition of SP-NK1R-mediated Neurogenic Inflammation in Experimental Acute Pancreatitis in Mice

C. Han,1 T. Liu,1 Y. Wen,1 M. Zhu,1 X. Ma,1 J. Yang,1 K. Jiang,1 T. Jin,1 L. Deng,1 D. Du,2 A.R. Philips,3 J.A. Windsor,4 D.N. Criddle,5 R. Mukherjee,6 R. Sutton,6 Q. Xia,1 W. Huang.11Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China; 2West China-Washington Mitochondria and Metabolism Centre, West China Hospital, Sichuan University, Chengdu, China; 3Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand; 4Surgical and Translational Research Center, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; 5Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; 6Liverpool Pancreatitis Research Group, Royal Liverpool University Hospital and Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.

Background: The severity of abdominal pain is significantly correlated with disease severity and reduced quality of life in patients with acute pancreatitis (AP). Traditional Chinese formula chaiqin chengqi decoction (CQCQD) has been used in China to treat AP patients for many decades and its use is associated with markedly reduced requirements for analgesics. We sought to investigate the nature and mechanisms of analgesic effects of CQCQD in experimental AP.

Methods: Freshly isolated murine pancreatic acinar cells were incubated with taurolithocholic acid 3-sulfate disodium salt (TLCS; 500 μM), cholecystokinin (CCK; 100 nM), or substance P (SP; 1 μM) for 30 minutes with or without co-incubation of CQCQD (5 mg/ml); internalization of SP receptor (R) neurokinin-1 R (NK1R) was observed by confocal microscope. Mice received 7 intraperitoneal injections of cerulein (50 μg/kg) at hourly intervals, while control mice received normal saline injections. In the treatment group, 3 doses of CQCQD (10 g/kg intragastric administration) were begun at the third injection of cerulein, 2 h apart. Pain was assessed by Von Frey Filaments (VFF) test starting 30 min after the last injection of cerulein or saline injection. All animals were humanely sacrificed 12 h after the first cerulein injection to evaluate AP severity and neurogenic inflammation.

Results: TLCS, CCK and SP induced marked NK1R internalization and this was largely prevented by CQCQD co-incubation. Cerulein injections caused typical AP changes that were associated with decreased VFF threshold, reduced expression of pancreatic PAR2 and increased expression of c-Fos, PGP9.5, and RAMP1 in dorsal root ganglia. CQCQD administration significantly ameliorated the severity of AP and reverted VFF thresholds. CQCQD reduced expression of c-Fos, PGP9.5, and RAMP1, but statistical significance was not reached when compared with the cerulein group.

Conclusions: CQCQD prevented NK1R internalization in acinar cells and subsequent neurogenic inflammation, reducing nociception in experimental AP.

Patients With Chronic Pancreatitis Referred for Pancreatic Endotherapy Suffer From Poor Quality of Life

S. Han,1 M. Min,2 W.G. Park,3 S. Wani,1 A.R. Attwell,1 B.C. Brauer,1 M.S. Wagh,1 H.T. Hammad,1 W. Wassef,2 R.J. Shah.1

1Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO; 2Gastroenterology, University of Massachusetts Medical Center, Worcester, MA; 3Gastroenterology and Hepatology, Stanford University, Stanford, CA.

Background: Pancreatic Endotherapy (PeT) offers treatment options for patients with chronic pancreatitis (CP)-related complications including pancreatic duct stones, strictures, and pancreatic fluid collections. As few studies have examined the effect of PeT on quality of life (QOL), the aim of this study was to evaluate the baseline QOL of patients referred for PeT.

Methods: In this prospective multicenter study, subjects with CP referred for PeT (stricture dilation and stenting, lithotripsy, fluid collection drainage, and celiac plexus block) were given the PANcreatitis Quality Of Life Instrument (PANQOLI, 0-90, higher score representing better QOL) and a Visual Analog Scale (VAS, 0-100) for pain prior to any therapy. A control CP population not referred for PeT received the same questionnaires. Mean PANQOLI scores, VAS scores, and daily opiate requirements were compared between the groups using an unpaired t test. Multivariate linear regression was performed to identify risk factors for worse PANQOLI scores.

Results: Of the 147 total subjects (mean age 51.4, 53.7% male), 81 (55%) were referred for PeT. The PeT group had a significantly worse mean PANQOLI score than the control group (55 vs 59.3, P = 0.02) with lower scores in self-worth and emotional function. The two groups had no differences in VAS pain scores (42.4 vs 44.5, P = 0.68) or opiate requirements (70.4 vs 107.8 mg morphine/day, P = 0.08). Within the PeT group, subjects referred for celiac plexus block had the worst QOL (mean PANQOLI: 51.5) and highest pain levels (mean VAS: 55.9). Multivariate linear regression revealed that younger age was associated with worse PANQOLI scores (β: 0.51, P < 0.001).

Conclusions: Results of this multicenter study demonstrate that patients with CP referred for PeT have a worse QOL than patients not referred for PeT primarily due to poor self-worth and emotional function, which warrants further evaluation in studies examining whether PeT improves QOL in CP.

Myeloid-specific Dopamine D2 Receptor Signaling Controls Acute Pancreatitis Via Inhibiting M1 Macrophage Activation

X. Han,1,2 J.B. Ni,1,2 Z.K. Wu,1,2 L. Wen,1,2 X.P. Wang,1,2 G.Y. Hu,1,21Department of Gastroenterology, Shanghai General Hospital and 2Shanghai Key Laboratory of Pancreatic Disease, Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China.

Background: Macrophage infiltration and activation plays an important role on acute pancreatitis (AP). Our previous study showed that pancreas-specific dopamine D2 receptor (DRD2) signaling protects against AP. However, it is unclear whether myeloid-specific DRD2 signaling mediates AP severity. Therefore, in this study, we investigated the role of myeloid-specific DRD2 signaling on pancreatitis and macrophage polarization.

Methods: L-arginine-induced or cerulein and lipopolysaccharide (LPS)-induced AP was establised in wild-type and myeloid-specific Drd2-/- mice. Bone marrow-derived macrophages (BMDMs) were isolated and cultured from wild-type and myeloid-specific Drd2-/- mice, and then induced to M1 phenotype by LPS and IFNγ, or M2 phenotype by IL4. Changes of dopaminergic system in M1 or M2 macophages, effects of DRD2 activation on macrophage polarization, oxidative stress, NFκB and inflammasome signaling in BMDMs or in AP models were analyzed by qRT-PCR, western blotting, and flow cytometry.

Results: Dopaminergic synthesis was activated both in M1 and M2 macrophages, but DA receptor (DRD) expression was down-regulated in M1 while upregulated in M2 macrophages. Myeloid-specific Drd2-/- worsened pancreas injury and systemetic inflammation during AP and promoted macrophage to a pro-inflammatory M1 phenotype. DRD2 activation inhibited M1 macrophage activation in the in vivo and ex vivo setting of experimental AP. Furthermore, DRD2 activation in M1 macrophage from wild-type mice inhibited NADPH oxidase-induced ROS generation, consequently inhibited downstream NF-κB signaling and NLRP3 inflammasome activation. While M1 macrophage from myeloid-specific Drd2-/- exhibited increased NADPH oxidase-induced oxidative stress and consqeuently enhanced NF-κB signaling and NLRP3 inflammasome activation.

Conclusions: Our results showed that myeloid-specific DRD2 signaling controls AP through mediating M1 macrophage polarization and preventing macrophage ROS production, NF-κB signaling, and NLRP3 inflammasome activation. These novel finding suggested that DRD2 agonist might serve as a potential treatment for patients with AP.

Risk of Malignancy for Worrisome Features in Intraductal Papillary Mucinous Neoplasm: A Meta-analysis

Y. Han, J.S. Kang, Y.J. Choi, Y. Byun, H. Kim, W. Kwon, J.Y. Jang

Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Background: International guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) recommended surgical resection of those with specific characteristic. We performed meta-analysis to evaluate the risk of malignancy associated with revised Fukuoka guideline for the IPMN.

Method: We performed a comprehensive search of MEDLINE from January 1, 2000, to April 30, 2019, for studies that included any of the features mentioned in the consensus guidelines for pathological diagnosis by surgical resection or biopsy of branch duct IPMNs. Data were analyzed from 46 studies for the following features: cyst size greater than 3 cm, the presence of mural nodules, dilated main pancreatic duct, symptoms, and main duct vs branch duct IPMNs. Malignant IPMNs were defined as those with high grade dysplasia or invasive carcinoma. A meta-analysis was performed for each risk factor to calculate pooled odds ratios (ORs). A random-effects model was used, based on the assumption of variation among study populations.

Results: The risks of malignancy associated with individual cyst features were as follows: cyst size greater than 3 cm (OR, 1.78; 95% confidence interval [CI], 1.26–2.52), presence of a mural nodule (OR, 4.13; 95% CI, 3.59–4.75), cyst wall thickening (OR, 2.75; 95% CI, 1.64–4.60), dilatation of the main pancreatic duct (OR, 3.72; 95% CI, 2.63–5.26), and increased serum level of CA 19-9 (OR, 5.68; 95% CI, 2.45–13.18).

Conclusions: Based on a meta-analysis, worrisome features proposed by the international guidelines for resection of IPMN were highly associated with malignancy. Therefore, the presence of a worrisome feature should be treated for suspicious malignancy, carefully considering the weight of each feature's risk of malignancy.

Better Prediction of Post-resection Survival After Neoadjuvant Treatment (NAT) in Pancreatic Cancer: The PANAMA (PAncreatic cancer NeoAdjuvant MAssachusetts)-score

T. Hank,1,2 M. Sandini,1,2 C.R. Ferrone,1 M. Mino-Kenudson,3 M. Qadan,1 U. Klaiber,2 M. Weniger,1 U. Hinz,2 A.L. Warshaw,1 T. Hackert,2 K.D. Lillemoe,1 O. Strobel,2 C. Fernández-del Castillo.11Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA; 2Department of General Surgery, Heidelberg University Hospital, Heidelberg, Germany; 3Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Prognostic stratification following NAT for pancreatic cancer is challenging, since pathological determinants change during therapy. Prediction models such as the recently released 8th edition of the AJCC-staging system lack validation in the neoadjuvant setting. This study modelled and externally validated a new prognostic score based on pathological parameters and preoperative CA 19-9 levels.

Methods: NAT patients resected at MGH between 2007-2017 were analyzed. Tumor size, lymph-node involvement, R-status, and CA 19-9 levels were assessed by Kaplan-Meier survival analysis, and weighed with a Cox-proportional model. The PANAMA-score was computed from these variables according to a scale from 0 to 8 points and the predictive ability compared with the AJCC-staging system. The reproducibility of the score was assessed by receiver operating characteristic (ROC) curves through external validation in an independent cohort of contemporary NAT patients resected at Heidelberg University Hospital.

Results: The training cohort consisted of 216 patients. Multivariate analysis identified tumor size (0-3 points), number of positive lymph-nodes (0-2 points), positive R-status (0-2 points) and CA 19-9 ≥100 U/mL (0-1 points) as independently associated with impaired survival. Survival analysis according to a low (0-2 points), intermediate (3-5 points) and high (6-8 points) PANAMA-score indicated a good discriminatory power of the metric system (log-rank P = 0.003). The respective median survivals for these groups were not reached, 25 months, and 12 months. The PANAMA-score provided better accuracy than the AJCC-staging system, with AUC = 0.75 (0.68–0.80) vs AUC = 0.68 (0.56–0.79), respectively. External validation in 258 NAT patients confirmed the prognostic ability of the score, with AUC = 0.79 (0.67–0.90).

Conclusions: Stratification of post-resection survival after NAT using the 8th edition of the AJCC-staging system is suboptimal. The proposed PANAMA-score, based on independent predictors of post-resection survival, provides better discrimination and identifies a subgroup of patients who are at high-risk of early death. These patients could potentially be targeted for additional interventions.

Diabetes Mellitus is Associated With Unfavorable Pathologic Features, Increased Postoperative Mortality, and Worse Long-term Survival in Resected Pancreatic Cancer

T. Hank, M. Sandini, M. Qadan, M. Weniger, D. Ciprani, A. Li, C.R. Ferrone, A.L. Warshaw, K.D. Lillemoe, C. Fernández-del Castillo

Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: The risk of pancreatic cancer is increased in patients with diabetes mellitus, and even higher in cases of new-onset diabetes. However, the impact of diabetes mellitus on outcomes following surgical resection is not fully understood. The aim of this study was to explore the effects of diabetes on short and long-term outcomes in a single-institution cohort of patients undergoing resection for pancreatic cancer.

Methods: Surgical resections for pancreatic cancer between 2007 to 2016 were identified from a prospective database. Data on demographics, pathology, and perioperative outcomes were compared between patients with or without diabetes mellitus. Survival analysis was performed using Kaplan-Meier curves and adjusted for confounders by a Cox-proportional hazards model.

Results: 662 patients were identified, of whom 277 (41.8%) had diabetes mellitus. Diabetic patients were predominantly male, had higher BMI, and had higher ASA-scores than non-diabetic patients. On final pathology, diabetes was associated with larger tumors (30 vs 26 mm; P = 0.041), higher rates of lymph-node involvement (69% vs 59%; P = 0.031), and higher rates of perineural invasion (88% vs 82%; P = 0.026). Despite similar severe complication rates, diabetic patients had higher 30-day mortality (3.2% vs 0.8%; P = 0.019) and longer hospital stay (8 vs 7 days; P = 0.019). Diabetic patients had significantly worse median overall survival (18 vs 34 months; P < 0.001). A subset analysis showed this effect to be more pronounced in 290 patients who received neoadjuvant treatment, with median survival of 18 vs 54 months (P < 0.001) in patients with and without diabetes, respectively. On multivariate analysis, diabetes mellitus was confirmed as an independent predictor of post-resection survival (HR, 1.51; P = 0.001).

Conclusions: Diabetes mellitus is commonly encountered in patients with pancreatic cancer, and was associated with unfavorable pathology, and worse postoperative and long-term outcomes. These effects were more pronounced in patients who underwent resection after neoadjuvant therapy.

BZW1 Facilitates Pancreatic Ductal Adenocarcinoma Growth Through Potentiating HIF1α/c-MYC IRES-dependent Translation

J. Hao.

Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.

Background: The desmoplasia and poor vascularity cause severe metabolic stress in pancreatic ductal adenocarcinomas (PDACs). Cancer cells preferentially metabolize glucose by glycolysis to support cell survival and growth. We investigated the roles of BZW1 in the growth of PDAC.

Methods: BZW1 expression levels were detected in PDAC tissues and cell lines. BZW1 gene was overexpressed or knocked down in PDAC cells using CRISPR/Cas9 system and cell proliferation and apoptosis were measured. Regulation of glycolysis by BZW1 was assessed by determination of the extracellular acid ratio, glucose consumption and lactate production as well as metabolomics. We analyzed TCGA data to identify correlations between BZW1 and glycolysis-related genes. PDAC cell lines were grown as xenograft tumors in mice, and tumor growth and metabolism were measured by imaging analyses.

Results: BZW1 was overexpressed in human PDAC tissues compared with non-tumor tissues. Increased levels of BZW1 was correlated with tumor size and patient survival time. Overexpression of BZW1 increased proliferation and prevented apoptosis both in cells and xenograft tumors in mice. We observed a correlation between BZW1 and glycolytic flux in PDAC cells. The mRNA level of BZW1 was positively correlated with multiple glycolysis enzymes in TCGA data. BZW1 recruits PERK to eIF2α leading to its phosphorylation, which promoted HIF1α/c-MYC internal ribosome entry site (IRES) -dependent translation to increase the Warburg effect. Administration of Salubrinal to xenograft mice slowed growth and metabolism of established pancreatic tumors and prolonged survival of the mice.

Conclusions: PDACs have increased levels of BZW1, which promoted HIF1α/c-MYC IRES-depend translation via activating eIF2α phosphorylation. These increases facilitate tumor glycolysis under metabolic stress and promote growth of pancreatic tumors and PDAC xenograft tumors.

Clinical Characteristics of Smoking Related Chronic Pancreatitis

L. Hao,1,2 Y. Liu,3,4 H.L. Guo,3,4 Z.S. Li,3,4 L.H. Hu,3,41Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University, Hangzhou, China; 2Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China; 3Department of Gastroenterology, Gongli Hospital, The Second Military Medical University, Shanghai, China; 4Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.

Background: The pathogenesis of chronic pancreatitis (CP) is incompletely understood. With the in-depth researches, smoking has a toxic effect on pancreas. Targeted researches on smoking related CP should be carried out.

Methods: CP patients admitted to our center from January 2000 to December 2013 were enrolled. Characteristics were compared between smoker group, drinker group and group of patients who never smoke or drink (control group). Cumulative rates of diabetes mellitus (DM), steatorrhea, pancreatic stone, pancreatic pseudocyst (PPC), and biliary stricture after the onset of CP were calculated, respectively.

Results: A total of 1324 patients were enrolled. Among them, 55 were assigned to the smoker group, 80 to the drinker group, and 1189 to the control group. Smokers are different from the other two groups in many aspects, especially in age at the onset and diagnosis of CP, initial manifestation, and type of pain. The development of DM (P = 0.011), and PPC (P = 0.033) were significantly earlier and more common in the smoker group than the other two groups. Steatorrhea also developed significantly more and earlier in the smoker group than the control group (P = 0.029).

Conclusions: The clinical course of CP caused by tobacco is different from that caused by alcohol. Tobacco may accelerate the loss of endocrine and exocrine function, and development of PPCs. Accordingly, less pain was observed. Thus, smoking related CP may be an independent subgroup of CP, similar to alcoholic CP.

Acinar Cell Carcinoma With Tumor Expression Into the Pancreatic Duct

S. Harada, Y. Fujimoto, G. Shindo, M. Yamashita, K. Ishibashi, M. Nonaka, A. Furudoi, H. Hyougo, Y. Aisaka, H. Komatsu, H. Tokumo

Department of Gastroenterology and Hepatology, JA Hiroshima General Hospital, Hiroshima, Japan.

Background: Pancreatic acinar cell carcinoma (ACC) is a relatively rare tumor that accounts for about 1% of all pancreatic carcinomas in Japan. Here we report a rare case of ACC which progress into the pancreatic duct.

Case: A 71-year-old woman consulted to a hospital with right hypochondrial pain. Abdominal ultrasonography revealed a gallbladder stone and she was admitted to our hospital for further examination of the tumor. Abdominal CT scan showed a 2cm tumor in the head of the pancreas. In contrast-enhanced CT, the surrounding area of the tumor was enhanced gradually. The main pancreatic duct was not dilated. MRI showed a low signal at T1WI and a high signal at T2WI. In MRCP, the tumor was suspected communicating with a branch of pancreatic duct. EUS revealed an irregular hypoechoic mass in the pancreatic head and a hypoechoic area was observed around the mass. We suspected fluid retention around the tumor. In ERP, a tumor image was observed in the branch of pancreatic duct. On FDG-PET scan, an abnormal accumulation of SUVmax 3.5 FDG was detected in the pancreatic head. The preoperative diagnosis was intraductal ductal papillary tumor, ACC, or neuroendocrine tumor. We performed a subtotal pylorus-reserving pancreatoduodenectomy. The final histological diagnosis revealed the ACC of pancreas. A part of the ACC was invading into the branched pancreatic ducts of the pancreatic head.

Conclusions: We report a rare case of ACC. We make a comprehensive review of the literature.

Clinical Significance of Drainage Culture Contamination in Pancreatic Fistula After Distal Pancreatectomy

T. Harino,1 K. Noguchi,1 Y. Yanagimoto,1 Y. Takahashi,1 M. Hirota,1 T. Tanida,1 Y. Tomimaru,2 S. Noura,1 H. Imamura,1 J. Shimizu,1 T. Iwazawa,1 K. Dono.11Department of Surgery, Toyonaka Municipal Hospital; 2Department of Gastroenterological Surgery, Osaka University, Suita, Japan.

Background: Postoperative pancreatic fistula (POPF) is one of the most harmful complications after distal pancreatectomy (DP). Although it has been reported that drain culture-positive is associated with the occurrence of POPF after pancreatoduodenectomy (PD), the association with DP remains unclear.

Methods: A total of 66 patients who underwent DP at our institution from January 2010 to May 2019 were retrospectively analyzed to investigate the relationship between POPF and drain fluid culture. Postoperative pancreatic fistula was graded based on the International Study Group for Pancreatic Fistula grading criteria.

Results: Of 66 patients, the mean age was 67.5 ± 17.5 years, male to female ratio was 42/24. The pancreatic disease included 37 cases of pancreatic cancer, 6 cases of NET, 5 cases of SPN, 7 cases of IPMN, 3 cases of MCN and 8 cases of others. Open surgery was performed in 44 cases whereas laparoscopic surgery was performed in 22 cases. The mean operative time was 251.7 ± 93.6 minutes and mean intra-operative blood loss was 352.9 ± 371.3 mL. Combined gastrointestinal resection was performed in 11 cases. Grade B/C POPF was observed in 20 cases (30.3%). The incidence of grade B/C POPF was significantly higher in the culture-positive cases (14/15; 93.3%) than in the culture-negative cases (6/51; 11.7%) (P < 0.0001). The culture was positive in 2 cases (3.0%) within 3 POD (post-operative day); moreover, both cases developed grade B/C POPF. Staphylococcus contamination was detected in 3.8% (1/6 cases) in drainage tube removal before 4 POD, compared to 12.5% (5/40 cases) in drainage tube removal after 5 POD. This result indicated that long-term of drainage might cause infection.

Conclusions: POPF was significantly higher in culture-positive cases. Drainage which lasts more than 5 days can be a risk factor of retrograde infection.

An Update to the Phase 1/2 Study Evaluating the Pharmacokinetics, Efficacy, and Safety of Camostat Mesilate in the Treatment of Chronic Pancreatitis (TACTIC)

P.A. Hart,1 J. Nuttall,2 on behalf of the TACTIC Study Team

1Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; 2Kangen Pharmaceuticals, America LLC, Kansas City, KS.

Background: Chronic pancreatitis (CP) frequently causes an abdominal pain syndrome associated with an impaired quality of life, with no consistently effective treatment strategy. Camostat mesilate (NI-03), a serine protease inhibitor, is approved at 200 mg 3 times daily (TID) in Japan to alleviate symptoms of CP. A phase 1/2 study (NCT02693093) was designed to study camostat as a treatment for CP in the United States. The initial phase studied the pharmacokinetics and safety of 100, 200, or 300 mg doses, and demonstrated safety in 18 subjects. The phase 2 double-blind, randomized, parallel-group, dose-ranging study is underway to further assess the safety and efficacy of camostat versus placebo.

Methods: For phase 2, subjects aged ≥18 years diagnosed with CP with a baseline average daily worst pain score ≥4 using the numeric rating system (NRS) and receiving ≤100 mg morphine equivalents daily are being randomized to receive camostat at 100, 200, or 300 mg TID or placebo for 28 days. The primary endpoint is a 4-week change from baseline of the average daily worst pain intensity score with the NRS. Secondary endpoints include efficacy analyses of patient-reported outcomes and safety outcomes.

Results: As of May 20, 2019, 63 subjects have completed the study out of 78 subjects enrolled into phase 2. A total of six serious adverse events (SAEs) have been reported in three subjects; none of these events were dose-limiting toxicities. In all but one case, the SAEs occurred during the follow-up period and none were considered related to study treatment. Only one subject has withdrawn due to an adverse event of nausea/vomiting while on treatment, which was considered possibly related to treatment.

Discussion: No major concerns were identified in a blinded interim safety analysis, and the phase 2 assessment of efficacy and safety is ongoing.

Usefulness of Endoscopic Ultrasonography-guided Pancreatic Duct Drainage for Patients in ERCP Failure With Pancreatitis Due to Obstruction of Pancreatic Duct

S. Hasegawa, T. Sato, K. Kubota, T. Takahashi, Y. Kurita, K. Hosono, A. Nakajima.

Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan.

Background: The usefulness and safety of endoscopic ultrasonography-guided pancreatic duct drainage (EUS-PD) is reported as a salvage therapy of cases where normal ERCP is difficult for recurrent pancreatitis due to the obstruction of the pancreatic duct and the obstruction of the pancreatic tract. We evaluated the feasibility and efficacy of EUS-PD (Rendezvous technique or ante-grade stenting).

Methods: We included consecutive 14 patients (age: mean 68 years; range, 39–78 years, ten men) who were performed EUS-PD from October 2010 to April 2019. We retrospectively investigated technical success rate, clinical success rate and adverse event. In our strategy of EUS-PD, first we try the rendezvous technique in case of normal dissection and that the passage of guidewire to pancreatic duct stenosis is possible. As the next method, we try the antegrade stenting in case of postoperative anatomic stenosis in the case that the passage of guidewire is impossible.

Results: EUS-PD was required due to the recurrent acute pancreatitis in all 14 patients. Underlying disease was chronic pancreatitis in 10, stricture of pancreatodigestive anastomosis after pancreatoduodenectomy in 2, stricture of pancreatic duct after endoscopic papillectomy in 1, and cholangiocarcinoma in 1. Rendezvous procedure were performed in 7 patients, antegrade stenting were in 5, only pancreatography were in 2. The technical success rates of rendezvous and antegrade stenting were 78% (7/9) and 100% (5/5), and in all cases were 86% (12/14). Clinical success was achieved in 100% (12/12). The adverse event rate was 36% (5/14) and included cases of mild pancreatitis in 2 and peritonitis in 3.

Conclusions: EUS-PD is a technically feasible and relatively safe option for patients who failed conventional ERCP.

Residual Total Pancreatectomy for Pancreatic Cancer Arising From the Remnant Pancreas After Pancreatectomy: Operative Outcome and Genetic Mutation Analysis

D. Hashimoto, T. Okawa, F. Matsumura, Y. Shibata.

Department of Gastroenterological Surgery, Omuta Tenryo Hospital, Omuta, Japan.

Background: Residual total pancreatectomy (RTP) is performed for local recurrence of pancreatic cancer (PC) or new primary PC after initial pancreatic resection. There are limited data available regarding this so-called remnant PC and R-TP. The aim of this retrospective study was to assess outcomes after RTP and establish a treatment strategy for remnant PC via RAS mutation analysis.

Methods: Operative outcome of RTP (n = 18) and one-stage TP (OTP (n = 15) were analyzed retrospectively from 2005 to 2015 in a single institution. RTP group included 9 pancreatic head RTP (hRTP) after distal pancreatectomy and 9 pancreatic tail RTP (tRTP) after pancreaticoduodenectomy. In the other multicenter retrospective cohort of remnant PC, overall survival (n = 50) and RAS mutation (n = 17) of the initial tumor and of remnant PC were analyzed.

Results: In the single institution cohort, the median operative time and the median blood loss were not significantly different between hRTP (525 min, 741 g) and O-TP (568 min, 723 g). However, tRTP revealed significantly shorter operative time (369 min) and less bleeding (318 g). There were no in-hospital deaths in all groups. Postoperative complications were observed in 2 patients (13%) in OTP (delayed gastric emptying, cholangitis) and 2 patients (22%) in hRTP (pneumonitis, bile leakage). No postoperative complications were observed after tRTP. In the multicenter cohort, 37 patients underwent a second pancreatectomy for remnant PC (resected group), while 13 patients were not operated (unresected group). The median overall survival times were 42.2 months in the resected group and 12.3 months in the unresected group (HR, 0.374; 95% CI, 0.17–0.83). In RAS mutation analysis, no case had completely consistent missense variants between the initial tumor and remnant PC.

Conclusions: RTP is a feasible procedure for remnant PC and can prolong patient survival. RAS mutation analysis indicated that many remnant PCs are developed from metachronous multifocal origins.

Side to End Method of Endoscopic Double Stenting (EDS) for Malignant Biliary and Duodenal Obstructions is Safe and Easy for Re-intervention

R. Hashimoto, T. Hisano, M. Miki, R. Sugimoto, M. Furukawa.

Department of Hepato-Biliary-Pancreatology, National Hospital Organization, Kyusyu Cancer Center, Fukuoka, Japan.

Background: EDS for malignant biliary and duodenal obstruction has been performed. Although the prognosis for the cases with malignant gastric outlet obstruction (GOO) is described as poor, advances in chemotherapy have led to prolonged prognosis and re-intervention has been increasing. ERCP via the duodenal stent is considered to be difficult to manipulate, and the success rate of re-intervention for biliary strictures has been reported as 30-40%. We reviewed retrospectively the efficacy, safety, and re-intervention success rate of cases who underwent EDS with side to end method for malignant biliary and duodenal obstruction.

Methods: 21 cases underwent this method for malignant biliary and duodenal obstruction in our hospital from May 2012 to May 2019.18 cases had pancreatic cancer and others had Vater’s papillary cancer, colon cancer, and vaginal cancer, respectively. The long-term outcomes were assessed in the cases.

Results: The procedure success rate was 100%. One case had stomach ache accompanied with the pancreatic duct expansion as the adverse event. The overall survival after EDS was 21-590 day (median term was 129 day). After EDS, 15 cases needed re-intervention. In 3 cases the duodenal stricture was so strong that the endoscope could not reach to the papilla. But in the accessible cases, the success rate of re-intervention was 100% and biliary stent replacement and additional treatment was able to be performed. Although biliary metallic stent was found to be broken as the adverse event in one case, the removal and replacement could be done. After EDS, chemotherapy could be continued in 15 cases.

Conclusions: Re-intervention under ERCP is considered to be difficult, however, using side to end method, re-intervention could be possible with high success rate after EDS for malignant biliary and duodenal obstructions. It would contribute to prolongation for the survival.

Adipophilin Expression is an Indicator of Poor Prognosis in Patients With Pancreatic Ductal Adenocarcinoma: An Immunohistochemical Analysis

Y. Hashimoto,1 M. Ishida,2 H. Ryota,1 T. Yamamoto,1 H. Kosaka,1 S. Hirooka,1 S. Yamaki,1 M. Kotsuka,1 Y. Matsui,1 H. Yanagimoto,1 K. Tsuta,2 S. Satoi.1Departments of 1Surgery and 2Pathology and Clinical Laboratory, Kansai Medical University, Osaka, Japan.

Background: Adipophilin is a lipid droplet-associated protein, and its expression has been correlated with aggressive clinical behavior in some types of carcinomas, though its role in pancreatic ductal adenocarcinoma (PDAC) has not been clarified. This study aimed to evaluate the role of adipophilin in PDAC.

Methods: By immunohistochemical staining using tissue microarrays, we analyzed the expression profiles of adipophilin in 181 consecutive PDAC patients who underwent macroscopic margin-negative resection from January 2008 to December 2015. Overall survival (OS) and recurrence-free survival (RFS) were compared based on adipophilin expression, and the risk factors for OS, RFS, and early recurrence (within 6 months) were analyzed.

Results: Of the 181 evaluated patients, 51 (28.2%) were positive for adipophilin expression. A histopathological grade of 3 (P = 0.0012), higher CA 19-9 level (P = 0.0016), and R1 status (P = 0.028) were significantly associated with adipophilin- positive patients who had significantly poor OS and RFS compared to those associated with adipophilin-negative patients (P = 0.0007 and P = 0.0022, respectively). They also showed a significantly higher incidence of early recurrence (P = 0.030), based on multivariate analyses.

Conclusions: Adipophilin is a potential independent prognostic marker for PDAC.

Borderline Resectable Pancreatic Cancer With Artery Involvement: Preoperative Evaluation & Response

S. Hata, A. Kuroda, M. Hayasaka, H. Yamaguchi, M. Teruya, M. Kaminishi.

Department of Gastrointestinal Surgery, Showa General Hospital, Tokyo, Japan.

Background: It has been still controversial to perform surgical resection with borderline resectable pancreatic cancer (BRPC) with artery involvement (BR-A), because an aggressive surgery leads to high morbidity and mortality with low R0 rate for the BR-A patients. Precise evaluation of the tumor status after neoadjuvant therapy is important. In this study, we evaluated the relationship between the preoperative evaluation and R0 resection rate.

Methods: Six patients who had BR-A and received neoadjuvant therapy before potentially undergoing surgery at our institution between 2015 and 2019 were enrolled. We collected data on imaging, tumor markers, pathologic response and resection rate.

Results: According to the findings of computed tomography (CT) imaging, 5 patients (83%) had partial response and 1 patient (17%) had stable disease. However, the abutment to the superior mesenteric artery did not disappear in all patients and no patient got downstaged by neoadjuvant therapy. High 18F-fluorodeoxyglucose (FDG) accumulation in positron emission tomography (PET) was markedly decreased in all patients after neoadjuvant therapy. Serum CA 19-9 level before neoadjuvant therapy is high in 3 patients and that of after neoadjuvant therapy decreased to within normal range in all the 3 patients. As for pathologic response grade according to the Evans criteria, 3 patients (50%) had 1b, 2 patients (33%) had 2b, and the other (17%) had 3. The R0 resection rate was 100% (6/6).

Conclusions: After neoadjuvant therapy, 100% (6/6) of patients with BR-A successfully undergo R0 resection. When evaluating neoadjuvant therapy effect in the BR-A patients, tumor markers and FDG-PET in addition to CT imaging would be useful.

Classification of Cyst Type by Circulating Cell-free DNA as a Liquid Biopsy for Pancreatic Cystic Neoplasms

T. Hata,1 M. Mizuma,1 F. Motoi,1 M. Iseki,1 Y. Omori,2 S. Aoki,1 T. Takadate,1 K. Kawaguchi,1 T. Aoki,1 T. Morikawa,1 K. Nakagawa,1 H. Hayashi,1 T. Kamei,1 T. Naitoh,1 T. Furukawa,2 M. Unno. 1

Departmentd of 1Surgery and 2Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Pancreatic cystic neoplasms are becoming increasingly prevalent due to the improvement of high-resolution imaging modalities. To select the optimal management, accurate diagnosis of cyst type and the prediction of histological grades need to be improved. In this study, we examined the clinical utility of liquid biopsy in pancreatic cystic neoplasms.

Methods: A total of 34 patients with histologically proven Intraductal papillary mucinous neoplasms (IPMN, n = 20), Mucinous cystic neoplasm (MCN, n = 9), Solid pseudopapillary neoplasm (SPN, n = 5) were included in this study. Circulating cell-free DNA (ccfDNA) was extracted from plasma, and the hot-spot somatic mutations of KRAS (codons 12 and 13) and GNAS (codon 201) were analyzed using droplet digital PCR. We compared the prevalence and variant pattern of KRAS/GNAS mutations between the plasma and paired surgically aspirated cyst fluid samples. Clinicopathological features of ccfDNA mutant-positive cases were also investigated.

Results: The positive prevalence of GNAS mutant alleles in ccfDNA samples was significantly higher in cases with IPMN (16 of 20 cases, 80%) than with other cystic neoplasms (22% of MCN and 0% of SPN cases, P < 0.001). We also detected GNAS mutations in all available IPMN cyst fluid samples (10/10, 100%). Identical GNAS missense variants were detected in 7 of 8 evaluable paired samples of plasma and cyst fluid harboring GNAS mutations. On the other hand, only 2 (10%) ccfDNA samples harbored the KRAS mutant alleles in cases with IPMN, whereas KRAS mutations were observed in 75% of IPMN cyst fluid samples. KRAS/GNAS mutant allele frequencies from ccfDNA showed similar distributions between low-grade and high-grade dysplasia IPMN cases.

Conclusions:GNAS mutation detection in ccfDNA may serve as a novel biomarker for differential diagnosis of IPMN from other pancreatic cystic neoplasms. However, it is insufficiently accurate for predicting high-risk IPMN.

Pancreaticoduodenectomy was Performed for Patients With Stenosis of Celiac Axis

M. Hayasaka, S. Hata, A. Kuroda, H. Yamaguchi, M. Teruya, N. Kaminishi

Department of Gastroenterological Surgery, Showa General Hospital, Tokyo, Japan.

Background: Stenosis of celiac axis is rarely symptomatic, but during the procedure of pancreaticoduodenectomy, it leads to ischemia of hepatic artery or organs of upper abdomen, and it can cause morbidity and mortality.

Methods: From January 2011 to March 2019, pancreaticoduodenectomy was performed for 162 patients in our institute. 5 cases of them with stenosis of celiac axis were enrolled in this study. The diagnosis, cause of stenosis, treatment, morbidity of these patients were evaluated.

Results: The median age of patients performed pancreaticoduodenectomy with stenosis of celiac axis was 70 years old. 1 case also had stenosis of superior mesenteric artery (SMA). The diagnosis of 5 patients was as followed; 2 cases were cholangiocarcinoma, 1 case was Vater papilla cancer, 1 case was IPMC, and another case was pancreatic head cancer. The cause of celiac axis stenosis was arteriosclerosis in 3 cases, and median arcuate ligament syndrome in 2 cases. 2 arteriosclerosis cases underwent pancreaticoduodenectomy with preserving arcade between celiac axis and SMA, 1 arteriosclerosis case was performed stent placement to celiac axis. 1 case of median arcuate ligament syndrome was performed coil embolization of anterior superior pancreaticoduodenal artery (ASPDA) before the operation, and another case underwent median arcuate ligament resection during pancreaticoduodenectomy. None of 5 cases suffered from ischemia of upper abdominal organs, but 1 arcade preserving case experienced bleeding of pseudo aneurysm of ASPDA, and he underwent coil embolization.

Conclusions: When performing pancreaticoduodenectomy for patients with stenosis of celiac axis, precise evaluation of collateral artery flow is needed. And insertion of stent to celiac axis, or dividing median arcuate ligament, preserving the collaterals between SMA and celiac axis could prevent from abdominal ischemia.

Usefulness of Sound Speed Correction Mode in Endoscopic Ultrasonography for Diagnosing Pancreatic Diseases

K. Hayashi, S. Ikarashi, S. Terai.

Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.

Background: Contrast-enhanced Harmonic Endosopic Ultrasonography (EUS) and EUS elastography has contributed to the diagnosis of the pancreatic diseases. However, because neither technique is quantitative, an objective method for numerical evaluation is preferred. The aim of this study was to examine the usefulness of using a sound speed correction mode to measure the optimal ultrasonic speed for an area of interest.

Methods: From December 2017 to September 2018, at our department, 87 patients underwent EUS using sound speed correction mode. Using the SU-1 system (Scope: EG-580UR/EG-580UT [FUJIFILM]), sound speed correction values (m/s) were measured thrice in an area of interest in each organ to calculate the mean value. We examined the (1) patient characteristics, and calculated the differences in the mean sound speed correction values between (2) pancreas with early stage chronic pancreatitis and chronic pancreatitis, and, (3) pancreatic cancer and background pancreas and other disease.

Results: (1) The subjects comprised 45 men and 42 women, with median age of 65 years (range, 20–88 years), and had intraductal papillary mucinous neoplasm (IPMN) (n = 19), pancreatic cancer (n = 12), biliary diseases (n = 14), autoimmune pancreatitis (AIP) (n = 6), or other diseases (n = 36). Three patients had early chronic pancreatitis and 3 cases had chronic pancreatitis. The mean sound speed correction values measured were as follows: (2) early chronic pancreatitis, 1510 (1477–1513) m/s; chronic pancreatitis, 1517 (1513–1603) m/s (P = 0.08). (3) pancreatic cancer, 1530 (1520–1557) m/s, background pancreas, 1513 (1413–1603) m/s (P = 0.01). AIP, 1523 (1507–1527) m/s (P = 0.88).

Conclusions: Differences in mean sound speed correction values was observed between the pancreas cancer and background pancreas. A sound speed correction mode may be useful for the diagnosis of pancreatic cancer.

Endoscopic Ultrasound Guided Pancreatic Duct Intervention and Pancreaticogastrostomy Using a Novel Cross-platform Technique With Small Caliber Devices

U. Hayat,1 M.L. Freeman,1 G. Trikudanathan,1 N. Azeem,1 S.K. Amateau,1 J.S. Mallery.11Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN.

Background: Endoscopic ultrasound (EUS) guided pancreaticogastrostomy (PG) has been used as an alternative to surgery to drain pancreatic ducts for treatment of disconnected pancreatic duct syndrome (DPDS). Previous techniques involved using needle-knife cautery, bougie dilation or a stent extraction screw to allow stent passage through the gastric wall and pancreatic parenchyma, with potential for severe complications including duct leak, especially if drainage fails. A novel technique employing EUS guided puncture of the main pancreatic duct (MPD) with a 19 or a 22 gauge needle, passage of an 0.018 guidewire, dilation of the tract with a small diameter (4 F) angioplasty balloon and placement of 3 F plastic stents with the pigtail curled inside the duct as an anchor.

Methods: This is a retrospective case series at a single tertiary center. EUS-guided PG was considered when conventional endoscopic pancreatic duct drainage failed. Main outcomes included technical and clinic success and complications.

Results: 8 patients underwent PG. Indications were DPDS (n = 4), stenotic pancreaticoenteral anastomosis after Whipple procedure (n = 3) and chronic pancreatitis with dilated MPD (n = 1). Median MPD diameter was 6.75 mm [IQR, 2.8–7.6]. Technical success was achieved in 7 (88%) of 8 cases; angioplasty balloon passed into the pancreatic duct in all accessed ducts. There was one asymptomatic duct leak, and no major or delayed complications, with clinical improvement (complete or partial) in 5 (71%) of 8.

Conclusions: EUS-guided PG using a small caliber guidewire, 4 F angioplasty balloon, and reverse 3F single pigtail stents offers a safe and atraumatic alternative without use of cautery.

Irreversible Electroporation Followed by Chemotherapy vs Chemotherapy Alone for Locally Advanced Pancreatic Cancer: A Large Cohort Propensity Score Analysis

C.B. He, 1 J. Wang, 1,2 S.P. Li, 1Departments of 1Pancreatobiliary Surgery and 2Ultrasonics, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.

Background: Locally advanced pancreatic cancer (LAPC) has a dismal prognosis with the standard chemotherapy and the local progression contributed to nearly one-third of deaths of these patients. Irreversible electroporation (IRE) is a local destructive method which is feasible for the treatment of LAPC. The aim of this study was to evaluate IRE combined with chemotherapy as a new treatment and compared its efficacy with that of chemotherapy alone for LAPC patients.

Methods: Data of LAPC patients who received chemotherapy combined IRE or not were extracted from database of the Surveillance, Epidemiology, and End Results (SEER) and Sun Yat-sen University Cancer Center (SYSUCC). The efficacy of these two treatments was compared based on data analyzed with propensity score matching (PSM) analysis.

Results: In all, 3515 LAPC patients from SEER database were included, including 3348 patients received chemotherapy and 167 patients received combination therapy of IRE and chemotherapy. Additionally, 36 patients who received IRE plus chemotherapy and another 96 patients who received chemotherapy from the SYSUCC were included. After PSM, survival rates were compared between two groups. Patients in combination group achieved better survival than those in chemotherapy group [SEER: overall survival (OS), 16.0 months (95% CI, 12.0–21.0) vs 9.0 months (95% CI, 7.2–11.6), P < 0.001; SYSUCC: OS, 21.6 months (95% CI, 17.8–25.3) vs 7.1 months (95% CI, 5.4–9.5), P = 0.006]. Moreover, similar better results in terms of cancer-specific survival (CSS) and progression-free survival (PFS) were observed in patients who received combination therapy compared with chemotherapy alone. IRE combined with chemotherapy was shown as a favorable factor for OS, CSS and PFS in LAPC patients.

Conclusions: Patients with LAPC who received IRE combined with chemotherapy had better survival compared with those after chemotherapy treatment alone. This combination method may be a more suitable way of treatment for patients with LAPC.

Single Cell RNA-Sequencing to Study Heterogeneity in the Pancreatic Cancer Microenvironment

M. Heckler, 1 P.J. Lenehan, 1,2 L.R. Ali, 1 K. Roehle, 1 S.J. Crowley, 1 K.S. Ventre, 1 Anze Godicelj, 1 A.M. Luoma, 1 K.W. Wucherpfennig, 1 A. Aguirre, 3 J. Agudo, 1 S.K. Dougan, 11Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA; 2Medical Scientist Training Program, Harvard Medical School, Boston, MA; 3Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.

Background: The failure of immunotherapies to date emphasizes the need to better understand the immune response to pancreatic tumors. Immunosuppressive myeloid cells comprise the majority of the PDAC tumor microenvironment (TME), but how these populations change in response to immunotherapy is incompletely characterized. We find that mouse models of pancreatic cancer respond to small molecule SMAC mimetics, and have shown that these drugs elicit robust T-cell dependent anti-tumor immunity.

Methods: We performed single cell and limited bulk RNA-sequencing of sorted CD45+ cells from murine pancreatic tumors treated with vehicle or the SMAC mimetic LCL161. We also performed scRNAseq on human pancreatic adenocarcinoma to identify the myeloid cell subsets present.

Results: From murine pancreatic tumors, we recovered 6 distinct populations of myeloid cells, including embryonic yolksac derived macrophages, macrophages derived from hematopoietic stem cells, and infiltrating monocytes. LCL161 treatment resulted in a relative increase in infiltrating monocytes and a phenotypic shift in these populations toward increased phagocytosis. Immunofluorescence and flow cytometry confirmed that more myeloid cells from drug-treated mice phagocytosed tumor cells than in vehicle-treated mice. From human pancreatic tumors, we have identified six distinct cell populations by scRNAseq: tumor cells, T cells, B cells, macrophages, mast cells, and fibroblasts. Analysis of interacting cell surface proteins highlighted a potential role for other immune cells in sustaining and polarizing tumor associated macrophages via CSF1/CSF1R interactions.

Conclusions: Single cell RNA-sequencing facilitates the analysis of heterogeneity within the PDAC microenvironment. Activation of non-canonical NFκB signaling reprograms tumor associated macrophages to increase their phagocytic activity and significantly reduces tumor growth.

Accuracy of Blood Culture to Diagnose Multidrug-Resistant Organisms in Patients With Infected WON

D. Hira, 1 Y. Tsuji, 2 M. Ueno, 1 K. Morimoto, 1 Y. Kiyosuke, 1 E. Ishida, 1 M. Mizuno, 21Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Kurashiki, Japan; 2Office of Institutional Research, Shiga University of Medical Science, Otsu, Japan.

Background: Infected walled-off necrosis (WON) is a serious complication following acute pancreatitis. In early period of infection, we have to start empiric antibiotic treatment without drainage, often. However, such empirical challenges often fail to treat infected WON due to multidrug-resistant organisms. To address this issue, we investigated the accuracy of blood culture to diagnose multidrug-resistant organisms in patients with infected WON.

Methods: By chart reviewing, we investigated the consecutive 1101 patients with acute pancreatitis, retrospectively. All patients were treated in Kurashiki Central Hospital between January 2010 and December 2018. Patients with infected WON were enrolled. Infected WON was diagnosed based on both images and culture examinations. Patients’ blood samples and specimens of WON collected by endoscopic, percutaneous, or surgical drainage were used to perform culture exams. The microorganisms, which were obtained by culture exams, were tested multidrug-resistant or not. All of the multidrug-resistant organisms were classified into 1) carbapenem-resistant bacteria, 2) bacteria with extended-spectrum β-lactamase (ESBL), and 3) fungi. Comparing to culture exams using specimens of WON, we calculated the accuracy of blood culture.

Results: Twenty-three patients were included. Median age and sex (male/female) were 68 years and 16/7, respectively. Sixteen patients (69.6%) had received empiric antibiotics treatment before drainage. Among the 23 patients, 17 (73.9%) culture of specimens were positive, and 15 patients (88.2%) were diagnosed as multidrug-resistant bacteria and/or fungi. Carbapenem-resistant bacteria, ESBL-producing bacteria, and fungi were found in 11, 3, and 8 patients, respectively. The most common fungus was Candida albicans. Accuracy of blood culture to diagnose multidrug-resistant organisms was 0.391 (95% CI, 0.197–0.615).

Conclusions: Accuracy of blood culture to diagnose multidrug-resistant organisms in patients with infected WON was poor.

Expression of CD133 as a Biomarker in Pancreatic Cancer

K. Hirano, K. Shibuya, T. Watanabe, S. Sawada, I. Yoshioka, T. Fujii

Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan.

Background: Pancreatic cancer is one of the most lethal neoplasm in the world. CD133 was reported as a cancer stem cell (CSC) marker in several malignant tumors involving pancreatic cancer. We demonstrated the relationship between the expression of CD133 in the tissue of pancreatic cancer and clinicopathological findings and prognosis.

Methods: Tissue microarray (TMA) blocks were created from 66 cases who performed pancreatectomy between 1998 and 2013 in our institute. Of 66 cases, 7 cases were diagnosed IPMA or bile duct cancer with pathological examinations. Cases that were received neoadjuvant chemotherapy, were not performed curative surgery, or were not enough medical records were excluded. 49 cases were enrolled in this study. The tumor tissues of these cases were stained with CD133. CD133 expression was evaluated with distribution and intensity, a score of 0 to 3, corresponding to negative, weak, moderate and strong positivity. Two different researchers evaluated the scores. The average scores were calculated and higher than 0.5 points were considered positive.

Clinicopathological findings, relapse-free survival and disease-free survival were compared between the group of CD133 (+) and CD133 (-).

Results: 35 cases were enrolled in CD133 (+) and 14 cases were in CD133 (-). There was no significant different in the clinical features. There was significant different in lymphatic invasion, neural invasion in the CD133 (+) group. Moreover, multivariable analysis was demonstrated that higher expression of CD133 was related to the worse disease-free survival and relapse-free survival. Relapse free survival of CD133+ was significantly worse than CD133-; P = 0.012 (log-rank) and P value (Wilcoxon). And overall survival of CD133+ was also significantly worse than CD133-; P = 0.025 (log-rank).

Conclusions: Pancreatic cancer positive for CD133 was demonstrated poor prognosis. The expression of CD133 in the tumor tissue was considered the useful biomarker of pancreatic cancer.

Examination About The Relation Between Imaging Findings and Histological Grade Diagnosis for Pancreatic Neuroendocrine Neoplasm (Pan-NEN)

T. Hirano, M. Serikawa, Y. Ishii, T. Tsuboi, R. Kawamura, K. Tsushima, Y. Saitoh, T. Sekito, S. Nakamura, A. Fukiage, J. Ikemoto, Y. Kiyoshita, S. Saeki, Y. Tamura, K. Chayama

Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan.

Background: We investigated the relationship between imaging findings and histological grade in Pan-NEN and examine whether the histological grade could be diagnosed from imaging findings.

Methods: From 2007 to 2019, 81 Pan-NEN cases were diagnosed in our hospital, which were classified into well differentiated Pan-NET (G1, G2, G3) and poorly differentiated Pan-NEC based on WHO classification 2017. We defined the following as atypical imaging findings; borderline irregularity, borderline ambiguity, internal heterogeneity, no early staining, cystic degeneration, calcification, main pancreatic duct stenosis, which were detected on contrast-enhanced CT and EUS. The relationship between histologic differentiation and typical or atypical imaging findings in these cases were compared and analyzed retrospectively.

Results: Of 81 cases, the number for each histologic grade is as follows; in typical imaging cases, G1were 26, G2 were 8, G3 and NEC were 0, in atypical cases, G1 were 22, G2 were 19, G3 were 2, and NEC were 4. The number of cases of each histological grade for each atypical finding is shown below; borderline irregularity (G1:7, G2:7, G3:2, NEC:2), borderline ambiguity (G1:3, G2:5, G3:2, NEC:1), internal heterogeneity (G1:6, G2:9, G3:2, NEC:2), no early staining (G1:4, G2:8, G3:2, NEC:4), cystic degeneration (G1:8, G2:4, G3:0, NEC:0), calcification (G1:3, G2:6, G3:0, NEC:1), main pancreatic duct stenosis (G1:1, G2:10, G3:0, NEC:1). Compared with well differentiated types (G1/G2/G3) and poorly differentiated type (NEC), there was a significant difference in no early staining (P = 0.0018), but there was no difference between G3 and NEC.

Conclusions: It was suggested that CT findings stained in early phase could be useful for differential diagnosis between well-differentiated Pan-NET and NEC. Although between Pan-NETG3 and Pan-NEC, imaging findings alone is not enough, and it is necessary to make comprehensive diagnosis added histopathological diagnosis.

The Potency of SMAD4 and RUNX3 as Markers of Prognostic Prediction

K. Hirose, 1 Y. Omori, 1 R. Higuchi, 2 M. Yamamoto, 2 T. Furukawa, 11Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan.

Background:SMAD4/DPC4 is one of the ‘big four’ genes, namely, KRAS, SMAD4, CDKN2A, and TP53, that are considered to play primary roles in tumorigenesis and progression of pancreatic cancer. RUNX3 was initially found to be a neurogenic TrkC neuron-specific transcription factor and also has critical functions in lineage specification and homeostasis of CD8-lineage T lymphocytes. Besides, RUNX3 functions as a tumor suppressor in some kinds of cancers through TGF-beta, Wnt, and other signaling pathways. A published report has indicated that RUNX3 and SMAD4 coordinately regulate the balance between cancer cell proliferation and dissemination in genetically engineered mouse models. We aimed to uncover the relevance of genetic and expression state of SMAD4 and RUNX3 as well as KRAS in the pancreatic cancer.

Methods: We examined associations between clinicopathological features and molecular features including copy number variation, mutation, and protein expression of SMAD4; protein expression of RUNX3; and mutation of KRAS in 100 patients with surgically resected pancreatic ductal adenocarcinoma (PDAC).

Results: We found that retain of the expression of SMAD4 was significantly associated with metastatic recurrences of PDAC. Retain of SMAD4 was significantly associated with the null expression of RUNX3. Moreover, the patients with PDAC showing retained expression of SMAD4 and null expression of RUNX3 revealed significantly poor prognosis compared with the others, although the RUNX3 expression alone did not show any specific association with clinicopathological features.

Conclusions: These results suggest that retain of SMAD4 and the null expression of RUNX3 may promote the metastatic recurrence in pancreatic cancer, resulting in poor prognosis.

Continuous Regional Arterial Infusion Versus Intravenous Administration of Proteinase Inhibitor, Nafamostat Mesilate, for Predicted Severe Acute Pancreatitis: A Multicenter Randomized Open-label Trial

M. Hirota, 1 K. Kitamura, 2 M. Takenaka, 3 E. Iwasaki, 4 K. Takeda, 5 Y. Takeyama, 6 T. Mayumi, 7 T. Ito, 8 T. Gabata, 9 T. Shimosegawa, 101Division of Gastroenterology and Hepatology, Tohoku Medical and Pharmaceutical University, Miyagi, Japan; 2Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan; 3Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan; 4Division of Gastroenterology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; 5Miyagi Branch, Health Insurance Claims Review & Reimbursement Services, Miyagi, Japan; 6Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan; 7Department of Emergency Medicine, University of Occupational and Environmental Health, Fukuoka, Japan; 8Department of Gastroenterology and Hepatology, International University of Health and Welfare, Fukuoka, Japan; 9Department of Radiology, Kanazawa University, Graduate School of Medical Sciences, Kanazawa, Japan; 10Department of Gastroenterology, South Miyagi Medical Center, Miyagi, Japan.

Background: Continuous regional arterial infusion (CRAI) of the proteinase inhibitor nafamostat mesilate (NM) is used in the context of predicted severe acute pancreatitis (SAP) to prevent the development of pancreatic necrosis. Although this specific therapy for SAP is well known in Japan, its efficacy and safety remain unclear.

Methods: This multicenter, open-label, randomized controlled trial enrolled 39 predicted SAP patients with low enhanced pancreatic parenchyma on computed tomography (CT). Twenty patients were assigned to the CRAI group, while 19 served as controls and were administered NM at the same dose intravenously (IV group). The primary endpoint was the development of pancreatic necrosis as determined by CT on Day 14, judged by blinded central review.

Results: There was no difference between the CRAI and IV groups regarding the percentages of participants who developed pancreatic necrosis (more than 1/3 of the pancreas: 25.0% vs 15.8%, P = 0.694; more than 2/3 of the pancreas: 20% vs 5.7%, P = 0.341). The early analgesic effect in the CRAI group was evaluated based on 24-hour cumulative fentanyl consumption and additional administration by iv-patient-controlled analgesia. The consumption (mg) in the CRAI and IV groups on Day 2 (0.4582 ± 0.2117 vs 0.8489 ± 0.4246, respectively, P = 0.021) and Day 3 (0.4968 ± 0.1194 vs 0.9464 ± 0.5847, respectively, P = 0.040) and the additional administration on Day 2 (0.7 ± 1.0 vs 4.0 ± 3.9, respectively, P = 0.018) showed that the CRAI group used significantly less anesthesia. There were two adverse events related to CRAI, namely splenic infarction and bleeding.

Conclusions: The early analgesic effect of CRAI therapy with NM was superior to that of IV NM. However, CRAI did not inhibit the development of pancreatic necrosis as expected. Less invasive IV therapy can be considered a viable alternative to CRAI therapy.

Serum Proteomics Reveals Inflammation- and Lipid Metabolism-related Proteins Whose Levels Differ Between Pancreatic Ductal Adenocarcinoma Patients With Short or Long Survival

M. Holm, 1,2,3,4 M. Saraswat, 5,6,7 S. Joenväärä, 5,6 H. Seppänen, 1 R. Renkonen, 5,6 C. Haglund, 1,3Departments of 1Surgery and 2Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 3Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; 4Applied Tumor Genomics Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; 5Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland; 6HUSLAB, Helsinki University Hospital, Helsinki, Finland; 7Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.

Background: Pancreatic ductal adenocarcinoma (PDAC) is the most common and aggressive subtype of pancreatic cancer, with a 5-year survival rate of only 5%. Surgery offers the only chance of a cure, although most patients present with metastatic, unresectable disease. New biomarkers to aid in predicting the prognosis of PDAC patients are needed, and mass spectrometric techniques are often used to analyze the proteome for potential biomarker candidates. Prognostic markers for PDAC could give information about patients’ prognoses and aid in treatment decisions by separating patients with a poor prognosis from those with a good prognosis.

Methods: For this study, 22 PDAC patients were chosen according to survival (short or long), and preoperative serum samples from these patients were analyzed using Ultra Performance Liquid Chromatography-Ultra Definition Mass Spectrometry (UPLC-UDMSE). The differences between the two groups were analyzed using the Mann-Whitney U test, Principal Component Analysis, and pathway analysis.

Results: We discovered 31 serum proteins whose levels differed significantly between PDAC patients with short or long survival. The top three proteins according to fold change were CD5 antigen-like, keratin, type II cytoskeletal 2 epidermal, and diphosphomevalonate decarboxylase. The levels of several complement components and enzymes also differed between the two groups. Pathway analysis revealed that the serum proteins whose levels differed between the groups were related to inflammation, which is known to contribute to cancer initiation and progression, and several of the identified acute phase proteins displayed higher levels in patients with short survival. Major pathways enriched among the differentially expressed proteins were inflammation-related pathways, as well as lipid and bile acid metabolism, indicating altered lipid metabolism.

Conclusions: We have identified multiple serum proteins, including complement components and several enzymes, that may be of value as new non-invasive prognostic markers to differentiate between PDAC patients with short or long survival.

Stratification of Pancreatic Cancer Risk in the General Population Using an Apolipoprotein A2 Isoform Blood Test

K. Honda, 1 T. Kobayashi, 2 Y. Sato, 2 S. Nishiumi, 2 S. Okaya, 1 K. Takeuchi, 1 K. Nagashima, 3 M. Yoshida, 21Department of Biomarkers for Early Detection of Cancer, National Cancer Center Research Institute, Tokyo, Japan; 2Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan; 3Research Center for Medical and Health Data Science, The Institute of Statistical Mathematics, Tachikawa, Japan.

Background: Given the low incidence of pancreatic cancer, screening the general population using invasive methods is not feasible. However, combining invasive screening and noninvasive biomarkers for detecting pancreatic cancer and its precancerous lesions could reduce mortality. We recently identified unique alterations in various apolipoprotein A2 isoforms (apoA2-is), in the form of different C-terminal amino acids, in cases of pancreatic cancer and its precancerous lesions. We developed an enzyme-linked immunosorbent assay (ELISA) kit to measure the concentrations of circulating apoA2-is. We then initiated experimental screening for pancreatic cancer using apoA2-is.

Methods: Non-symptomatic participants were enrolled from 6 medical institutes between October 2015 and January 2017. Plasma samples were collected, and apoA2-is were measured using the ELISA kit. Positive participants (apoA2-is <35 μg/ml) subsequently underwent contrast-enhanced computed tomography, magnetic resonance imaging, or endoscopic ultrasonography screening.

Results: A total of 5120 participants were enrolled in this study, and blood tests were positive in 84 participants (positive rate, 1.6%). Fifty-four of 84 positive blood test participants (64%) underwent imaging examinations, and pancreatic abnormalities were detected in 26 of the 54 participants (48.1%; 95% confidence interval [CI], 34.3%–62.2%). One case of pancreatic ductal adenocarcinoma (PDAC), 14 cystic lesions of the pancreas, including 9 intrapancreatic mucinous neoplasms, and 3 chronic pancreatitis cases were identified in participants at high risk for PDAC. The positive predictive value for identifying PDAC and high-risk individuals with a positive apoA2-is blood test was 33.3% (18 of 54; 95% CI, 21.1%–47.5%).

Conclusions: The apoA2-is ELISA blood test demonstrated the potential to identify individuals at high risk of PDAC in the general population without invasive and/or expensive methods. This biomarker test could be useful for efficiently screening the general population for pancreatic cancer.

Proteomic and RNA Profiling of the Human Matrisome Reveals Distinct Signatures in PDAC

K.C. Honselmann, 1,2 U. Wellner, 2 O. Schilling, 3 D.J. Birnbaum, 1,4 S.K. Begg, 1 P. Finetti, 4 D. Birnbaum, 4 F. Bertucci, 4 D. Ting, 5 E. Tai, 5 T. Keck, 2 M. Taylor, 6 M. Mino-Kenudson, 6 V. Deshpande, 6 K.D. Lillemoe, 1 C. Fernández-del Castillo, 1 A.L. Warshaw, 1 C. Ferrone, 1 U. Wellner, 2 A.S. Liss, 11Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA; 2Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany; 3Institute of Surgical Pathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany; 4Department of Surgery and Molecular Oncology, Marseille Cancer Research Center, Paoli-Calmettes Institute, Aix-Marseille University, Marseille, France; 5MGH Cancer Research Center, Harvard Medical School, Boston, MA; 6Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Pancreatic ductal adenocarcinoma (PDAC) is characterized by a strong desmoplastic reaction, contributing to its dismal prognosis. The extracellular matrix and its affiliated proteins are composed of as many as 1029 proteins which collectively are referred to as the matrisome. However, the PDAC matrisome is poorly characterized.

Methods: We performed RNA-seq from laser capture microdissected (LCM) stromal and epithelial compartments of 19 resected human PDAC samples. In addition, shot gun proteomics from FFPE samples of 42 resected PDAC patients with clinicopathological data were analyzed and unsupervised clustering of matrisome expression profiles as well as protein enrichment analysis was performed with R software and Enrichr package.

Results: RNAseq analysis of LCM PDAC samples revealed a total of 839/1029 matrisome genes defined in silico. 459 matrisome genes were common to more than two thirds of the 19 patient samples, with 59-79% of these genes commonly expressed in both stromal and cancer cells. In contrast, matrisome overlap between different tumors ranged between 26-40%. Proteomic profiles from 42 bulk tissues identified 36% (164 of 459) of common proteins, however, only 19% and 8% of the proteins encoded by genes uniquely expressed in the cancer and stroma. Unsupervised cluster analysis identified five distinct clusters of matrisome proteins that correlated with disease free survival (Cluster 1, mean 23 ± 6, Cluster 2, 39 ± 13, Cluster 3, 16 ± 5, Cluster 4, 56 ± 12, and Cluster 5, 70 ± 0 months, P = 0.005). Several drug and pathway signatures were enriched in the distinct clusters, for example, cluster 1 was strongly associated with angiotensin II and picremolimus, cluster 3 with cisplatin and cluster 4 with sunitinib.

Conclusions: This study highlights the shared matrisome expression of both cancer and stromal cells. In addition, proteomic matrisome profiles correlate with patient survival and suggest drugs that target these proteins.

Analysis of Phosphorylated Smad3 Signaling in the Intraductal Papillary Mucinous Neoplasm of the Pancreas

Y. Hori, 1 T. Ikeura, 1 T. Yamaguchi, 1 T. Tomiyama, 1 Y. Ando, 1 K. Yoshida, 1 T. Fukui, 1 K. Uchida, 1 M. Takaoka, 1 K. Matsuzaki, 1 A. Nishio, 1 M. Ishida, 2 S. Satoi, 3 K. Okazaki, 11Division of Gastroenterology and Hepatology; and Departments of 2Pathology and 3Surgery, Kansai Medical University, Hirakata, Japan.

Background: Intraductal papillary mucinous neoplasm (IPMN) is a slow growing neoplasm, although malignant IPMN has poor prognosis. Thus, we focused on the carcinogenesis of IPMN and its molecular biological change. Transforming growth factor β (TGF-β) signaling activates both its type I receptor and c-Jun NH2-terminal kinase (JNK), which phosphorylate Smad3 at the COOH-terminal (pSmad3C) and linker regions (pSmad3L) respectively. In human liver and colorectal carcinogenesis, it is reported that activated JNK induces the transition from a tumor-suppressive pSmad3C pathway to an oncogenic pSmad3L pathway. The aim of this study is to clarify transitions in phosphorylated Smad3 signaling during IPMN carcinogenesis.

Methods: By using immunohistochemistry, the expression of pSmad3C and pSmad3L from 51 IPMN surgical specimens resected at our institution between 2010 and 2013 were investigated. The expression of Ki-67 and c-Myc were also examined.

Results: The median pSmad3C positive rate was 79.2% in low-grade dysplasia, 74.9% in high-grade dysplasia, 42.0% in invasive carcinoma (P < 0.01) whereas that of pSmad3L was 3.4%, 4.3%, 42.4% (P < 0.01). The expression of c-Myc was frequently observed in pSmad3L-positive cells. Negative relationship between the expression of pSmad3C and Ki-67 (P < 0.01, r = -0.73) and positive relationship between the expression of pSmad3L and Ki-67 (P < 0.01, r = 0.61) were confirmed. The pSmad3L/pSmad3C ratio was different between the recurrence group and the non-recurrence group (P = 0.02).

Conclusions: Molecular biological therapy targeted pSmad3L pathway can be useful for malignant IPMN. pSmad3L/pSmad3C ratio may be useful as a prognostic predictor in IPMN.

Covered Duodenal Metal Stents Prolong Biliary Stent Patency in Double Stenting

Y. Hori, I. Naitoh, K. Hayashi

Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.

Background: Endoscopic biliary and duodenal stenting (DS; double stenting) is widely accepted as a palliation therapy for malignant bilioduodenal obstruction in patients with pancreatic cancer. The aim of the current study was to investigate the feasibility, safety and predictors of recurrent biliary obstruction (RBO) in patients with DS.

Methods: Patients with pancreatic cancer who underwent DS from April 2004 to March 2017 were analyzed retrospectively with regard to clinical outcomes, adverse events and predictive factors of RBO.

Results: A total of 79 consecutive patients was enrolled. Technical success of DS was achieved in 78 patients (98.7%). Symptoms due to biliary and duodenal obstruction were improved in 68 patients (86.1%). RBO occurred in 18 patients (22.8%). Adverse events other than RBO were as follows: recurrent duodenal obstruction in 10 patients (12.7%) (tumor ingrowth: 2, tumor overgrowth: 4, food impaction: 3, symptomatic stent migration: 1), asymptomatic stent migration in 4 patients (5.1%) and pneumonia in 1 patient (1.3%). Pancreatitis did not occur. The median times to RBO and overall survival from DS were 81 and 102 days, respectively. Placement of a duodenal uncovered self-expandable metal stent (U-SEMS) was significantly associated with RBO in the multivariable analysis (P = 0.007). Time to RBO was significantly longer in the duodenal covered self-expandable metal stent (C-SEMS) group than the U-SEMS group (P = 0.02).

Conclusions: Double stenting was safe and effective for malignant bilioduodenal obstruction. Duodenal U-SEMS is a risk factor for RBO. The C-SEMS is the preferred type of duodenal SEMS in patients with DS.

Surgical Technique and Outcomes of Duodenum-preserving Pancreatic Head Resection for Benign Lesions

A. Horiguchi, M. Ito, Y. Asano, S. Arakawa, M. Shimura, T. Ochi, C. Hayashi, T. Kawai, N. Yasuoka

Fujita Health University, Bantane Hospital, Toyoake, Japan.

Background: Surgical treatment for benign tumors of the head of the pancreas is often performed using “traditional” procedures such as pancreatoduodenectomy (PD). However, this approaches result in the loss of the upper gastrointestinal and biliary anatomy with subsequent impairment of exocrine and endocrine functions. Therefore, avoiding unnecessary loss of pancreatic tissue and further deteriorations in endocrine and exocrine pancreatic functions are important challenges for surgeons managing benign tumors of the pancreas. For patients, it would be beneficial for their QOL if PD could be avoided. DPPHR is technically difficult and time-consuming due to reconcile these antinomic techniques, which is complete resection in the pancreatic head and preservation of both the bile duct and the pancreaticoduodenal vessels.

Methods: We retrospectively reviewed the records of 156 patients who underwent pancreatic head resection.

Results: We studied retrospectively 68 cases that underwent DPPHR, 88 patients who underwent PD with benign or low grade malignant pancreatic head tumors. The blood loss in DPPHR was significantly lower than that in PD. There was no significant difference in operative factors and postoperative complications. Both exocrine and endocrine function and the long-term results following DPPHR were superior to those following PD.

Conclusions: In benign or low-grade malignant tumors of the head of the pancreas, DPPHR should be favored over the PD, if there is no compromise with oncologic radicality.

BUN Change From Admission and Levels at 24-48 Hours are Significant Predictors of Severity in Pediatric Acute Pancreatitis

L.N. Hornung, 1 P.R. Farrell, 2,3 P. Farmer, 3,4 A. Serrette, 3,5 T.K. Lin, 2,7 J.D. Nathan, 6,8 D.S. Vitale, 2,7 M. Abu-El-Haija, 2,7Division of 1Biostatistics and Epidemiology and 2Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3Pediatric Residency Program, Children’s Hospital of the King’s Daughters, Norfolk, VA; 4Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA; 5Division of Emergency Medicine, Cohen Children's Medical Center, New Hyde Park, NY; 6Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Departments of 7Pediatrics and 8Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.

Background: Pediatric acute pancreatitis (AP) is increasing in incidence, but there remains limited information regarding optimal management in this population. Previous authors have reported BUN levels and change at 24 hours can be predictive of developing severe AP in adults; this has not yet been shown in the pediatric population. BUN on admission has been shown to predict AP severity in pediatric patients. Our objective was to examine BUN change from admission and BUN values at 24-48 hours to identify patients most likely to develop any form of severe AP.

Methods: Pediatric patients with a primary diagnosis of first AP episode were included. Patients were retrospectively examined at Children’s Hospital of the Kings Daughters (Norfolk, VA) during a 5 year period. Prospectively collected patient data of first AP episode at Cincinnati Children’s Hospital Medical Center were also included. Group differences between mild and both moderately severe and severe AP (combined were called SAP) were analyzed.

Results: A total of 176 primary AP patients were included for analysis; 39 (22%) met criteria for SAP. The SAP group had elevated BUN levels on admission (P < 0.001; SAP: median 15.5, IQR 11.0–22.5 vs mild: median 10.0, IQR, 8.0–13.0). Patients who developed SAP had a significantly smaller percent decrease in BUN from admission to 24-48 hours (P = 0.002), SAP median decrease 21.5% (IQR, 12.5–38.5) vs mild group 35.7% decrease (IQR, 22.2–52.9). This resulted in BUN values remaining significantly higher (P < 0.001) after 24 hours for SAP (median 12.5, IQR, 8.0–19.0) compared to the mild group (median, 7.0; IQR, 5.0–10.0). Elevated BUN levels within 24-48 hours were predictive of developing SAP (AUROC, 0.76; 95% CI, 0.66–0.85).

Conclusions: BUN level change from admission and BUN value at 24-48 hours are significant predictors of the development of SAP.

EUS-Elastography is a Useful Tool for Diagnosis of Chronic Pancreatitis

A.H. Hosui, T.T. Tanimoto, K.M. Matsumoto, N.H. Hiramatsu

Department of Gastroenterology and Hepatology, Osaka Rosai Hospital, Osaka, Japan.

Background: Recently, a concept of early chronic pancreatitis (ECP) has been paid attention, which is regarded as a stage of chronic pancreatitis (CP) with preserved pancreatic function and potentially reversible features (Pancreatology 2018). Imaging by EUS is needed for diagnosis of CP or ECP, but we sometimes have a difficulty in diagnosis and judge subjectively. On the other hand, liver stiffness can be measured by real-time tissue elastography (RTE) without liver biopsy and it becomes possible to quantify tissue stiffness. The aim of this study is to clarify the usefulness of RTE for diagnosis of ECP and CP.

Patients and Methods: One hundred and twenty-seven patients who have consecutively received EUS and RTE for diagnosis of CP or ECP were retrospectively analyzed in this study. EUS device was following; video processor: EU-M2 PREMIER PLUS, fiberscopy: GF-UGT260. The values of elastography were evaluated using the ratio of the value of pancreas (head-body) to that of stomach wall. Measurements were performed more than three times and the mean value was adopted in this study.

Results: Backgrounds of patients in this study were following; male/female: 58/69, the mean age: 69.2 ± 12.4 (33–85) years. Eleven patients were diagnosed as CP, and fifty-three patients who have satisfied more than 2 points in EUS imaging were ECP. Sixty-nine patients who have only satisfied one or less than one point were defined as a control group. The mean values of elastography (CP, ECP, control) were 10.31 ± 7.54, 7.88 ± 4.73, 4.80 ± 3.18, respectively, and the value of ECP was significantly higher than that of control (P < 0.01), and lower than that of CP (P < 0.01). The diagnostic cut-off values were 5.17 (AUC, 0.76) among control and ECP, and 8.02 (AUC, 0.79) among ECP and CP.

Conclusions: EUS-elastography can be a useful tool for diagnosis of CP and ECP by quantification of tissue stiffness of pancreas.

MiR-361-3p Regulates ERK1/2-induced EMT in an Ago2-Dependent Manner Via DUSP2 mRNA Degradation in Pancreatic Ductal Adenocarcinoma

J.S. Hu, L. Li, H.Z. Chen, G.Q. Zhang, H. Liu, R. Kong, H. Chen, Y.W. Wang, Y.L. Li, F.Y. Tian, X.J. Lv, G.Q. Li, B. Sun

Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.

Background: Metastasis remains the one of the most intractable challenges in pancreatic ductal adenocarcinoma (PDAC) biology, and epithelial-to-mesenchymal transition (EMT) is essential for epithelium originated solid tumor metastasis cascade. Emerging evidences supports that aberrant miRNA expression is involved in pancreatic cancer progression. Hence, understanding the role of miRNA in PDAC EMT may provide crucial advance against PDAC.

Methods: Quantitative real-time PCR (qRT-PCR) was used to measure the levels of miR-361-3p, DUSP2, and Ago2 in tissues. The effect of miR-361-3p on metastasis of PDAC cells was evaluated by Transwell assay and wound healing assay in vitro and orthotopic and liver metastasis pancreatic cancer model in vivo. Luciferase assay, qPCR and western blot and Ago2 co-immunoprecipitation were performed to identify the direct target of miR-361-3p.

Results: MiR-361-3p was found to be associated with advanced stage of PDAC and poor prognosis. Overexpression of miR-361-3p promoted pancreatic cancer cells metastasis in vivo and in vitro by enhancing ERK1/2-mediated EMT. Mechanistic investigations identified DUSP2 as a direct target of miR-361-3p and DUSP2 was revealed to be involved in miR-361-3p-induced EMT by leading to inactivation of ERK pathway. Furthermore, miR-361-3p-induced EMT was dependent on Argonaute 2 (Ago2) and enforced expression of Ago2 enhanced miR-361-3p interference.

Conclusions: We report that miR-361-3p functions as an oncomiR in promoting metastasis and identify miR-361-3p/DUSP2/ERK axis as a novel EMT axis dependent on Ago2 in PDAC.

YAP1 Overexpression Enhances the Aerobic Glycolysis Process Via Suppression of EGLN2 in Pancreatic Ductal Adenocarcinoma

P.F. Hu, 1 Y. Liang, 1 Z.W. Cai, 1 H.W. Wang, 1 C.Y. Jiang, 1 W. Wang, 11Department of General Surgery, Huadong Hospital, Fudan University, Shanghai, China.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive disease with remarkably high mortality rates. Recent years have witnessed the contribution of altered metabolism to PDAC malignancies maintenance. However, the molecular mechanism underlying the glucose metabolism reprogramming remains elusive. The aim of this study was to uncover the role of Yes-associated protein (YAP1) in regulation of aerobic glycolysis in PDAC.

Methods: YAP1 expression was silenced by shRNA and its effect on glycolytic activity and mitochondrial respiration were analyzed by Agilent Seahorse XF Analyzers. The effect of YAP1 on Hypoxia inducible factor-1α (HIF-1α) and its transcriptional activity on glycolytic genes were examined by shRNA mediated silencing of YAP1. The underlying mechanism of YAP1 on HIF-1α protein level control was analyzed by exploring the interaction between YAP1 and egg-laying-defective nine family (EGLN) members, which are well-established regulators of HIF-1α protein level. In the end, the implications of YAP1, EGLN and glycolytic genes in prognosis were analyzed by using the TCGA dataset.

Results: Silencing YAP1 expression inhibited anabolic glycolysis through regulating HIF-1α protein level, transcriptional activity and HIF-1α-targeted glycolytic genes in pancreatic cancer cells. In depth analysis demonstrated that EGLN2, a modulator of HIF-1α protein level, was a direct target of YAP1. Lower EGLN2 expression predicted worse prognosis. By analysis of the TCGA dataset and immunohistochemistry staining, we demonstrated that YAP1 expression negatively correlated with EGLN2 expression.

Conclusions: The present study demonstrated that YAP1 positively regulated aerobic glycolysis by inhibition of EGLN2 expression, which resulted in up-regulated HIF-1α protein level and its targeted glycolytic genes. Our results suggest that YAP1 may be a promising prediction and treatment target for human PDAC.

IGF2BP2 Regulates DANCR by Serving as an N6-methyladenosine Reader

X.G. Hu, 1,2 W.X. Peng, 2,3 H.X. Zhou, 1 J.H Jiang, 1 X.C. Zhou, 4 D.S. Huang, 1 Y.Y. Mo, 2,5 L. Yang, 11Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China; 2Cancer Institute, University of Mississippi Medical Center, Jackson, MS; 3Department of Cell Biology, School of Medicine, Jiangsu University, Zhenjiang, China; Departments of 4Pathology and 5Pharmacology/Toxicology, University of Mississippi Medical Center, Jackson, MS.

Background: The major function of Insulin-like growth factor 2 mRNA-binding protein 2 (IGF2BP2) is to regulate cell metabolism. However, emerging evidence indicates that IGF2BP2 plays a role in cancer, but the underlying mechanism is largely unknown. The purpose of this study was to explore the role of IGF2BP2 in pancreatic cancer.

Methods: IGF2BP2 expression was detected in pancreatic cancer by tissue microarrays(TMA). DANCR was identified as a potential target of IGF2BP2 by LncRNA profiling. To investigate the IGF2BP2 and DANCR functions, we generate IGF2BP2-KO and DANCR-KO cell line. A series of cytological function assays and xenograft mice models were used to determine the role of IGF2BP2 and DANCR in cell proliferation, stemness-like properties and tumorgenesis. RNA immunoprecipitation (RIP) and RNA pulldown was performed to clarify the regulation between IGF2BP2 and DANCR.

Results: Here we showed that upregulation of IGF2BP2 is associated with poor outcomes of pancreatic cancer patients and suppression of IGF2BP2 inhibits cell proliferation. We further showed that IGF2BP2 regulates lncRNA DANCR. Ectopic expression IGF2BP2 enhances, whereas knockdown (KD) or knockout (KO) of IGF2BP2 suppresses DANCR expression. Moreover, in vivo RNA precipitation and reciprocal RNA immunoprecipitation revealed that IGF2BP2 interacts with DANCR. DANCR promotes cell proliferation and stemness-like properties. Experiments with xenograft models revealed that while ectopic expression of DANCR promotes, DANCR KO suppresses tumor growth. Mechanistically, DANCR is modified at N6-methyladenosine (m6A) and mutagenesis assay identified that adenosine at 664 of DANCR is critical to the interaction between IGF2BP2 and DANCR where IGF2BP2 serves a reader for m6A modified DANCR and stabilizes DANCR RNA.

Conclusions: Together, these results suggest that DANCR is a novel target for IGF2BP2 through m6A modification, and IGF2BP2 and DANCR work together to promote cancer stemness-like properties and pancreatic cancer pathogenesis.

Development and Multicenter Validation of a Nomogram for Preoperative Prediction of Lymph Node Positivity in Pancreatic Cancer (NeoPangram)

J. Hua, 1,2,3 S. Shi, 1,2,3 X.J. Yu, 1,2,31Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; 2Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China; 3Shanghai Pancreatic Cancer Institute, Shanghai, China.

Background: Neoadjuvant therapy is associated with a lower incidence of positive lymph nodes (LNs) in patients with pancreatic cancer. The aim of this study was to develop and validate a nomogram to preoperatively predict LN-positive pancreatic cancer patients who are potential candidates for neoadjuvant therapy.

Methods: A total of 558 patients with resected pancreatic cancer were randomly and equally divided into development and internal validation cohorts. Multivariable logistic regression analysis was used to construct the nomogram. Model performance was evaluated by discrimination, calibration, and clinical usefulness. An independent multicenter cohort consisting of 250 patients was used for external validation.

Results: A four-marker signature was built consisting of carbohydrate antigen (CA) 19-9, CA 125, CA 242, and CA 50. A nomogram was constructed to predict LN metastasis using three predictors identified by multivariable analysis: risk score of the four-marker signature (P = 0.011), computed tomography-reported LN status (P < 0.001), and clinical tumor stage (P = 0.076). The prediction model exhibited good discrimination ability, with C-indexes of 0.806, 0.742, and 0.763 for the development, internal validation, and external validation cohorts, respectively. The model also showed good calibration and clinical usefulness. A cut-off value for the probability of LN metastasis (0.72) was determined to separate low-risk and high-risk patients. Kaplan-Meier survival analysis revealed a good coincidence of survival curves between the nomogram-predicted and real LN status.

Conclusions: This nomogram enables the identification of pancreatic cancer patients at high risk for LN positivity, who may have more advanced disease and thus potentially benefit from neoadjuvant therapy.

New-onset Diabetes and Interethnic Variation in Metabolic Markers for Pancreatic Cancer Risk

B.Z. Huang, 1,2 S.J. Pandol, 3,4 C.Y. Jeon, 5 S.T. Chari, 6 C.A. Sugar, 7,8 C.R. Chao, 1 Z.F. Zhang, 2 B.U. Wu, 9 V.W. Setiawan, 10,111Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA; 2Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA; 3Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 4VA Greater Los Angeles Healthcare System, Los Angeles, CA; 5Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA; 6Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 7Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, CA; 8Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA; 9Center for Pancreatic Care, Division of Gastroenterology, Kaiser Permanente, Los Angeles, CA; 10Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA; 11Norris Comprehensive Cancer Center, Los Angeles, CA.

Background: Prior observational studies in predominantly white populations have suggested that new-onset diabetes is associated with elevated pancreatic cancer risk. We sought to determine whether this relationship applies in other races/ethnicities and to establish a metabolic profile for those at high risk for pancreatic cancer.

Methods: We conducted a population-based cohort study of Asian, black, Hispanic and white patients from Kaiser Permanente Southern California during 2006-2016. Diabetes patients were identified using glucose and hemoglobin A1c (HbA1c) measurements. We used Cox regression to assess the relationship between diabetes status/duration and pancreatic cancer. For incident diabetes patients, we compared longitudinal changes in glucose, HbA1c and weight leading up to diabetes diagnosis between those with and without pancreatic cancer.

Results: We identified 2002 incident cases of pancreatic cancer among 1,499,627 patients with 7.5 million person-years of follow-up. Compared to those without diabetes, individuals with incident diabetes and shorter disease durations (≤1 year: RR, 6.91; 95% CI, 5.76–8.30; >1 year: RR, 1.96; 95% CI, 1.62–2.38) had the highest pancreatic cancer risk. Among incident diabetes patients, those with pancreatic cancer had steeper increases of glucose (median percent difference 27.4 vs 19.8%, P < 0.0001), HbA1c (median percent difference 9.4 vs 5.3%, P < 0.0001) and greater weight loss (median percent difference -2.0 vs 0.0%, P < 0.0001) compared to non-cases during the time prior to diabetes. Racial/ethnic differences in metabolic changes by pancreatic cancer status were observed, with more pronounced differences in Asians and blacks for glucose, in blacks and whites for HbA1c, and in Asians and whites for weight (P values for heterogeneity ≤0.01).

Conclusions: In this large ethnically diverse population, increased pancreatic cancer risk for new-onset diabetes is observed among racial/ethnic minorities. While metabolic profiles vary by race to some extent, weight loss and poor glycemic control consistently point to increased pancreatic cancer risk across multiple races.

Tumour-derived Interleukin 35 Leads to Gemcitabine Chemoresistance by Inducing SOD2 Expression

C. Huang, Z. Li, Y. Ge, J. Hao

Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.

Background: Drug resistance to gemcitabine limits its efficacy in clinics, and overcoming gemcitabine chemoresistance remains a challenge. IL-35 is a dimer comprising the IL-12α and IL-27β chains. Previously we reported that expression of IL-35 is increased in pancreatic ductal adenocarcinomas (PDACs) compared with normal pancreatic tissues, and promotes metastasis and tumor angiogenesis. Here, we investigated the roles of IL-35 in Gemcitabine chemoresistance in PDAC.

Methods: Genome wide RNA sequencing was performed to identify differential gene sets in Gemcitabine resistant (GR) and Gemcitabine sensitive (GS) cells. Roles of IL-35 in gemcitabine resistance were determined by flow cytometry in vitro and TUNEL staining assay in vivo. The reactive oxygen species (ROS) were detected by Dihydroethidium (DHE) staining. Patient-derived xenograft (PDX) mice models were used to detect the therapeutic efficacy of an IL-35 neutralizing antibody.

Results: In vitro and in vivo assays we found that the resistance to Gemcitabine could be disseminated from GR PDACs to GS PDACs. In the secretory proteins significantly elevated in GR PDACs, IL-35 was identified to mediate the resistance dissemination among PDACs. IL35 decreased the Gemcitabine sensitivity by scavenging the Gemcitabine-induced ROS accumulation in PDACs. Mechanically, IL-35 activated transcription of Superoxide dismutase 2 (SOD2) through a GP130-STAT1 signaling pathway. The treatment of Gemcitabine enhanced IL-35 transcriptional expression via NF-κB signaling pathway. Furthermore, IL-35 initiated self-activation in PDACs by inducing GP130:IL12RB2 – STAT1:STAT4 signaling cascades. A neutralizing antibody against IL-35 resulted in significant enhanced sensitivity to Gemcitabine and decreased tumor growth in PDX mice models.

Conclusions: The resistance to Gemcitabine could be disseminated among PDACs, mediated by IL-35/SOD2 signaling. IL35 might serve as a therapeutic target for patients with pancreatic cancer.

Induced CD10 Expression During Monocyte to Macrophage Differentiation Identify a Different Subset of Macrophages in Pancreatic Cancer

X. Huang, 1,2 S. Li, 1,21State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; 2Department of Pancreatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China.

Background: Tumor associated macrophages (TAMs) promoted pancreatic cancer (PC) initiation and progression and were traditionally categorized into M1 or M2. However, this simplified classification does not fully represent the complexity and novel therapeutic targets especially cell surface molecules are urgently needed. The aim of this study was to evaluate CD10 expression by monocytes/macrophages and its clinical significance in PDAC.

Methods: Human peripheral blood CD14+ monocytes were freshly isolated using magnetic beads and cultured with human AB serum for 7 days to differentiate into macrophage in vitro, THP-1 cell line were cultured and treated with 100 ng/ml PMA for 72 hours to induce macrophage differentiation. Reverse transcription-quantitative PCR, immunohistochemistry, immunofluorescence, western blot, flow cytometry were performed to detect CD10 expression. To explore whether the PMA activated protein kinase C (PKC)-dependent MAPK signaling pathway participated in inducing CD10 expression, MAPK inhibitors PD98059, SP600125, SB203580 were used. Beyond that, fluorescence-activated cell sorting based on CD10 expression by THP-1 and RNA sequencing (RNA-seq) were performed to identify the difference between CD10+ and CD10- THP-1 cells.

Results: CD10 was expressed by partial human monocytes and much more cells expressed CD10 after differentiation into macrophages in vitro (13.19% vs 41.39%; P<0.0001). It was also highly expressed by TAMs in PC tissues. Monocytic cell line THP-1 cells did not express CD10, intriguingly, PMA could induce CD10 expression through MAPK pathway, both at the mRNA and protein levels. Beyond that we found that tumor supernate from PC cells could enhance CD10 expression. RNA-seq demonstrated that CD10 could identify a different subset of macrophages.

Conclusions: Here in this study we demonstrated CD10 expression by subsets of monocytes or macrophages and found enhanced CD10 expression during monocytes to macrophages differentiation, suggesting that CD may serve as a therapeutic target to treat PC.

The Treatment of Nanoparticle Albumin-bound Paclitaxel Plus Cisplatin for Pancreatic Squamous Cell Carcinoma Patient With BRCA2 Germline Mutation

X. Huang, 1 C. Wang, 2 Z. Huang, 1 Z. Zhou, 1 L. Xu, 1 H. Zhou, 1 Z. Huang, 3 X. Che, 41Department of Hepatobiliary & Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China; 2Department of Hepatology, Huizhou Municipal Central Hospital, Hui Zhou, China; Departments of 3Hepatobiliary Surgery and 4Gastrointestinal & Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

Background: Squamous cell carcinoma of the pancreas accounts for 0.5-2% of all exocrine neoplasms with poor prognosis, which is attributed to the poor response of available therapeutic regimens as well as the limited efficacy of new therapies.

Method: We report a case of a 52-year-old female patient with metastatic primary squamous cell carcinoma of the pancreas harboring a BRCA2 germline mutation. The tumor was located in the tail of the pancreas and had invaded the posterior wall of the stomach and the splenic artery, and was accompanied by multiple hepatic and lymph node metastases in the left supraclavicular fossa. Based on the results of gene detection and a multi-disciplinary panel discussion, we decided to use a nanoparticle albumin combined with paclitaxel cisplatin regimen.

Results: After 10 cycles of nanoparticle albumin-bound paclitaxel (125 mg/m2) combined with cisplatin (75 mg/m2) treatment, repeat imaging examination showed that both hepatic and lymph node metastases (regional and distanced lymph nodes) had complete response and primary tumor diameter regressed from 5.7 cm to 1.5 cm. Even in the advanced stage, the tumor met the surgical resection criteria for the treatment of pancreatic carcinomas and a posterior radical antegrade modular pancreatosplenectomy was performed. Pathological results confirmed the previous diagnosis and showed severe degeneration after chemotherapy in both primary tumor and lymph nodes.

Conclusions: The BRCA2 germline mutation appeared to enhance platinum-sensitivity. Nanoparticle albumin-bound paclitaxel had higher efficiency of intracellular delivery of paclitaxel through the albumin-based nanoparticle technology. The nanoparticle albumin-bound paclitaxel and cisplatin combination demonstrated higher clinical activity and survival advantages in metastatic squamous cell carcinoma. To our knowledge, this is a rare reported case of a primary pancreatic squamous cell carcinoma patient with BRCA2 mutation, and the treatment of nanoparticle albumin-bound paclitaxel plus cisplatin was confirmed to be an effective and tolerable option that even downstages resectability.

Development and Validation of New Nomogram for Predicting Clinically Relevant Postoperative Pancreatic Fistula After Pancreatoduodenectomy

X.T. Huang, C.S. Huang, W. Chen, J.P. Cai, T.T. Gan, J.H. Li, Q.C. Xu, L.J. Liang, X.Y. Yin

Department of Pancreato-Biliary Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.

Background: Currently there lacks of an ideal model for accurately predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). This study aimed at developing a novel nomogram with high accuracy in predicting CR-POPF after PD.

Methods: A total of 762 patients undergoing PD at our centre between January 2010 and May 2018 were enrolled and assigned into testing (N = 535) and validation (N = 227) cohort. Receiver operating characteristics (ROC) curve was used to determine the cut-off value of factors in prediction of CR-POPF, and univariate and multivariate logistic regression analyses were performed to evaluate their predictive values. Nomogram was developed on the basis of significant predictors. The performance of nomogram was evaluated by using area under ROC curve (AUC), net reclassification index, calibration curve, and decision curve analysis.

Results: In testing cohort, 535 patients were included of whom 48 developed CR-POPF. Four predictors were significantly associated with CR-POPF: body mass index ≥24.0 kg/m2, pancreatic duct diameter <3 mm, serum C-reactive protein on postoperative day 1 (POD1) ≥26.5 mg/L, and drainage fluid amylase on POD1 ≥1843 U/L (all P < 0.05). Prediction of nomogram was accurate with AUC of 0.986 (95% confidence interval [CI], 0.978–0.994) in testing cohort and 0.969 (95% CI, 0.947–0.992) in validation cohort. The predictive accuracy of nomogram was better than that of other fistula risk score systems both in testing and validation cohort (all P < 0.001).

Conclusions: The novel nomogram could predict CR-POPF after PD based on four easily available predictors. It would have high clinical value due to its accuracy and convenience.

Prediction of Tumor Prognosis of Pancreatic Neuroendocrine Tumors Using Image, Surgical, and Pathologic Findings

Y. Huang, F. Chen, C. Chen, R. Wan, G. Hu, M. Xu

Department of Gastroenterology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.

Background: Unequivocal clinical markers for prediction of the outcome of pancreatic neuroendocrine tumors (PNETs) remain obscure. We evaluate the value of MRI, CT, surgical and pathologic findings as potential prognostic factors of PNETS.

Methods: Clinical data of 54 patients with PNETs at Shanghai General Hospital from 2012 to 2019 was retrospectively analyzed. Kaplan-Meier method and Cox proportional hazards model were used for survival analysis. CT and MRI findings were evaluated as potential prediction parameters by using Fisher’s exact test and Kruskal-Wallis H test.

Result: Among all patients, there were 33 stage I, 10 stage II, 6 stage III, 5 stage IV, 24 G1, 24 G2, and 6 G3. Ill-defined boundary predicted higher TNM stage, grade and rate of recurrence or death both in CT and MRI (P < 0.05). Greater tumor diameter indicated a higher grade in CT and MRI (P < 0.05). Among CT findings, the predictors for higher TNM stages were distant metastases and lymph node enlargement (P < 0.05). In MRI, tumor enhancement and pancreatic duct dilatation displayed statistical significance among TNM stages (P < 0.05). Univariate analysis showed that TNM stage, grade, margin status, lymph node metastases are related to both disease-free survival (DFS) and overall survival (OS) (P < 0.05). Peripancreatic invasion and perineural invasion are associated with DFS while distant metastases are associated with OS (P < 0.05). Multivariate survival analysis showed that peripancreatic invasion (HR, 2.28; P < 0.05) and lymph node metastases (HR, 2.18; P < 0.05) have an impact on DFS, while positive margin status (HR, 2.85; P < 0.05) is an independent risk factor for OS.

Conclusions: Peripancreatic invasion, lymph node metastases and ill-defined boundary detected by CT or MRI could be independent risk factors for clinical outcome of PNETs.

Dissecting Transcriptomic Heterogeneity in Patient-Derived Pancreatic Ductal Adenocarcinoma With Single-Nucleus RNA-seq

W.L. Hwang, 1,2,3,4 K. Jagadeesh, 1 O. Ashenberg, 1 E. Drokhlyansky, 1 G. Eng, 2,5 N.V. Wittenberghe, 1 W. Freed-Pastor, 2,6 C. Rodriguez, 7 D. Dionne, 1 J. Waldman, 1 M. Cuoco, 1 L. Nguyen, 1 A. Tsankov, 1 C. Lambden, 1 C. Porter, 1 J. Schenkel, 2,8 L. Lambert, 2 D. Ciprani, 7 S. Raghavan, 6 P. Winter, 2 D.P. Ryan, 9 D. Haas-Kogan, 4 J.Y. Wo, 3 C. Eyler, 3 J.D. Mancias, 4 D.T. Ting, 9 C.D. Weekes, 9 C.R. Ferrone, 7 J.S. Loeffler, 3 A.J. Aguirre, 6 M. Mino-Kenudson, 5 T.S. Hong, 3 O. Rozenblatt-Rosen, 1 C. Fernández-del Castillo, 7 A.S. Liss, 7 A. Regev, 1 T.E. Jacks, 21Broad Institute, Cambridge, MA; 2Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA; 3Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA; 4Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA; 5Department of Pathology, Massachusetts General Hospital, Boston, MA; 6Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; 7Department of Surgery, Massachusetts General Hospital, Boston, MA; 8Department of Pathology, Brigham and Women’s Hospital, Boston, MA; 9Department of Medical Oncology, Massachusetts General Hospital, Boston, MA.

Background: Pancreatic ductal adenocarcinoma (PDAC) remains a treatment-refractory disease. Rare cell types, including those responsible for resistance, are difficult to detect with bulk transcriptomic profiling. Indeed, several previously-identified transcriptomic subtypes of PDAC are unintentionally driven by “contaminating” stromal components. Single-cell transcriptomics provides an unprecedented degree of resolution into the properties of individual cells. However, RNA extraction from RNase- and stroma-rich pancreatic tissue is difficult and prior single-cell efforts have been limited by suboptimal dissociation/RNA quality. We developed a robust single- nucleus RNA-seq (sNuc-seq) technique compatible with frozen archival PDAC specimens.

Methods: Patients with localized PDAC undergoing surgical resection with or without neoadjuvant chemoradiotherapy were consented for this IRB-approved study. Specimens were screened for RNA Integrity Number >6. Single nuclei suspensions were extracted from flash frozen primary PDAC specimens and organoids. Approximately 8000 nuclei were loaded on the 10x Genomics Chromium platform per sample to generate and sequence 3' gene expression libraries (Illumina HiSeq 2500, 125 bp paired-end reads).

Results: Both treatment-naïve (n = 9) and treatment-resistant (n = 4) specimens yielded high-quality sNuc-seq data (>1000 nuclei per sample, >1000 median genes per nucleus). In each tumor, distinct clusters with gene expression profiles consistent with ductal, fibroblast, endothelial, endocrine, lymphocyte, and myeloid cell populations were identified. Malignant cells were confirmed by inferred copy number variation analysis and segregated into several distinct clusters for each individual patient highlighting intratumoral heterogeneity. While some malignant clusters corresponded to previously identified basal-squamous and classical-progenitor bulk subtypes, others featured expression profiles distinct from known subtypes, including cells with upregulation of hypoxia-associated or cytoskeletal genes.

Conclusions: Applying sNuc-seq to treatment-naïve and pretreated PDAC specimens, we uncovered significant intratumoral heterogeneity in the malignant and stromal compartments and identified malignant cells featuring transcriptomic programs that do not fit previously identified bulk subtypes. Characterization of treatment resistance programs and spatial relationships is ongoing.

CA 19-9 Decrease (<50%) at 8 Weeks is a Negative Predictive Factor for the Induction of Second-Line Chemotherapy After Nab-Paclitaxel Plus Gemcitabine for Patients With Advanced Pancreatic Cancer

K. Iede, 1 T. Yamada, 2 Y. Tsuda, 2 S. Nakashima, 2Departments of 1Clinical Oncology and 2Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan.

Background: Second-line (2L) chemotherapy is important for improved survival. However, the induction rate of 2L chemotherapy after nab-paclitaxel plus gemcitabine (AG) for advanced pancreatic cancer (APC) is not satisfied and early recognition of the ineffectiveness of AG in patients with a favorable clinical condition may increase the induction rate of 2L chemotherapy. Thus, we retrospectively investigated the predictive factors at 8 weeks for the induction of 2L chemotherapy.

Methods: From January 2015 to January 2019, 41 patients with APC underwent AG as first-line chemotherapy at our institute. 33 patients were survive and evaluated at 8 weeks. Of these patients, 16 patients (48%) underwent 2L chemotherapy after AG (2L group), 17 (52%) underwent no 2L chemotherapy (best supportive care [BSC] group). The clinical features at 8 weeks were retrospectively compared between the 2L groups and BSC groups.

Results: The induction rate of 2L chemotherapy was 48% and most patients received S-1 monotherapy (81%). With the exception of the CA 19-9 decrease (<50%) at 8 weeks, the baseline characteristics did not differ significantly. CA 19-9 decrease (<50%) at 8 weeks were more frequent in the 2L than BSC group (P = 0.024). CA 19-9 decrease (<50%) at 8 weeks was identified as an independent negative predictive factor for the induction of 2L chemotherapy in the multivariate analysis.

Conclusions: CA 19-9 decrease (<50%) at 8 weeks may mean the ineffectiveness of AG and we may need to move to 2L chemotherapy without delay.

Endoscopic Interventions Using Balloon-assisted Enteroscopy to Treat Postoperative Pancreatic Diseases Following Pancreaticoduodenectomy

T. Iemoto, T. Sanuki, M. Miki

Department of Gastroenterology, Kita-harima Medical Center, Ono, Japan.

Background: Recently, patients with malignant tumors treated with pancreaticoduodenectomy (PD) had long-term survival due to the progress of surgical management and chemotherapy. However, complications following PD and postoperative pancreas diseases represent a concern for patients. Although endoscopic retrograde cholangiopancreatography (ERCP) using balloon-assisted enteroscopy (BAE-ERCP) is effective for biliary diseases following PD, there are few reports of this intervention for pancreatic diseases. Endoscopic interventions for the pancreaticojejunostomy anastomotic site have generally been considered difficult, as the site is often located in the tangential direction considering the endoscopic view.

Methods: BAE-ERCP procedures were performed in 8 patients with pancreatic diseases following PD between October 2013 and April 2019. Subsequently, we examined the success rate of the intervention for postoperative pancreatic diseases, focusing on detecting the pancreaticojejunostomy anastomotic site.

Results: A total of 8 patients had undergone pancreaticoduodenectomy. The primary diseases were ampullary duodenum carcinoma, pancreatic carcinoma, and intraductal papillary neoplasm. Six patients developed acute pancreatitis due to pancreaticojejunostomy anastomotic stricture. The two other patients were suspected of having recurrent pancreatic cancer. The success rate of the endoscopic intervention was 63% (5/8 patients). The pancreaticojejunostomy anastomotic site was observed by confirming the suture or pancreatic juice outflow by indigo carmine dispersion. In 3 patients with pancreaticojejunostomy anastomotic stricture, it was resolved by endoscopic balloon dilatation. Two patients with pancreatic tumors were pathologically diagnosed with cancer by pancreatic juice cytology. The pancreaticojejunostomy anastomotic site was not successfully detected in 3 patients due to the stricture.

Conclusions: The success rate of endoscopic interventions using balloon-assisted enteroscopy for pancreatic diseases with pancreaticojejunostomy anastomotic stricture is not high. The confirmation of suture and pancreatic juice outflow by indigo carmine dispersion was effective for detecting the pancreaticojejunostomy anastomotic site.

Tissue Clearing Technology Allows Three-dimensional Counting of Pancreatic Neuroendocrine Neoplasms Obtained by EUS-FNAB

E. Ikeda, 1,2 J. Ushio, 1 Y. Kawasaki, 1 Y. Tada, 1 K. Yokoyama, 1 K. Tamada, 1 H. Onodera, 3,4 N. Fukushima, 2Divisions of 1Gastroenterology and 2Pathology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan; 3Department of Electrical and Electronic Engineering, and 4Photon Science Center, The University of Tokyo, Tokyo, Japan.

Background: Proper grading diagnosis of pancreatic neuroendocrine neoplasms (PanNETs) is necessary for proper treatment. Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) specimens are limited due to their small amount of cells. A goal of our research is to develop a protocol for the three-dimensional (3D) immunohistochemical evaluation using a lab-on-a-chip device with tissue clearing technology. In this present study, we evaluated the utility of the 3D counting of tumor cells and Ki-67 positive cells on EUS-FNAB specimens during the process of conventional histopathological assessment.

Design: FNAB tissue samples obtained from PanNETs were applied. Fresh biopsy specimens were fixed quickly by formalin. After fixation, specimens were fluorescently stained with DAPI (4',6-diamidino-2-phenylindole) and Ki-67 antibody, and then optically cleared using transparency-enhancing technology: illumination of cleared organs to identify target molecules method (LUCID; Onodera H, 2014, Google Patents), and visualized using confocal laser microscopy. Ki-67 positive cells were counted in 3D images. After obtaining the 3D images, all specimens were embedded with paraffin and were subsequently sectioned into thin slices and histopathologically assessed using hematoxylin–eosin (H&E) staining and Ki-67 immunostaining again.

Results: All specimens were successfully cleared by LUCID in less than 30 mins. Morphological observation of the tumor tissue was facilitated by artificial digital “H&E” images. The tissue clearing and 3D image-analysis allowed us to obtain approximately 150 times number of tumor cells in counting Ki-67 positive cells on FNAB specimens. The quality of tissue samples after tissue clearing & image analysis was sufficient for conventional histopathological examination.

Conclusions: The tissue clearing and 3D imaging with confocal laser scanning microscopy enabled us to observe and count larger number of tumor cells compared to conventional 2D assessments. The present first trial will lead to an establishment of an appropriate diagnostic method for small tissue specimens.

Clinical Features and Pathologic Diagnosis Strategy of Early Diagnosis of Pancreatic Cancer

J. Ikemoto, 1 M. Serikawa, 1 Y. Ishii, 1 T. Tsuboi, 1 R. Kawamura, 1 K. Tsushima, 1 Y. Saito, 1 T. Sekito, 1 S. Nakamura, 1 T. Hirano, 1 A. Fukiage, 1 Y. Kiyoshita, 1 S. Saeki, 1 Y. Tamura, 1 Y. Murakami, 2 K. Arihiro, 3Departments of 1Gastroenterology and Metabolism, 2Surgery, and 3Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan.

Background: Pancreatic ductal carcinoma (PDAC) has poor prognosis of all carcinomas. Early diagnosis is extremely important to improve the prognosis, however, it is still challenging. We examined the clinicopathologic features through early-stage PDAC cases experienced in our hospital and clarified the appropriate diagnosis strategy for them.

Methods: From 2007 to 2018, 20 early-stage PDAC cases were diagnosed in our hospital, which was based on the seventh edition of the Japanese Classification of Pancreatic Carcinoma. Out of 20 cases, 4 were Stage 0 and 16 were Stage I. We retrospectively analyzed each of the following, clinical features, imaging findings, and method of cytological diagnosis.

Results: 15 cases were asymptomatic, two had loss weight, two had abdominal pain and one had back pain. In the asymptomatic cases, 8 cases were checked up by accident with ultrasonography. 2 cases had PDAC family history, 7 cases had diabetes, and 6 cases showed elevation of tumor markers. MRCP was performed in 17 cases, of which 14 cases showed main pancreatic duct (MPD) stenosis. Tumor detection rate by CT, MRI, and EUS were 43.7% (7/16), 45.5% (5/11), and 87.5% (14/16) in Stage I cases. ERCP was performed in all cases. The sensitivity of single cytology using pancreatic juice obtained by ERP was 31.6% (6/19), brushing cytology of MPD stenosis was 70% (7/10), and repeated cytology by endoscopic naso-pancreatic drainage (ENPD) catheter was 47.1% (8/17). EUS-FNA diagnosed as adenocarcinoma in 5 out of 7cases (71%) of Stage I. Preoperative pathological diagnosis was possible in 80% of early-stage PDAC cases.

Conclusions: Localized stenosis of MPD detected by MRCP and hypoechoic mass detected by EUS are important findings for early diagnosis of PDAC. To improve the sensitivity of preoperative pathological diagnosis, the combined use of brushing cytology of MPD stenosis and repeated cytology by ENPD should be useful.

For Establishment of Laparoscopic Pancreatoduodenectomy

N. Ikenaga, K. T. Ohtsuka, Y. Watanabe, Y. Mori, K. Nakata, M. Nakamura

Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan.

Background and Methods: The careful patient selection for laparoscopic pancreatoduodenectomy (LPD) is necessary during introductory period. We investigated if preoperative information such as body mass index (BMI), history of previous pancreatitis and vascular anomalies around pancreatic head obtained by 3D imaging affected surgical results and perioperative complications in LPD.

Results: Operation time was longer in 6 patients with BMI ≥25 kg/m2 than others with BMI <25 kg/m2 (median: 680 min vs 501 min; P < 0.001). Perioperative complications including pancreatic fistula was more highly occurred in patients with BMI ≥25 kg/m2 than others (100% vs 42%, P = 0.01). The amount of blood loss during LPD was significantly larger in patients with history of previous pancreatitis than those without pancreatitis (median: 630 ml vs 401 ml, P = 0.03). One of patients with previous pancreatitis underwent conversion to open resection. But, conversely, no complications occurred and the length of postoperative hospital stay was shorter in patients with previous pancreatitis than others (median: 17 days vs 35.5 days, P = 0.03). Nine patients who had anomalous major arteries such as right hepatic artery branching from superior mesenteric artery (SMA) or left hepatic artery branching from left gastric artery showed higher incidence of pancreatic fistula compared with patients without artery anomalies (P = 0.02).

Conclusions: LPD for patients with high BMI should be avoided during introductory period. LPD for patients with the history of previous pancreatitis is technically difficult, but may be feasible after establishment of the procedure in the sight of good postoperative course. The cause of high occurrence of pancreatic fistula in patients with anomalous arteries around pancreatic head should be elucidated.

Efficacy of rTM for Elderly Patients Suffering From Pancreatic Cancer With DIC

S. Ikeoka, T. Eguchi, A. Okada

Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan.

Background: Pancreatic cancer (PC) can be accompanied by cholangitis. The prognosis tends to be to worse in cases involving disseminated intravascular coagulation (DIC). Patients in elderly populations are more likely to be in poor general condition, and chemotherapy is often not an option for these patients. However, DIC treatment may leave chemotherapy as an option and improve patient prognosis. We examined the effects of recombinant human soluble thrombomodulin (rTM) for elderly patients suffering from PC with DIC at our hospital.

Methods: We retrospectively analyzed 44 PC patients with DIC treated from November 2011 and March 2018 at our hospital. The patients were divided into two groups: PC patients over the age of 75, defined as the elderly (Group E, 21 patients); and those under the age of 75, defined as the non-elderly (Group N, 23 patients). We evaluated clinical outcomes by comparing DIC scores. The secondary endpoints were DIC resolution rate, and overall survival (OS) duration.

Results: The median of performance status (PS) in Group E was significantly higher than in Group N (E/N; 2.1/1.6, P < 0.05). We found no significant differences in DIC resolution rate between the two groups (E/N; 42 %/26 %). DIC scores improved significantly, from 5 to 4, at the end of rTM administration in both groups (P < 0.05). The total OS was 33 days. We found no significant differences between the two groups in OS duration (E/N; 32 days/34 days) or rate of chemotherapy after DIC withdrawal (E/N; 34 %/23 %).

Conclusions: Although the elderly group fared worse than the non-elderly group in general condition, clinical outcomes, including DIC solution rate and survival periods, were equivalent for both groups. DIC treatment may contribute to improved prognosis for elderly PC patients.

MRCP Findings in Early Chronic Pancreatitis Diagnosed According to the Japanese Diagnostic Criteria

T. Ikeura, T. Ito, T. Mitsuyama, H. Miyoshi, M. Shimatani, K. Uchida, M. Takaoka, K. Okazaki

The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan.

Background: In the Japanese diagnostic criteria for chronic pancreatitis (CP), the clinical criteria for the diagnosis of early CP was proposed. According to the criteria, the diagnosis of early CP can be made based on clinical features and imaging findings on endoscopic ultrasonography (EUS) or endoscopic retrograde cholangiopancreatography (ERCP); however, in clinical practice, EUS rather than ERCP is performed for examining patients suspected of early CP. The purpose of the current study was to study the pancreatic ductal changes of early CP on MRCP.

Methods: One-hundred-sixty-five patients with clinically suspected early CP were included in the study. Though the medical record, we collected the medical information and reviewed EUS and MRCP images.

Results: Of 165 patients, 88 (53%) were male and a median age was 65 years (range, 23–85 years). When applying the Japanese diagnostic criteria for early CP to all of 165 patients, 25 of 165 patients (15%) fulfilled the diagnostic criteria. In comparing clinical features between early CP and non-early CP, irregular dilatation of ≥3 duct branches was more often seen in early CP compared to non-early CP (56% in early CP vs 26% in non-early CP, P = 0.004), although main duct diameter was comparable (2.06 mm in early CP vs 1.96 in non-early CP, P = 0.698). Regarding the diagnostic performance for early CP based on irregular dilatation of ≥3 duct branches on MRCP, the sensitivity and specificity were 36% and 89%, respectively.

Conclusions: The results of our study suggest the ductal alteration of branches on MRCP could already occur in early CP. The combination of EUS and MRCP findings may improve the diagnostic accuracy of early CP.

Systematic Review on Viral Hepatitis-Attributed Acute Pancreatitis

Z. Imam, 1 C.R. Simons-Linares, 2 P. Chahal, 21Internal Medicine Department, William Beaumont Hospital, Royal Oak, MI; 2Gastroenterology and Hepatology Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Background: Viral hepatitis that concomitantly causes acute pancreatitis (AP) inflammation has been reported but not yet studied.

Methods: A comprehensive review of PubMed’s database of English language from the time of its inception and until April 12, 2019 was performed by two blinded reviewers. AP diagnosis and severity were defined as per the Revised Atlanta Classification. Viral hepatitis infections were diagnosed by serology and/or histology. A diagnosis of viral infection, with a concurrent AP diagnosis, a temporal resolution of both entities and the attempt to exclude the most common etiologies of AP defined viral hepatitis-attributed AP.

Results: 71 cases of viral hepatitis causing concomitant AP were found. 20 AP cases were attributed to Hepatitis A virus (HAV), 16 AP cases to Hepatitis B virus (HBV), and 35 AP cases to Hepatitis E virus (HEV). Mean ages were 24.3 ± 1.9, 40.5 ± 3.1, and 31.5 ± 3.05 for HAV, HBV, HEV cases respectively. Male to female ratio were 2.25:1, 4.33:1, and 8:1 respectively. 37.5% of HBV AP patients were immunocompromised (IC). Latency of AP from jaundice onset was 6.7 (range, 0–21), 11.9 (0–60), 8.8 (0–37) days respectively. Mean AST levels were 1042 (44–5520), 1550 (514–3200), 362 (71–3690), and ALT levels were 1406 (20–6680), 1894 (72–7521), 1093 (103–5214), respectively. AP severity, mild and moderately-severe AP: 80% (HAV), 31.3% (HBV), 82.9% (HEV); Severe AP: 20% (HAV), 66.7% (HBV) and 14.3% (HEV). Mortality was 25% (HAV), 56.3% of (HBV), and 11.8% (HEV). Only one case of HCV-attributed AP was reported with a favorable outcome.

Conclusions: Viral hepatitis causing concomitant AP is a rare entity and outcomes vary depending on the type of hepatitis virus. HEV AP appears to have a male predominance. Over one-third of HBV attributed AP occurred in IC patients, with higher mortality. Direct acinar injury by active viral replication has been suggested as the mechanism of injury.

Viral-induced Acute Pancreatitis: A Systematic Review

Z. Imam, 1 C.R. Simons-Linares, 2 P. Chahal, 21Internal Medicine Department, William Beaumont Hospital, Royal Oak, MI; 2Gastroenterology and Hepatology Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Background: Infectious etiologies is a rare cause of acute pancreatitis (AP). We sought to investigate the frequency of viral-induced AP (VIAP), describe its natural disease and clinical features.

Methods: A comprehensive review of PubMed’s database of English language from the time of its inception and until April 12, 2019 was performed by two blinded reviewers. AP diagnosis and severity were defined as per the Revised Atlanta Classification. Viral infections were diagnosed by serology and/or histology. A diagnosis of viral infection, with a concurrent AP diagnosis, a temporal resolution of both entities and the attempt to exclude the most common etiologies of AP defined VIAP. Graft pancreatitis studies and non-English publications were excluded. Bias risk was assessed with the Murad tool derived from the Newcastle-Ottawa scale.

Results: 209 cases were identified in 128 publications meeting criteria for VIAP. Most studies 101 (78.3%) were at high risk of bias. Mean age was 38.9 ± 1.28 yrs. Male to female ratio was 2.2:1, and 52 (28.0%) of 186 patients were immunocompromised. Mean lipase was 1590 (range, 61–16,879) and mean amylase was 1237 (range, 33–14,800). Viral hepatitis (A, B, C, D and E) was the most common virus (34.4%), followed by coxsackie and echoviruses at 14.8%, hemorrhagic fever viruses at 12.4%, CMV at 12.0%, VZV at 10.5%, mumps and measles at 3.8%, primary HIV infection at 3.8%, HSV at 1.9%, EBV at 1.9% and the remainder of cases (1.9%) attributed to adenovirus, influenza H1N1, and multiple viruses were implicated in 1% of cases. Severity of AP was: 43.1% mild, 11.7% moderately severe, 32.4% severe. Death was reported in 42 (20.1%) patients.

Conclusions: Majority of VIAP patients were not immunocompromised (72%). Importantly, among those who died, 71.4% were immunocompromised. Mortality rate was higher than that reported for AP from other etiologies in the literature.

Effect of Preoperative Nab-paclitaxel and Gemcitabine on Pancreatic Cancer Stroma

K. Ishido, 1 N. Kimura, 1 T. Wakiya, 1 H. Nagase, 1 T. Odagiri, 1 Y. Mitsuhashi, 1 S. Goto, 2 T. Yoshizawa, 2 H. Kijima, 2 K. Hakamada, 1Departments of 1Gastroenterological Surgery and 2Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.

Background: We investigated the pathological impact of gemcitabine (GEM) and nab-paclitaxel (PTX) on pancreatic duct adenocarcinoma (PDAC).

Methods: We retrospectively studied 58 patients who underwent curative surgery for PDAC between 2010 and 2018 at Hirosaki University Hospital, including 13 who received presurgical nab-PTX + GEM (GnP group), 20 who received presurgical S-1 + GEM (GS group), and 25 who received no presurgical treatment (control group). Morphological evaluation was performed regarding nuclear, cytoplasmic and stromal findings, which were scored from 0 to +3. Specimens received patients’ clinicopathological changes were compared by group.

Results: The GnP group showed significant decrease in serum CA 19-9 level (GnP, -88.2%; GS, -40.6%, P = 0.02) and PDAC tumor size (GnP, -57.3%; GS, -20.8%, P = 0.003). Although the three groups did not significantly differ in morphological findings (nuclear and cytoplasmic changes), the GnP group scored significantly lower for inflammatory cell infiltration of stromal tissues than did the other groups (GnP, 1.24 ± 0.24; GS, 2.08 ± 0.19; control, 2.13 ± 0.12), and showed a significantly lower percentage of αSMA-expressing tissue (GnP, 2.1%; GS, 29.2%; control, 38.6%; P < 0.01), and a significantly greater percentage of tissue that was strongly stained by Masson’s trichrome, than did the other groups (GnP, 72.4%; GS,53.2%; control, 47.0%; P < 0.01).

Conclusions: GnP directly affected cancer-associated fibroblasts, which might be the key mechanism of its strong effect on pancreatic cancer.

Transcriptome Sequencing Analysis to Uncover Long Non-coding RNAs Associated With Mitogen-activated Protein Kinase (MAPK) Pathway in Pancreatic Cancer

T. Ishikawa, 1.2 T. Ogawa, 2 Y. Katori, 2 T. Furukawa, 1Departments of 1Investigative Pathology and 2Otolaryngology - Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Activation of the mitogen-activated protein kinase (MAPK) pathway driven by the gain-of-function mutation of KRAS is thought to play a crucial role in gene expression associated with malignant phenotypes of the pancreatic cancer. Accumulating evidences suggest that aberrant expression of long non-coding RNAs (lncRNAs) is associated with phenotypes of the pancreatic cancer. However, a cause of the aberrant expression of lncRNAs in cancer cells is not well known. We aimed to uncover an association between MAPK activity and aberrant expression of lncRNAs in pancreatic cancer cells.

Methods: Cells of three human pancreatic cancer cell lines, namely, MIA PaCa-2, AsPC-1, and PCI35, were cultured in standard condition or treated with MEK inhibitor, U0126. Immunoblots were performed to assess the expression of phosphorylated MAPK. Transcriptome sequencing analyses were performed to investigate altered expression of lncRNAs as well as protein coding genes.

Results: The examined pancreatic cancer cells showed strong expression of phosphorylated MAPK in standard culture condition, which was efficiently inhibited by the MEK inhibitor. The transcriptome sequencing revealed that 2383 lncRNAs were evidently expressed in the cells in total. Among them, 45 lncRNAs revealed two-fold or more changes in the expression level in statistical significance by the MAPK inhibition in at least one of the three cell lines. Some of those lncRNAs were supposed to play roles in malignant phenotypes of cancer cells.

Conclusions: We detected 45 lncRNAs that were associated with MAPK activity in pancreatic cancer cells. They might be candidates for new biomarkers or therapeutic targets.

Comparison Between the Efficacy of Radial- and Convex-Arrayed Echoendoscopes for Indirect Findings of Pancreatic Cancer at an Early Stage

Y. Ishikawa-Kakiya, H. Maruyama, K. Tanoue, K. Hayashi, M. Yamamura, K. Taira, Y. Nagami, T. Tanigawa, T. Watanabe, Y. Fujiwara.

Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan

Background: Endoscopic ultrasonography (EUS) is useful for the detection of pancreatic cancer. Indirect findings (localized stenosis of the pancreatic duct, caliber change, dilatation of the branch duct, and slightly low echoic lesion) detected by EUS are important to detect pancreatic cancer at an early stage. Two types of EUS are commonly used: radial-arrayed echoendoscope and convex-arrayed echoendoscope. There is no comparative study on their efficacy for detecting the indirect findings. Here, we aimed to compare the efficacies of radial and convex echoendoscopes in detecting the indirect findings.

Methods: We enrolled 260 consecutive patients who underwent EUS for screening the pancreas between April 2017 and November 2018. We retrospectively evaluated the detection rate of indirect findings of pancreatic cancer.

Results: The detection rates of indirect findings of radial-arrayed and convex-arrayed echoendoscopes were 11.5% and 2.9%, respectively. The detection rate of radial-arrayed echoendoscope was superior to that of convex-arrayed echoendoscope (P = 0.01). Logistic regression analysis showed that radial-arrayed echoendoscope was significantly superior to convex-arrayed echoendoscope (crude OR, 4.67; 95% CI, 1.35−16.2; P = 0.02). Three patients with indirect findings were diagnosed with pancreatic cancer (stage IA) and intraductal papillary mucinous carcinoma.

Conclusions: Radial-arrayed echoendoscope was useful for the detection of indirect findings in pancreatic cancer at an early stage.

Analysis of Saliva Metabolites to Develop Early Detection System for Pancreatic Cancer

J. Itakura, 1 M. Sugimoto, 2,3 M. Sunamura, 4 K. Takahashi, 1 R. Saito, 1 N. Hosomura, 1 H. Amemiya, 1 H. Kawaida, 1 H. Okamoto, 1 H. Kohno, 1 D. Ichikawa, 1 M. Ootaka, 5 Y. Yoda, 5 H. Shindo, 6 S. Takano, 6 M. Fukazawa, 6 T. Sato. 61Department of Surgery, University of Yamanashi, Yamanashi, Japan; 2Research and Development Center for Minimally Invasive Therapies Health Promotion and Preemptive Medicine, Tokyo Medical University, Tokyo, Japan; 3Institute for Advanced Biosciences, Keio University, Tsuruoka, Yamagata, Japan; 4Fourth Department of Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan; 5Yamanashi Koseiren Health Care Center, Kofu, Japan; 6First Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan.

Background: The development of early and low-invasive detection system is important for improving the survival rate and prognosis of pancreatic cancer (PC). Polyamines have been reported as possible biomarkers in urine and saliva samples in various cancers. Here, we conducted metabolomic analyses to explore novel biomarkers in salivary metabolites including polyamines and also various hydrophilic metabolites.

Methods: Sample collection of PC patients was conducted at University of Yamanashi Hospital. All pancreatic cancer patients were diagnosed histologically and had not received any prior treatment before sampling. As control sample collection of healthy volunteers were conducted at Tokyo Medical University Hospital and Yamanashi Kohseiren Health Care Center. The patients were not allowed to take any food except water intake after 9:00 p.m. on the previous day. All samples were collected at 7:00–11:00 a.m. Approximately 400 μL of unstimulated saliva was collected. Liquid chromatography-mass spectrometry (LC-MS) and capillary electrophoresis-MS (CE-MS) were used for metabolomic analyses.

Result: Forty-eight pancreatic cancer patients (PC) and 2364 healthy volunteers (C) were enrolled in this study. Forty-eight PC cases were 26 male and 22 female, and the average age was 69.7 (51–83) years old. They consist of stage I (n = 4), stage II (n = 2), stage III (n = 21), stage IVa (n = 15), and stage IVb (n = 6). As for the surgery, 25 PD, 18 DP, 3 TP, and 2 palliative operations were performed. Metabolomic analysis identified and quantified 515 metabolites in saliva samples. Of these, 77 metabolites were frequently detected (at least >50% per group). Among quantified metabolites 28 metabolites showed significant differences between PC and C, 22 metabolites between early PC (stage I/II) and C. These metabolites included various polyamines, such as N1-acetylspermidine and N1,8-acetylspermidine, amino acids and intermediate metabolites in glycolysis.

Conclusions: We conducted LC-MS-based metabolomics for comprehensive analyses of hydrophilic metabolites including polyamines in saliva samples from PC patients. The overall metabolite concentration patterns collected from pancreatic cancer patients showed large difference from healthy volunteers. Among quantified metabolites, several metabolites including polyamines showed significant differences between PC and healthy volunteers. The difference was observed even in the early stage of PC. The salivary metabolites showed potential for use in early and low-invasive detection system screening for pancreatic cancer.

Long-Term Outcomes After Main Pancreatic Duct Re-stenosis in Patients With Chronic Pancreatitis Using a Single 10 Fr S-Type Plastic Stent and Multiple Plastic Stents

K. Ito, N. Okano, K. Watanabe, Y. Yamada, K. Yoshimoto, S. Iwasaki, K. Takuma, S. Hara, Y. Kishimoto, Y. Igarashi.

Division of Gastroenterology and Hepatology, Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan.

Background: Placement of a 10-Fr single plastic stent is an effective treatment for main pancreatic duct (MPD) strictures with chronic pancreatitis (CP). Additional endoscopic treatments such as repeated stent replacement, multiple plastic stents (MPS), or surgical pancreaticojejunostomy are required for MPD re-stricture cases. However, few reports exist regarding long-term follow-ups in such cases. The aim of this study was to evaluate the long-term outcomes of additional endoscopic treatments after MPD re-stenosis with CP.

Methods: We retrospectively evaluated 59 CP cases treated with single 10-Fr S-type PS (Olympus Co.) placements between January 2005 and December 2017. These cases were followed up for more than 2 years. For the primary endpoint, we first evaluated MPD re-stenosis cases using single 10-Fr S-type PS. The secondary endpoint was evaluation of refractory MPD stricture cases and MPS. The stent diameters were 7, 8.5, and 10 Fr. The stents were exchanged every 3 months and were removed when MPD dilation was observed using ERCP.

Results: MPD re-stricture occurred in 22 patients (37.2%) during a median follow-up period of 1900 days. A total of 17 patients (77.3%) showed MPD stricture resolution with a single 10-Fr S-type PS placement. Five patients (22.7%) received multiple plastic stenting because of refractory MPD stricture.The median number of stents was 2.4 (range, 2–3), and the median total diameter of the stents was 17.2 Fr. (range, 17–30). The MPS were removed after a mean time of 523.6 days (range, 350–1132 days), no frequent re-strictures were noted after MPS removal. No major complications were recorded.

Conclusions: Additional 10-Fr S-type EPS were effective for treating cases of MPD re-stricture. MPS is therefore a feasible method for treating cases of refractory MPD re-stricture. However, further studies are required to determine the timing, size, number, and length of MPS that are needed for optimal treatment.

The Organ Preservation in Pancreatic Surgery for Young Patients: Is There Better Method or Not?

M. Ito.

Department of Surgery, Fujita Health University, Toyoake, Japan.

Introduction: Improvement of diagnostic technology in recent years in the field of pancreatic surgery. We have focused on preservation of function after pancreatectomy, and have undergone duodenectomy preserved pancreatic head resection (DPPHR) and Letton-Wilson surgery as an organ-sparing procedure. Based on the assumption from the point of view of post-operative quality of life for patients 40 years or younger, compared with a standard type of operation by ingenuity of surgical technique at each facility and fat absorption ability after surgery was investigated.

Subjects and Results: 95 cases of pancreas preservation surgery were performed at our hospital during 1992 to December 2018. Among them, 9 young people (under 40 years old) who took part in the surgical procedure (n = 40 years old) were enrolled (6 duodenal preserved pancreatectomized resections, 3 cases of Letton-Wilson surgery), IPMN 2 cases, SPN: 3 cases, P-NET: 1 case, III b: 3 cases of pancreatic damage. In 2 of 9 cases, pancreatic fistula was recognized, but no other complication was observed. For long-term outcome of each case, we studied the case of weight change and postoperative HbA1c value or fat absorption function test using 13c trioctanoin for up to 14 years after operation. Even in the postoperative long term, it showed satisfactory results compared with pancreatoduoduodenectomy and routine surgery.

Discussion: Pancreas preserving surgery is particularly important for young patients. It seemed to be a technique that should be positively enforced for young patients who can expect long-term prognosis even from diseases.

Diagnosis, Treatment, and Long-term Prognosis for Type 1 Autoimmune Pancreatitis

T. Ito, 1 T. Ikeura, 1 K. Uchida, 1 S. Tsukuda, 1 T. Mitsuyama, 1 H. Miyoshi, 1 M. Shimatani, 1 M. Takaoka, 1 K. Okazaki, 11Division of Gastroenterology and Hepatology, the Third Department of Internal Medicine, Kansai Medical University, Hirakata, Japan.

Background: The concept of type 1 autoimmune pancreatitis (AIP) has been well known widely, but the method of administering steroids and the predictors of relapse have been unclear. Although serum IL-6 is useful for diagnosis Castleman's disease requiring differentiation from IgG4 related diseases, it is unclear in type 1 AIP. In this study, we examined the clinical significance of IL-6, the effectiveness of steroid pulse therapy, and the predictors of relapse after steroid therapy.

Methods: Ninety patients diagnosed type 1 AIP in Kansai Medical University between 2006 and 2018 were enrolled in this study. Study 1; Relationship between serum IL-6 at diagnosis and blood test, imaging findings and extra-pancreatic lesion. Study 2; Effectiveness of steroid pulse therapy as initial treatment. Study 3; Predictors of relapse after steroid therapy.

Results: Study 1; Thirty-seven patients measured serum IL-6 ware divided into normal group (<4 pg/ml) and high group (>4 pg/ml). There was a significant correlation with high CRP levels (P < 0.001) and hypoalbuminemia (P = 0.03) in high group. Study 2; Seventy-two patients underwent maintenance steroid therapy (MST) were divided into oral group (n = 23), half pulse (methyl-prednisolone 500 mg) group (n = 28), and mini-pulse (125 mg) group (n = 21). The examination values and the biliary stricture improved after treatment in all three groups. There was no significant difference among three groups for relapse. Study 3; Multivariate analysis identified three independent factors for relapse: Age <65 years (HR, 2.69; 95% CI, 1.26–5.95; P = 0.01), serum IgG4 before steroid therapy (HR, 2.58; 95% CI, 1.07–7.04; P = 0.035) and MST (HR, 0.210; 95% CI, 0.078–0.577; P = 0.003).

Conclusions: Serum IL-6 correlated with inflammatory response, steroid mini-pulse therapy as initial treatment was effective equally to oral steroid therapy, and the predictors of relapse were young, high IgG4 before treatment and MST.

Study on the Risk Factors of Pancreatic Carcinoma of Individuals With a Family History of Pancreatic Carcinoma

T. Itoh, F. Kinoshita, N. Otsuka, J. Akao, K. Nagao, J. Tahara, Y. Takayama, K. Tokushige, K. Shimizu.

Department of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan.

Background: The prognosis of pancreatic cancer is known to be extremely poor. Thus, by extracting the group with a high risk of pancreatic cancer, early discovery during follow-ups and early treatment are possible. We have attempted to extract individuals with a risk of pancreatic cancer by examining their history, family history, and images.

Methods: We gathered the history, family history, chronic pancreatitis Rosemont class scoring major of 2 points and minor of 1 point, diameter of the main pancreatic duct, and diameter of cyst for 52 patients with a family history of cancer in this hospital. We performed a retrospective statistical investigation of a pancreatic cancer history group and a non-pancreatic cancer history group.

Results: Of the 52 patients, 7 had familial pancreatic cancer lines, 6 had at least 2 second-degree relatives with pancreatic cancer, 24 had 1 second-degree relative with pancreatic cancer, and 3 had a history of pancreatic cancer. In both groups, main pancreatic duct diameter showed a significant difference (1.88 vs 7.67, P < 0.001). Moreover, a subgroup analysis performed on females with a family history of pancreatic cancer revealed that the status of breast cancer significantly increased the risk of pancreatic cancer (P = 0.0308).

Conclusions: The risk of onset of pancreatic cancer was suggested to be high in patients with a family history of cancer and found to have dilatation of the main pancreatic duct, and patients with a history of breast cancer. Gene analysis of a number of familial pancreatic cancer cases in Japan was reported to reveal mutation of breast cancer related genes. The possibility of gene mutation is high particularly among individuals with a history of breast cancer suggesting that such individuals require very careful follow-up.

BM-Derived Cells Destruct Basement Membrane and Induce Local Invasion of Pancreatic Cancer

C. Iwamoto, 1 K. Ohuchida, 1 Y. Ando, 1 T. Shinkawa, 1 Y. Ohtsubo, 1 K. Shindo, 1 T. Moriyama, 1 K. Nakata, 1 K. Miyawaki, 2 T. Ohtsuka, 1 K. Akashi, 2 M. Eto, 3 M. Nakamura, 1Departments of 1Surgery and Oncology, 2Medicine and Biosystemic Science, and 3Urology, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.

Background: The tumor microenvironment is diverse depending on the carcinoma. In gastric cancer, it has been reported that bone marrow (BM)-derived cells invade tumor tissues by local inflammatory reaction, form inflammatory microenvironment and produce cytokines and growth factors, leading to promoting carcinogenesis. In pancreatic cancer, mesenchymal stem cells-derived tumor stroma seems to promote tumor development. However, involvement of BM-derived cells on tumor progression and its mechanism remains unclear. We aimed to investigate its involvement in the remodeling of microenvironment and pancreatic cancer progression.

Methods & Results: Mouse models of allogeneic BM transplantation using newborn KC/ KPC mice were established. KC recipients’ pancreas didn’t turn cancerous, but BM-derived GFP+ cells were engrafted around acinar cells with atrophy. In KPC recipients’ pancreas, BM-derived multilineage hematopoietic cells were accumulated at invasive front, and especially the localization of macrophages including TAM or aSMA+ cells were similar to GFP+ cells. Then, human pancreatic cancer cells (PCCs) co-injected with peripheral blood (PB)-derived macrophages grew invasively in xenotransplantation models. PB-derived macrophages destructed basement membrane than pancreatic stellate cells (PSCs). We investigated the involvement of PB-derived macrophages in the invasive capability of PCCs, and found that the specific subpopulation of those cells led the invasion of PCCs similar to PSCs known as a leading cell in the invasion. Some PB-derived macrophages treated with PCCs supernatant expressed PSC marker.

Conclusions: The present data suggest that BM-derived cells recruited to pancreas in the pancreatic carcinogenesis are involved in invasion of PCCs, and also that the specific subpopulation of BM-derived macrophages transformed into PSC-like cells and acted as leading cells in the invasion of pancreatic cancer.

The Efficacy of Somatostatin Receptor Scintigraphy on the Diagnosis and Grading of Patients with Pancreatic Neuroendocrine Tumor: A Japanese Multicenter Cohort Study

H. Iwaya, 1 S. Hashimoto, 1 S. Tanoue, 1 S. Arima, 1 M. Hinokuchi, 1 M. Kawahira, 1 Y. Iwashita, 2 H. Taguchi, 3 F. Sasaki, 1 S. Kanmura, 1 A. Ido, 11Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan; 2Department of Gastroenterology, Kagoshima City Hospital, Kagoshima, Japan; 3Department of Gastroenterology, Saiseikai Sendai Hospital, Satsumasendai-shi, Japan.

Background: Although Somatostatin receptor scintigraphy (SRS) has a high detection rate for pancreatic neuroendocrine tumors (Pan-NET) and has been reported to be a useful imaging modality in the West, the clinical efficacy of this modality in Japanese patients has been still unclear. The aim of this study was to evaluate the diagnostic ability of SRS in Pan-NET compared with other image modalities (computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET], endoscopic ultrasonography [EUS]).

Methods: All patients with Pan-NET based on EUS-guided fine-needle aspiration (EUS-FNA) or surgical resection were included between January 2016 and March 2019. The study endpoints were as follows: 1) the evaluation of the diagnostic accuracy according to each modality and tumor size and 2) the comparison of the findings of SRS and the expression of somatostatin receptor subtype 2a (SSTR2a).

Results: A total of 42 Japanese patients were enrolled. The tumor grade was classified as G1 in 23 (54.8%), G2 in 11 (26.2%), G3 in 1 (2.4%) and NEC in 7 (16.6%). SRS, PET, CT, MRI, and EUS detected the primary lesion in 77.3% (17/22), 83.3% (15/18), 97.6% (40/41), 90.2% (37/41), and 97.6% (40/41) of cases, respectively. SRS for tumors <10 mm had a lower detection rate than the detection rate for tumors ≥10 mm (60% vs 82.4%, P = 0.29). All SRS-positive cases expressed SSTR2a. The concordance rate of SSTR2a expression with SRS findings was 84.6%.

Conclusions: SRS had an excellent detection rate for G1 and G2 cases, except for lesions <10 mm in size, and had a higher positive rate than PET for low-aggression tumor. SRS appeared to be a useful and reliable modality for lesions with SSTR2a positivity.

Minnelide Treatment Ameliorates Severity of Well-Established Chronic Pancreatitis by Suppressing the Activity of Pancreatic Stellate Cells

S. Iyer, 1 J. George, 2 M. Tarique, 1 E.P. Bava, 1 R. Dawra, 1 V. Dudeja, 1 A.K. Saluja, 11Department of Surgery, University of Miami Miller School of Medicine, Miami, FL; 2Department of Internal Medicine, New Haven Health-Bridgeport Hospital, Bridgeport, CT.

Background: Chronic pancreatitis (CP) is a fibro-inflammatory disease of the pancreas leading to acinar cell loss and exocrine-insufficiency. There is no specific cure for the disease owing to incomplete understanding of its pathophysiology. Triptolide, a diterpene-triepoxide has established anti-inflammatory and anti-cancer properties. In this study, we have evaluated the effect of Minnelide, a water-soluble analogue of Triptolide on well-established model of CP.

Methods: CP was induced in C57BL/6J mice using L-arginine (4.5 g/kg/dose X 2, once-a-week for 4 weeks). Minnelide treatment (0.2 mg/kg/day) was started in a therapeutic-fashion 1week after the 4th episode and continued for 4 weeks. Mice were euthanized one week after starting the treatment and at the end of treatment and different parameters were evaluated. In-order to eliminate model-specific bias, another model of CP was also developed by administering cerulein (50 μg/kg ×7 ×2 days/wk ×10 weeks) and evaluated using Minnelide. Finally, pancreatic stellate cells (PSCs), the primary mediators of fibrosis and inflammation, were characterized in vitro for their viability and activation profile following Triptolide treatment.

Results: In both the models of CP, Minnelide treatment resulted in significant improvement in pancreatic-atrophy as evaluated by pancreas-to-body weight ratio. Minnelide also considerably reduced pancreatic fibrosis and immune-infiltration as seen by histology, picrosirius-red staining and immunohistochemistry. qPCR and western-blotting suggested a considerable reduction in the expression of various pro-inflammatory and fibrosis markers in pancreatic lysate from animals treated with Minnelide. IL-4 and IL-10 peaked up in minnelide treated samples after one week of treatment, suggesting the anti-inflammatory potential of minnelide. In vitro triptolide treatment reduced viability of PSCs in a time-and-dose dependent manner. It also reduced collagen-deposition and expression of several pro-inflammatory genes and pro-fibrotic genes.

Conclusions: Minnelide was found to be highly effective in reducing the severity of well-established CP. This effect is mediated through reduced activation of PSCs.

Evaluation of the Prognostic Factors for Invasive Intraductal Papillary Mucinous Carcinoma and Compare of Outcome With Pancreatic Ductal Adenocarcinoma

W. Izumo, 1 R. Higuchi, 1 M. Shiihara, 1 K. Shimizu, 2 T. Furukawa, 3 M. Yamamoto, 1Departments of 1Surgery and 2Medicine, Institute of Gastroenterology, Tokyo Woman’s Medical University, Tokyo, Japan; 3Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Previous reports on the prognosis of invasive intraductal papillary mucinous carcinoma (IPMC) were inconclusive. The aim of this study was to compare prognosis between patients with invasive IPMC and pancreatic ductal adenocarcinoma (PDAC) and clarify the poor prognostic factors for invasive IPMC.

Methods: We analyzed 401 intraductal papillary mucinous neoplasm (including 114 invasive IPMC) and 560 PDAC patients, who underwent curative pancreatectomy, and evaluated the relationship between clinicopathological factors and outcome. The staging system of the UICC seventh edition was used for both invasive IPMC and PDAC.

Results: In patients with all pathological types, disease-specific survival (DSS) of invasive IPMC was significantly superior to PDAC at all stages (Stage I, IIA, and IIB: P = 0.041, 0.042, and 0.0055, respectively). In patients with only tubular adenocarcinoma, DSS of invasive IPMC was significantly superior to PDAC at only stage IIB (Stage I, IIA, and IIB: P = 0.27, 0.098, and 0.045, respectively). On multivariate analysis, carbohydrate antigen 19-9 (CA 19-9) ≥83 U/mL (hazard ratio [HR], 3.0), tumor size ≥2.2 cm (HR, 4.4), pathological tubular adenocarcinoma grade 2 (HR, 6.5), and lymph node metastasis (LNM; HR, 4.0) were risk factors for a shorter DSS in patients with invasive IPMC. When examining outcomes according to these factors, the 5 years DSS of patients with none plus one (n = 65), two (n = 27), three (n = 16), and four (n = 6) risk factors were 98.4%, 57.9%, 32.3%, and 16.7%, respectively (P < 0.0001).

Conclusions: In patients with all pathological types, DSS of invasive IPMC was significantly superior to PDAC at all stages. In patients with tubular adenocarcinoma, invasive IPMC was better prognosis than PDAC only at stage IIB. CA 19-9 ≥83 U/mL, tumor size ≥2.2 cm, LNM, and pathological tubular adenocarcinoma grade 2 were independent risk factors for poor outcomes and this risk scoring system was useful for predicting outcome in patients with invasive IPMC.

Preoperative Imaging Predictors for Early Recurrence After Complete Resection for Patients With Pancreatic Cancer

A. Izumozaki, 1 D. Inoue, 1 Y. Hori, 2 T. Komori, 1 F. Toshima, 1 S. Kobayashi, 1 T. Gabata, 11Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan; 2Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.

Background: Pancreatic ductal adenocarcinoma (PDAC) is considered as a highly lethal disease. For one of the reasons, early recurrences were frequently seen in PDAC patients, even though they underwent complete (R0) resection. To improve the prognosis of patients with pancreas cancer, pre-operative imaging biomarkers which predicts post-operative clinical course are required.

Methods: Patients that underwent upfront surgery with R0 resection for PDAC between January 2009 and December 2015 were selected. All patients were performed dynamic contrast-enhanced MDCT before surgery. The differences in clinical, pathological, and radiological factors between early recurrence and non-early recurrence groups (recurrence within 1-year after surgery, and within 2-year, versus non-early recurrence groups) were examined using the univariate and multivariate analysis. Overall survival (OS), and disease-free survival (DFS) were analyzed using the Kaplan-Meier method.

Results: Total 132 patients were included (82 males and 50 females; mean age; 71 years). Sixty-five and 91 patients belonged to recurrence within 1-, and 2-years groups, respectively. On univariate analysis, preoperative serum carbohydrate antigen (CA) 19-9 ≥37 U/mL (P = 0.03 and P = 0.02) and rim enhancement on CT examination (P = 0.002 and P = 0.01) were shown as statistically significant factors for recurrence within 1 and 2 years. On multivariate analysis, rim enhancement (OR, 3.11; P = 0.004) was an independent predictor of recurrence within 1 year, and preoperative serum CA 19-9 ≥37 U/mL (OR, 2.46; P = 0.04) and rim enhancement (OR, 2.68; P = 0.03) were independent predictors of recurrence within 2 years. Kaplan-Meier survival analysis demonstrated that rim enhancement had a significantly poorer OS (P = 0.009) and DFS (P = 0.002).

Conclusions: Rim enhancement at dynamic contrast-enhanced MDCT could be a useful imaging biomarker for the prediction of post-surgical course

Endoscopic Transmural Drainage Tailored to Quantity of Necrotic Debris is as Effective as Laparoscopic Drainage for Pancreatic Fluid Collections in Acute Pancreatitis: A Randomized Controlled Trial

S. Jagannath, 1 S. Angadi, 2 R. Sethia, 1 G.V. Teja, 1 A. Krishna, 2 O. Prakash, 2 S. Kumar, 2 V.K. Bansal, 2 P.K. Garg, 1Departments of 1Gastroenterology and 2Surgery, All India Institute of Medical Sciences, New Delhi, India.

Background: Symptomatic pancreatic fluid collections (PFCs) including pseudocyst and walled-off necrosis (WON) require drainage in patients with acute pancreatitis (AP). Both endoscopic and laparoscopic transmural drainage are practiced for drainage of PFCs but the superiority of either is not established. Superadded infection is more common with endoscopic drainage using plastic stents in WON. Our objective was to compare laparoscopic drainage with endoscopic drainage using either lumen apposing metal stents (LAMS) or plastic stents tailored to the amount of necrotic debris in the PFC following AP.

Methods: In a randomized controlled trial, patients with symptomatic pseudocyst/WON were randomized to either endoscopic or laparoscopic drainage. Endoscopic drainage was done under endosonography guidance, two plastic stents were placed if the PFC contained <1/3 necrotic debris and a LAMS (3 cm long, 16 mm diameter) was placed if it was >1/3. A sample size of 40 patients was calculated for a superiority trial. Resolution of PFC within 4 weeks by the intended modality and need for re-intervention due to infection/non-resolution were co-primary outcomes. Overall success was resolution of the PFC at 6 months.

Results: Forty patients were randomized: 20 to laparoscopic group and 20 to endoscopic group. Baseline characteristics were comparable between the groups. Both the groups had similar success after index intervention at 4 weeks (16 in laparoscopic vs 15 in endoscopic group, P = 0.70) and overall success (18 in laparoscopic group vs 17 in endoscopic group, P = 0.64). Median (interquartile range) duration of hospital stay was less in endoscopic group [6 (5–9) vs 4 days (4–8); P = 0.03]. Adverse events were similar between the groups.

Conclusions: Endoscopic transmural drainage using either LAMS or multiple plastic stents tailored to the amount of necrotic debris is as effective as laparoscopic drainage in patients with symptomatic PFCs with lesser hospital stay.

Systemic Therapy in Pancreatic Ductal Adenocarcinoma: Does Drug Selection, Sequence, and Duration Impact Survival

A.A. Javed, 1 A. Noor, 1 J.G. Sham, 1 A. Hasanain, 1 A.B. Blair, 1 N. Rozich, 1 D. Ho, 1 J.L. Cameron, 1 J. He, 1 R.A. Burkhart, 1 L. Zheng, 1 C.L. Wolfgang, 1 M.J. Weiss, 21The Pancreatic Cancer Precision Medicine Program, Johns Hopkins Medical Institutions, Baltimore, MD; 2Northwell Health Cancer Institute, Lake Success, New York, NY.

Background: To assess the impact of drug selection, sequence, and duration of systemic therapy on survival in patients with pancreatic ductal adenocarcinoma (PDAC).

Improvements in systemic therapies available for PDAC have resulted in increased utilization and prolonged survival. Despite multiple studies comparing the effectiveness of specific chemotherapy regimens, the relative effects of drug selection, sequence, and duration in the clinical setting remain poorly understood.

Methods: Patients undergoing surgery for PDAC between 2006 and 2017 after the administration of neoadjuvant therapy were identified from an institutional database. Patient-related, disease-specific, and chemotherapy-associated factors were analyzed.

Results: A total of 428 patients were identified with a mean age of 63.2 ± 9.3 years. The median duration of neoadjuvant therapy administration was 4.0 months (IQR, 2.1–6.0), most frequently utilized 5-Florouracil (5FU)-based chemotherapy (N = 204, 47.7%), followed by Gemcitabine-based regimens (N = 163, 38.1%). The median tumor size was 2.5 cm (IQR, 1.5–3.5), and 181 patients (42.3%) had nodal disease. Adjuvant therapy was administered in 52.3% (n = 224) of patients, with 146 (34.1%) and 68 (15.9%) patients receiving gemcitabine-based and 5FU-based adjuvant therapy, respectively.

The median overall survival (OS) was 18.3 months (IQR, 10.6–37.3), and presence of nodal disease was independently associated with poorer survival (P = 0.009). The utilization of 5FU-based therapies in both the neoadjuvant and adjuvant setting was associated with significantly improved OS (HR, 0.473; P = 0.008). In patients receiving less than four months of chemotherapy prior to surgery, receipt of adjuvant therapy was associated with prolonged OS (HR, 0.41; P < 0.001).

Conclusions: Systemic therapy type, sequence, and duration affect survival in patients with PDAC. Utilization of 5FU-based chemotherapy in both the neoadjuvant and adjuvant settings is associated with longer OS compared with other regimen combinations. In patients receiving less than four months of neoadjuvant chemotherapy, administration of adjuvant therapy is associated with improved survival.

Diabetes Medications and Risk of Pancreatic Cancer

C.Y. Jeon, 1,2,3 S.J. Pandol, 1,2,3 Y. Lin, 1,2 S. Kim, 1 J. Benhammou, 2,3 J. Pisegna, 2,31Cedars-Sinai Medical Center, Los Angeles, CA; 2VA Greater Los Angeles Healthcare System, Los Angeles, CA; 3University of California Los Angeles, Los Angeles, CA.

Background: Observational studies and controlled trials have shown that metformin is associated with reduced risk of pancreatic cancer, while glucagon-like peptide-1 (GLP-1)−based therapy is associated with increased risk of pancreatic cancer. Previous studies may have been confounded by severity of diabetes and extent of glucose control.

Methods: We aimed to evaluate the association of specific classes of diabetes medications with risk of pancreatic cancer in diabetes patients with rigorous adjustment for potential confounders. We analyzed data on 577,941 persons who were ever treated with combination oral hypoglycemic medications and 607,850 persons who were ever treated with insulin in a national population of veterans with diabetes. Diabetes medications of interest included biguanides (metformin), sulfonylureas, thiazolidinediones, alpha-glucosidase inhibitors, DPP-IV inhibitors, and GLP-1 receptor agonists. We performed Cox regression with time to event defined as time from initiation of oral hypoglycemic treatment or initiation of insulin treatment to incident pancreatic cancer. We adjusted for age, sex, smoking, alcoholism, comorbid conditions, hemoglobin A1c, weight change, diabetes complications, creatinine, cholesterol, bilirubin, RBC, alkaline phosphatase and alanine transaminase.

Results: History of treatment with metformin, sulfonylureas, thiazolidinediones, or alpha glucosidase inhibitors was not associated with pancreatic cancer. History of treatment with DPP-IV inhibitors was associated with a 43% increased risk of pancreatic cancer (HR, 1.43; 95% CI, 1.06–1.93) in persons who had initiated with oral hypoglycemic therapy, but not in persons initiating insulin treatment (HR, 1.08; 95% CI, 0.85–1.35).

Conclusions: Further studies are warranted on the risk of pancreatic cancer in persons treated with DPP-IV inhibitors.

Diverging Trends in Lifetime Drinking and Smoking Between Black and White Americans Diagnosed With Chronic Pancreatitis

C.Y. Jeon, 1,2 R. Feldman, 3 D.C. Whitcomb, 4 S. AlKaade, 5 N. Guda, 6 C.M. Wilcox, 7 V. Singh, 8 B.S. Sandhu, 9 D. Yadav, 41Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center, Los Angeles, CA; 2UCLA Fielding School of Public Health, Los Angeles, CA; 3Center for Research on Health Care Data Center, Department of Medicine, University of Pittsburgh, PA; 4Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA; 5SLUCare Center for Pancreatic Biliary Disorders, Saint Louis University, St. Louis, MO; 6Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin, Milwaukee, WI; 7Division of Gastroenterology and Hepatology, The University of Alabama at Birmingham, Birmingham, AL; 8John’s Hopkins University, Baltimore, MD; 9Richmond Gastroenterology Associates, Richmond, VA.

Background: Black Americans experience higher risk of chronic pancreatitis (CP) as compared to White Americans. It is unknown how lifetime trajectory in drinking and smoking contribute to the burden of CP in each race.

Methods: We analyzed data on 358 NAPS2 study participants who had completed a lifetime drinking history (LDH) questionnaire. Drinking data were collected for each phase starting from the time an individual started drinking until the time of enrollment. For each drinking phase, the following data were collected: drinking days in a month, drinks per drinking day and whether the subject drank more than usual on some days, and if so, how much.

Results: Physicians diagnosed alcoholic CP in a significantly greater proportion of Blacks (122/144, 87%) as compared to White participants (121/214, 57%, P < 0.001). Among those with alcoholic CP, Blacks were more likely to report current drinking (30.3% vs 16.5%, P = 0.011), higher average # of drinks/day during periods of drinking (5.3 vs 4.1, P = 0.047), and longer periods of drinking at the maximum level (10.0 vs 6.0 years, P = 0.0005) as compared to White participants. While current smoking was equally prevalent in both Black and White participants (69.7% vs 64.5%) with alcohol etiology, Blacks were less likely to smoke ≥1 pack/day (31.1%), as compared to White counterparts (57.9%, P < 0.0001). Similar trends in intensity of smoking were observed among Black and White CP patients of non-alcohol etiology (32.3% vs 18.2%, P = 0.11). Among those with alcohol etiology who smoked ≥1 pack/day, the intensity of drinking (drinks on a drinking day) in Black males was significantly greater at ages 35 (10 vs 6.1) and 45 years (6.7 vs 3.3) as compared to White males.

Conclusions: Intense and sustained drinking likely contributes to higher burden of CP in Black vs White Americans, while smoking intensity is higher among White Americans with CP.

VGF is a Poor Prognostic Indicator and Facilitates Growth and Metastasis in Pancreatic Neuroendocrine Neoplasms

M. Ji, A.A. Liu, D.L. Chen, L. Tang, L.G. Shi, Z.P. Fu, X. Liang, G. Yang, C.H. Shao.

Department of General Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China.

Background: Pancreatic neuroendocrine neoplasms (pNENs) are endocrine tumors arising in pancreas and is the most common neuroendocrine tumors. However, the expression of VGF and its functional consequences in pNENs has not been documented. The present study was aimed at investigating prognostic relevance of VGF expression in the lesions and resolving its roles in tumorigenesis of pNENs.

Methods: VGF expression was assessed by immunohistochemistry and real-time PCR from 39 pNENs patients. Kaplan-Meier analysis was performed to compare survival curves, and Cox regression analysis was performed to explore the independent prognostic value of VGF expression on the overall survival (OS) of pNENs patients. Harrel's concordance index was applied to calculate the predictive accuracy of established models. In vitro scratch wound healing and Transwell assays were used to assess the effect of VGF expression on pNENs cell migration and invasion, and Cell Counting Kit-8 and MTT assays were used to assess its effects on pNENs cell proliferation. In vivo QGP-1 cell xenograft model was used to evaluate the effect of VGF expression on pNENs tumor growth.

Results: Overexpression of VGF significantly enhanced the proliferation, colony formation, migration and invasion of pNENs cells. Conversely, knockdown of VGF suppressed pNENs cell proliferation, tumorigenesis and metastasis in vitro and in vivo. Clinical evidence indicated that VGF is highly expressed in pNENs tumor tissues and is related to the occurrence of lymph node metastasis, later TNM stage and a poor OS. We also found that VGF expression may serve as an independent prognostic factor for OS of pNENs patients.

Conclusions: The recognition of VGF in regulating tumor cell proliferation and metastasis indicated that VGF might be employed as a new diagnostic and prognostic marker. Targeting VGF highlights a novel therapeutic approach for pancreatic neuroendocrine neoplasms.

Primary Research in the Function and Mechanism of Erbb3 Activated Mutations in Malignant Progression of PDAC

M.Z. Ji, R.Q. Wei, A.A. Liu, D.L. Chen, L. Tang, L.G. Shi, Z.P. Fu, X. Liang, M. Ji, G. Yang, C.H. Shao.

Department of General Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China.

Background: How to screen the pancreatic cancer patients with erlotinib is unclear.

Methods: Detect the ErbB3 mutation of 92 pancreatic cancer specimens in ChangZheng Hospital. Construct Point mutations of ErbB3 genes A232V H465P and try to investigate the effect of ErbB3 wild-type and mutant cell lines (A232V, H465P) KP4 and PANC-1 proliferation when add erlotinib by using MTT colorimeter and Transwell assay. At last, investigate the mechanism of ERBB3 mutation affecting erlotinib therapeutic effect in A232V KP4 cell line by using MTT colorimeter and Transwell assay.

Results: We found 1 case nonsense mutation K498I.Another case is missense mutation H465P. In the function test of MTT, cell proliferation activity decreased obviously, and within the first 12 h had the greatest reduction in A232V KP4 cell line, in H465P KP4 cell line, cell proliferation activity decline is not strong enough in the first 12 h, the follow-up action is weaker (P < 0.05). In PANC-1 cell line, the decrease of cell proliferation activity is not obvious (P < 0.05). In Transwell assay, all of the ErbB3 mutant pancreatic cancer cell line proliferation was inhibited by erlotinib and the effect is strong (P < 0.05).In the mechanism test of MTT, the proliferation of the A232V KP4 cell line was decreased in the erlotinib group compared with that of the control group. After the addition of SSI into erlotinib, the inhibitory effect of erlotinib on the cell line was weakened. In Transwell assay, the result of migration ability is the same as MTT test (P < 0.05).

Conclusions: There are ErbB3 synonymous mutations and missense mutations in PDAC and the missense mutation rate is low, ErbB3 mutant pancreatic cancer cell line proliferation was inhibited by erlotinib, but the effect is weak except A232V KP4 cell line, the migration was also inhibited by erlotinib, and the effect is strong.

Improved Tumor Control With Anti-angiogenic Therapy After Gemcitabine and Nab-paclitaxel in Pancreatic Cancer

S. Ji, 1,2,3 Z. Zhang, 1,2,3 X. Xu, 1,2,3 X. Yu, 1,2,3Departments of 1Pancreatic Surgery and 2Oncology, Shanghai Medical College, Fudan University, Shanghai, China; 3Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China.

Objectives: Although the combination of nab-paclitaxel plus gemcitabine (AG) has been established as the first-line treatment in metastatic pancreatic cancer, the prolonged survival time was less than two months. VEGF-A (hereafter VEGF) elevation following paclitaxel has been reported. VEGF-induced chemoresistance cannot be neglected. Here, we sought to detect the changes of VEGF after gemcitabine and nab-paclitaxel treatment and explore its impact on chemotherapy in pancreatic cancer and elucidate the function of VEGF in reducing sensitivity of pancreatic cancer cells to AG regimen.

Experimental Design: Combining Ktrans, which was obtained via a DCE-MRI scan, with human cytokine array and ELISA, we analyzed the changes of VEGF and neovascularization in serum and cancer tissues after chemotherapy. The impact of anti-angiogenic therapy with chemotherapy was further validated in pancreatic cancer PDX mice. Finally, gene expression profiling was performed to identify associated core signaling pathways.

Results: The level of Ktrans and VEGF was elevated in pancreatic cancer patients treated by AG compared to gemcitabine alone via DCE-MRI and human cytokine array. In a real-world study, bevacizumab plus AG showed potential value as a salvage treatment of AG. VEGF significantly decreased gemcitabine sensitivity of pancreatic cancer cells in vitro. In a patient-derived xenograft (PDX) model, ELISA results indicated that the VEGF in serum is substantially elevated in mice after AG treatment. Then, AG combined with bevacizumab, a monoclonal antibody to VEGF, is superior to AG. Gene expression profiling data revealed that RRM1, a gemcitabine metabolizing enzyme, was a downstream target of VEGF. Meanwhile, RRM1 was a c-Myc target gene. Mechanistically, we demonstrated that VEGF upregulated RRM1 expression in a c-Myc-dependent manner.

Conclusions: Our results thus reveal that VEGF serves as a negative regulator of sensitivity to gemcitabine through regulation of the c-Myc/RRM1 axis in pancreatic cancer.

The Anatomical Features of Dorsal Pancreatic Artery in the Pancreatic Head and Its Clinical Significance in Laparoscopic Pancreatoduodenectomy

C.Y. Jiang, 1 Y. Liang, 2 Y. Deng, 1 Y.T. Chen, 1 Z.S. Dai, 3 H.W. Wang, 1 P.F. Hu, 1 Z.W. Cai, 1 W. Wang, 11Department of General Surgery and 2Minimally Invasive Center, Huadong Hospital, Fudan University, Shanghai, China; 3Anatomy Department, Shanghai Medical College, Fudan University, Shanghai, China.

Background: Bleeding control as one of the major challenges in laparoscopic pancreaticoduodenectomy (LPD) necessitates a considerable anatomical knowledge of the blood supply to the pancreatic head so as to improve the operative safety. This study aimed towards a better understanding of the anatomical features of the dorsal pancreatic artery (DPA), and its clinical significance in LPD.

Methods: Thirteen Chinese cadaveric specimens were used to study the blood supply of the pancreatic head. Between January 2016 and December 2018, seventy-five consecutive patients, who underwent LPD in our institute, were performed with computed tomography angiography as a preoperative detection of the DPA. The DPA was ligated prior to uncinate process dissection in thirty-six patients ("early DPA ligation"), as the others were assigned into the control group.

Results: In the thirteen cadaveric specimens, the DPA originates respectively from the splenic artery (46.1%), superior mesenteric artery (38.5%), common hepatic artery (7.7%) and right gastroepiploic artery (7.7%). The right branch of DPA gives off terminal arteries to form an “inner ring” in the pancreatic head, which communicates with the pancreaticoduodenal arterial arches by plenty of collateral arteries. As compared to the control group, the “early DPA ligation" group showed a significantly lower mean blood loss (190 ± 138 vs 268 ± 169, P = 0.033) and shorter mean resection time (121 ± 17 vs 131 ± 25, P = 0.047).

Conclusions: The DPA is one of the major blood supplies to the pancreatic head. The right branch of DPA gives off plenty of collateral branches to communicate with the pancreaticoduodenal arterial arches. DPA ligation prior to uncinate process dissection can help to completely block the blood supply to the pancreatic head and reduce the blood loss in LPD.

Depletion of Stromal Matrix Accelerates Tumor Progression in Pancreatic Ductal Adenocarcinoma

H.L. Jiang, 1,2 Z Wang, 2,3 E.A. Collisson, 1,21Department of Medicine, 2Helen Diller Family Comprehensive Cancer Center, and 3Department of Radiology, University of California, San Francisco, San Francisco, CA.

Background: Pancreatic ductal adenocarcinoma (PDAC) is featured with a desmoplastic reaction characterized by extensive deposition of extracellular matrix (ECM) components. Stromal remodeling leads to altered interactions between tumor cells and stromal compartments, which can promote tumor progression. Studies have shown that the stroma can either promote and or prevent pancreatic cancer progression, highlighting the conflicting and complicated issues and also the need for additional studies. LOXL2 (lysyl oxidase like-2) belongs to the lysyl oxidase (LOX) family and is essential for extracellular matrix stabilization. Inhibiting the activity of LOXL2 has been showing effectiveness in reducing collagen content and attenuating tissue fibrosis.

Methods and Results: In this study, by applying a specific anti-LOXL2 antibody, significant decreased matrix content was observed in the orthotopic PDAC mouse model. The low abundant matrix microenvironment led to lower tissue stiffness, less contrast retention on CT scanning and accelerated tumor growth with diminished animal survival.

Conclusions: Stroma depletion promotes rather than inhibits PDAC progression suggesting the caution to target stroma in PDAC treatment.

Oncogenic In-frame Deletion of BRAF Kinase in Pancreatic Ductal Adenocarcinoma

H.L. Jiang, 1,2 E.A. Collisson, 1,21Department of Medicine and 2Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA.

Background: The activation of the RAS/RAF/MEK/ERK pathway is critical for the proliferation, survival, and tumorigenesis of pancreatic ductal adenocarcinoma (PDAC). Deletions within the β3/αC-helix loop of BRAF kinase occur in 4% of KRAS wild-type pancreatic cancer and are mutually exclusive with KRAS mutations.

Methods and Results: Expression of N486-P490–deleted BRAF resulted in constitutive activation of MEK/ERK pathway, transformation of BA/F3 cells to grow exponentially in the absence of IL-3 and increased tumorigenicity of HA1E cells in mouse models. BRAF NVTAP deletions mainly function as BRAF/CRAF heterodimers, which are sensitive to PLX8394 (paradox breaker), LY3009120 (RAF dimer inhibitor) and trametinib (MEK inhibitor) but resistant to the BRAF inhibitor vemurafenib.

Conclusions: This study characterized oncogenic BRAF deletions functioned with a distinct activation mechanism dependent on the BRAF/CRAF dimer formation and revealed the single agent efficacy across the RAF and MEK inhibitors.

YAP is a Critical Mediator of AKR1B1-induced EMT and Cell Invasion in Pancreatic Cancer

Z.D. Jiang, 1 X.Q. Li, 1 Z. Wang, 2 Q.Y. Ma, 2Departments of 1General Surgery and 2Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China.

Background: Pancreatic cancer (PanCa) is a kind of malignant tumor with extremely high mortality. We found that Aldo-keto reductase 1 member B1 (AKR1B1) is overexpression in pancreatic cancer and AKR1B1 expression positively correlated with YAP expression in pancreatic cancer. Our recent studies have found YAP play an important role in PanCa cell epithelial-mesenchymal transition (EMT) and invasion. Thus, we speculate that YAP maybe a critical mediator of AKR1B1 induced EMT and invasion in PanCa cells.

Methods: Lentivirus vector AKR1B1-shRNA and Epalrestat (a specific inhibitor of AKR1B1) were used to suppress AKR1B1 expression in PanCa cells. MTT assay was used to detect the cytotoxicity of Epalrestat to PanCa cells. The invasion ability was determined by Transwell assay. The EMT related proteins E-cadherin, N-cadherin, Vimentin, Snail, Slug and YAP were detected by Western blot and Real-time RT-PCR. The nuclei YAP level was evaluated with Immunofluorescence staining assay.

Results: Knockdown of AKR1B1 by AKR1B1-shRNA and Epalrestat inhibit pancreatic cancer cell proliferation and invasion. N-cadherin, Vimentin, Snail, Slug, and YAP level was decreased by Knockdown of AKR1B1 or treatment with Epalrestat. But the invasion ability was reversed under overexpression of YAP in pancreatic cancer cells. The immunofluorescence results showed that the YAP nuclear location was significant decreased when AKR1B1 was knockdown with shAKR1B1 or treatment with Epalrestat.

Conclusions: YAP is a critical mediator of AKR1B1-induced tumorigenic events, including EMT and invasion.

Goal Directed Fluid Therapy in Spontaneously Breathing Patients With Predicted Severe and Moderately Severe Acute Pancreatitis: A Prospective Pilot Study of Passive Leg Raising Test

T. Jin, 1 L. Li, 1 L. Deng, 1 Z. Lin, 1 K. Jiang, 1 C. Hu, 1 X. Zhang, 1 N. Shi, 1 Q. Tan, 1 C. Cheng, 1 R. Zhang, 1 X. Zhou, 1 W. Yu, 1 P. Zhu, 1 T. Liu, 1 A.R. Philips, 2 G. Jia, 1 X. Yang, 1 R. Sutton, 3 W. Huang, 1 J.A. Windsor, 4 Q. Xia, 11Department of Integrated Traditional Chinese Medicine and Western Medicine, Sichuan Provincial Pancreatitis Center and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China; 2Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand; 3Liverpool Pancreatitis Research Group, Royal Liverpool University Hospital and Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; 4Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Background: Fluid therapy (FT) is key to early management of acute pancreatitis (AP), but there is no agreement on how to determine if volume expansion (VE) is required. This study aimed to investigate predicting response to VE (RVE) by passive leg raising test (PLRT) and change in stroke volume (△SV).

Methods: Patients with predicted severe or moderately severe AP were recruited <72 hours of pain onset and assessed at 0, 4, 8, 12, 18-20, 24 hours by objective clinical assessment (OCA; heart rate, hematocrit, urine output and mean arterial pressure), standardized PLRT (at 30, 60 and 120 seconds) and PLRT/△SV (blinded to OCA) using arterial line (Edwards EV1000A™, Irvine). If OCA <2, no VE given and FT rate was 1-3 ml/kg/h. If OCA ≥2, VE was given (250 ml normal saline over 10 min). The RVE determined the FT rate: responders (△SV >10%, 5-10 ml/kg/h) and non-responders (△SV ≤10%, 1-3 ml/kg/h). Clinical outcomes recorded. The prediction of RVE by OCA and PLRT/△SV were compared using Receiver Operating Characteristic analysis.

Results: Sixty-two patients (41 severe, 18 moderately severe) were recruited with median 31 hours from symptom onset. Overall median length of hospital stay was 13 days (IQR, 9-21), 12 admitted to ICU, 4 had necrosectomy, and 4 died. Responders received significantly more fluid between different intervals up to 12 hours than non-responders, but there was no difference in clinical outcome. Compared with OCA, PLRT/△SV at 60s and 120s was better at predicting RVE at 0 and 4 hours, and was the best at 8 hours [AUC for OCA 0.563 vs 0.773 (△SV-60s) vs 0.835 (△SV-120s) and equivalent at 12 hours.

Conclusions: This prospective blinded goal directed FT study is the first to evaluate PLRT in spontaneously breathing patients with AP and demonstrated it was superior to OCA in predicting RVE.

Contribution of Diet and Gut Microbiome to Acute Pancreatitis Severity and Disparity

B. Jung, 1 E.R. Mutlu, 2 G.I. Papachristou, 3 P. Grippo, 1 B.R. Boulay, 1 L. Tussing-Humphreys, 1 H.R. Gaskins, 4 N. Krett, 1 C. Yazici, 11University of Illinois at Chicago, Chicago, IL; 2Rush University Medical Center, Chicago, IL; 3University of Pittsburgh, Pittsburgh, PA; 4University of Illinois at Urbana-Champaign, Urbana-Champaign, IL.

Background: Acute pancreatitis (AP) is a major health-care burden. Diet has been implicated as a potentially modifiable risk factor. African Americans (AAs) are at increased risk with higher mortality indicative of health disparities. Here, we provide a novel hypothesis about contribution of diet and sulfidogenic bacteria (Bilophila wadsworthia, B.w) to AP severity and disparity based on data from two of our studies.

Methods: We collected dietary data using the Block Brief Food Frequency Questionnaire and obtained mucosal biopsies for gene copy number (gnc) microbiome assessment from AAs and non-Hispanic whites (NHWs). In addition, a brief diet questionnaire was used in subjects with AP. T-test or Mann-Whitney U test was used for continuous and Fisher’s exact test or ANOVA was used for categorical data analysis.

Results: In the first cohort, AAs (n = 77) had significantly higher meat and fat intake (g) compared to NHWs (n = 54) (1.45 ± 0.52 vs 1.18 ± 0.51; P = 0.007 and 44.19 ± 8.07 vs 40.16 ± 10.23, P = 0.008, respectively). AAs also had higher gcn of B.w compared to NHWs (1.58 vs 1.25, P < 0.001). In the second cohort (n = 407), subjects with severe AP (n = 79) consumed a higher percentage of meat-rich diet compared with mild (n = 225) and moderate AP (n = 103) subjects (84% vs 72% vs 67%, P = 0.04). The odds ratio for severe AP development was 2.5 times (95% CI, 1.24–5.32; P = 0.01) higher in subjects consuming meat-rich diet.

Conclusions: AAs consume a Diet High in Animal Protein and Fat (DH-APF) and have higher gcn of sulfidogenic bacteria. We hypothesize that DH-APF is a disease-modifying factor contributing to AP severity through its impact on sulfidogenic bacterial production of H2S triggering oxidative and inflammatory injury. A longitudinal study is funded to test this hypothesis using dietary, inflammatory, and gut microbiome data in AAs and Caucasians with and without AP.

External Validation of Nomograms to Predict Malignancy and Invasiveness Risk in Patients With Intraductal Papillary Mucinous Neoplasms, Using Eastern and Western Cohorts

W. Jung, 1,2 T. Park, 3 Y. Kim, 3 H. Park, 3 Y. Han, 1 J. He, 4 C.L. Wolfgang, 4 Al. Blair, 4 M. Farzan Rashid, 5 M.D. Kluger, 5 G.H. Su, 6 J.A. Chabot, 5 C. Yang, 7 W. Lou, 8 R. Valente, 9,10 M. Del Chiaro, 9 Y. Shyr, 11 S. Wang, 11 N.C. van Huijgevoort, 12 M.G. Besselink, 13 Y. Yang, 14 H. Kim, 1 W. Kwon, 1 S. Kim, 1 J. Jang, 11Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; 2Department of Surgery, Ajou University School of Medicine, Suwon, Korea; 3Department of Statistics, Seoul National University College of Natural Sciences, Seoul, Korea; 4Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; 5Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeon, New York, NY; 6Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY; 7Division of General Surgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; 8Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; 9Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; 10Digestive and Liver Disease Unit, Sapienza University of Rome, Rome, Italy; 11Departments of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan; 12Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, Amsterdam, Netherlands; 13Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; 14Department of General Surgery, Peking University First Hospital, Beijing, China.

Background: Intraductal papillary mucinous neoplasm (IPMN) is premalignant pancreatic lesion. International guidelines suggest several treatments and malignancy predictors but offer limited predictors of individual risk. A nomogram to predict individual IPMN malignancy risk was released with good diagnostic performance, based on a cohort of 2258 Korean or Japanese patients with IPMN. This study validated a nomogram to predict malignancy risk and invasiveness of IPMN, using Eastern and Western cohorts.

Methods: We collected clinicopathological and radiological data of patients who underwent pancreas resection for IPMN at 4 centers each in Eastern and Western countries. After excluding patients with ≥1 missing malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum CEA and CA 19-9 levels, and age), we analyzed data of the remaining 393 patients (Eastern: n = 265; Western: n = 128).

Results: Although mean age, sex, log value of serum CA 19-9, tumor location, main duct diameter, cyst size and presence of mural nodule differed between the Korea/Japan, Eastern and Western cohorts, rates of malignancy and invasive cancer did not significantly differ. Areas under the receiver operating characteristics curve (AUC) values using the nomogram to predict malignancy were Eastern: 0.745, Western: 0.856, and combined cohorts: 0.776; and to predict invasiveness were Eastern: 0.736, Western: 0.891, and combined cohorts: 0.788.

Conclusions: External validation of the nomogram showed good performance in predicting malignancy and invasive cancer in both Eastern and Western IPMN patients. The nomogram could be globally applicable to decide customized treatment options for patients with IPMN.

Clinical Results of Stage I Pancreatic Cancer With Special Attention to Recurrence

K. Kamei, I. Matsumoto, Y. Yoshida, K. Kawaguchi, M. Matsumoto, T. Murase, A. Takebe, Y. Takeyama.

Department of Surgery, Kindai University Hospital, Osaka, Japan.

Backgrounds: Although early diagnosis of pancreatic cancer is challenging, its clinical outcomes are not always satisfactory. This study sought to clarify the clinical outcomes of Stage I pancreatic cancer with special attention to recurrence and revisit the current issue and future perspective.

Methods: Clinical records of 35 patients who was treated between 2011 and 2017 and pathologically diagnosed with Stage I pancreatic cancer were retrospectively reviewed.

Results: Median age of the population was 69 (43–84) and 19 patients were male. Location of tumor was Ph in 21 and Pbt in 14 patients; 9 of them underwent neoadjuvant therapy. All patients achieved R0 resection with PD (n = 18), DP (n = 13), or TP (n = 4). IDC was confirmed in 29 and the remaining 6 were diagnosed with IPMC with following pathological stages: T1a/T1b/T1c/T2 in 1/5/22/7 patients, respectively, and Stage IA/IB in 28 and 7 patients, respectively. 1/3/5-year disease free survival rates were 94, 80, and 80%, respectively, and 1/3/5-disease-specific survival rates were 97, 97, and 84%, respectively. No specific clinical factors were associated with long-term outcomes in multivariate analysis, while there was no recurrence in IPMC. Of the 8 patients presenting with recurrence, 7 patients underwent adjuvant therapy and location of initial recurrence were liver (n = 3), distal nodes (n = 2), bone (n = 1), colon (n = 1), and pancreas remnant (n = 1), respectively. Among these, 3 patients with recurrence in bone, colon, and pancreas remnant were surgically treated and still alive, while early recurrences (n = 2) observed within 6 months after surgery were liver metastases and these patients died in short period.

Conclusions: There is no specific clinicopathological factors were extracted as a prognostic marker. Although early recurrence seems to be poor prognostic factor, selected patients with recurrence may be benefitted from multidisciplinary treatment including surgery.

Survival in Early Detected Pancreatic Cancer Gives a Glimpse Into the Promise of Early Detection

H. Kandlakunta, D. Singh, A. Sharma, S.J. Singh Nagpal, S.K. Garg, S. Majumder, S.T. Chari.

Gastroenterology and Hepatology Division, Mayo Clinic, Rochester, MN.

Introduction: By the time pancreatic cancer (PDAC) presents with clinical symptoms (abdominal pain, back pain, jaundice, cachexia) 85% patients have un-resectable disease. We correlated the presence and severity of symptoms to performance status, stage, treatment and survival in PDAC patients.

Methods: PDAC patients between 2013 and 2014 using Mayo Clinic tumor registry, manually verified for their cancer diagnosis cancer-related symptoms were abstracted from electronic medical records. At least 2 physician notes were referred from 3 different departments (GI, Oncology, Surgery) to verify the symptoms. Based on symptoms, patients were classified having: No or minimal symptoms (incidentally detected, isolated jaundice, or weight loss), moderate symptoms (abdominal/back pain not requiring narcotics, dyspepsia, early satiety with or without weight loss), severe symptoms (narcotic requiring abdominal/back pain, fatigue/anorexia with weight loss, nausea/vomiting, deep vein thrombosis).

Results: We identified 664 patients, of which, 53 (8%) had no/minimal symptoms, 105 (16%) had moderate symptoms and 506 (76%) had severe symptoms at the time of cancer diagnosis. Compared to patients with severe symptoms, patients with no/minimal and moderate symptoms had a better performance status (96% and 92% vs 83; P = 0.02), higher proportion of stage I/II (51% and 49% vs 25%, P < 0.001); higher resection rates (27% and 29% vs 17%; P = 0.009). The median survival (months) of patients with no/minimal and moderate symptom was significantly higher than one’s with severe symptom (14.5 and 13.5 vs 10.6; P = 0.01). The 1-and 3-year survivals were significantly higher in patients with no/minimal and moderate symptom compared to those with severe symptoms (62% and 59% vs 46%, P = 0.007; 25% and 12% vs 11%, P = 0.01, respectively).

Conclusions: Compared to current clinical care, detection of PDAC before severe symptoms will identify patients with better performance status, lower proportion of stage IV, higher resection and 3-year survival rates. Longer survival will require novel strategies to prevent recurrence following resection.

Prevention of Post Endoscopic Retrograde Cholangiopancreatography: Urinastatin Versus Nafamostat Mesylate

D. Kang, J. Lee, H. Nam.

Department of Gastroenterology, Pusan National University Yangsan Hospital, Yangsan, Korea.

Background: To prevent post ERCP pancreatitis (PEP), Urinastatin or Nafamostat mesylate is commonly used in Korea. However, no comparative study to evaluate both drugs. This study was performed to evaluate the efficacy of both drug for PEP prevention.

Methods: A total of 1797 patients were analyzed form Jan 2016 to Apr 2019. 1175 Patients received continuous infusion of 500 mL of 5% dextrose solution with 50 mg of nafamostat mesylate or 622 patients with 150,000 unit of Urinastatin. Serum amylase and lipase were checked before ERCP, 4 and 24 hours after ERCP, and when clinically indicated. Pancreatitis is diagnosed if there are raised amylase or lipase more than three times normal limits and abdominal pain consistent with acute pancreatitis

Results: There was a significant difference in the incidence of PEP between the Urinastatin and Nafamostat groups (2.09% vs 4.09%, respectively, OR, 0.501295; 95% CI, Z statistic: 2.18, P = 0.029).

Conclusions: Urinastatin prophylaxis is more effective in the prevention of PEP, compared to Nafamostat mesylate.

Serotonin-producing Neuroendocrine Tumor of the Pancreas Associated With Pancreatic Duct Obstruction: Three Cases

A. Kanki, H. Sotozono, K. Yasokawa, K. Maeba, A. Yamamoto, T. Tamada.

Department of Radiology, Kawasaki Medical School, Kurashiki, Japan.

Clinically, pancreatic neuroendocrine tumors (PNETs) are classified as functioning tumors (functioning tumor) with symptoms or non-functioning tumors (non-functioning tumor) without symptoms. A non-functioning tumor has few clinical symptoms, and its discovery is occasionally delayed, but there are more frequent opportunities to detect PNETs in routine practice as a result of advances in and the widespread use of diagnostic imaging. In a typical case, a solid mass will show rapid initial contrast enhancement in a dynamic computerized tomography or magnetic resonance imaging (MRI) study or appear as a hyperintensity on T2-weighted or diffusion-weighted MRI images. Narrowing of the main pancreatic duct is rare. Even if a tumor is located near the main pancreatic duct, and compression or deviation of that duct is evident, the tumor will not lead to blockage of the main pancreatic duct. Nevertheless, rare cases of stenosis or obstruction of the pancreatic duct have been reported. Shi et al compared 6 patients with a PNET causing stenosis of the main pancreatic duct and 47 patients with a PNET in the control group, and they reported that significantly more of the patients with stenosis of the main pancreatic duct had a tumor that was immunoreactive for serotonin. Kawamoto et al. reported 6 cases of a serotonin-producing PNET causing stenosis of the main pancreatic duct. In all 3 cases seen by the current authors, the tumor was immunoreactive for serotonin. Serotonin stimulates cell division in fibroblasts, and it is reported to cause extensive intratumoral fibrosis. This is presumably a factor related to stenosis of the main pancreatic duct. The presence of an atypical PNET causing stenosis or obstruction of the pancreatic duct must be kept in mind when making a diagnosis.

Usefulness of Franseen FNA Needles in Histopathological Diagnosis of Autoimmune Pancreatitis

A. Kanno, Y. Tanaka, R. Matsumoto, T. Nabeshima, S. Hongo, S. Miura, T. Takikawa, S. Hamada, K. Kume, K. Kikuta, A. Masamune.

Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Histopathological diagnosis of AIP using EUS-FNA is not included in diagnosis under the International Consensus Diagnostic Criteria (ICDC). The usefulness of Franseen FNA needles in histopathological diagnosis of AIP is unknown. The aim of this study is to clarify the usefulness of Franseen FNA needles in histopathological diagnosis of AIP by EUS-FNA.

Methods: Of 83 AIP patients who underwent EUS-FNA between January 2015 and December 2018, 38 lesions collected from 38 patients using 22G Menghini needles (group M) and 45 lesions collected from 45 patients using 22G Franseen needles (group F) were included in this study. The AIP tissue preparations collected were read by a virtual slide scanner, and area measurements of white regions were compared. In addition, the number of positives among histological diagnostic criteria in ICDC and the number of punctures were also compared. Positive lymphocyte/plasma cell infiltration was defined as ≥10 CD38-positive plasma cells/high power field, positive IgG4-positive plasma cell infiltration was defined as ≥10 such cells/high power field, and storiform fibrosis and obliterative phlebitis were identified by a pathologist.

Results: No significant differences in patient background characteristics were found between the two groups (age ± SD years: M:F = 64.1 ± 11.5:67.3 ± 10.7; P = 0.46, Sex [male/female]: M:F = 28/10:34/11; P = 0.99, pancreatic enlargement [diffuse/localized]: M:F = 9/29:18/23; P = 0.41, IgG4 level ± SD mg/dl: M:F = 284.1 ± 147.2:221.1 ± 168.1; P = 0.30). No significant differences in (a) the number of positive ICDC histological endpoints were found between group M and group F (2.9 ± 0.8 versus 3.2 ± 0.7; P = 0.39). Meanwhile, Franseen needles could collect significantly more tissue with a significantly smaller number of punctures: (b) area mm2, group M, 7.8 ± 5.2 versus group F, 13.3 ± 8.5 (P < 0.01); and (c) number of punctures, group M, 4.1 ± 2.6 versus group F, 2.6 ± 1.7 (P < 0.01).

Conclusions: In histopathological diagnosis of AIP with EUS-FNA, Franseen FNA needles showed excellent performance of tissue collection and decreased the number of punctures.

Tff2-Expressing Cells in Pancreatic Duct Glands (PDG) are Somatic Progenitors That are the Site of Origin for Epithelial Cell Regeneration and Cancer Formation

V. Kansal, P. Mondal, D. Maroni, K.L. McAndrews, J.D. Price, S.P. Thayer.

Division of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE.

Background: Pancreatic duct glands (PDGs) are gland-like stem cell niches located along the pancreatic ducts. Epithelial progenitors within PDGs proliferate to regenerate the main duct epithelium. Cells within PDGs express different stem cell markers and have distinct cell fates. Trefoil factor 2 (Tff2) is uniquely expressed by certain cells within the PDGs. Tff2 deficiency accelerates tumor formation in cancer-prone mice, indicating that Tff2 functions as a tumor suppressor. The purpose of the current study is to determine the role of Tff2-expressing PDG cells in regeneration and cancer.

Methods: In vivo lineage tagging of Tff2-expressing cells was performed using Tff2-CreERT2;mT/mG and Tff2-CreERT2;mT/mG;LSL-KrasG12D;Smad4fl/fl mice to irreversibly GFP-tag and follow their progeny after inflammatory injury or in a PDAC mouse model. Cancer-prone mice were analyzed for tumor formation and GFP expression. Three-dimensional spheroids were generated from PDGs of wild-type, Tff2 knockout, and cancer-prone mice and single cell RNA sequencing was performed to define altered pathways common in Tff2-deficient and PDAC mice.

Results: After inflammatory injury Tff2-tagged GFP-positive cells expanded within PDGs and migrated to repopulate the main duct epithelium at early time points. By five days post-inflammation, there was a contraction of GFP cells to pre-inflammation numbers suggesting that Tff2 may identify transient amplifying cells. Introduction of oncogenic mutations to Tff2-expressing PDG cells resulted in continued expansion without contraction of GFP-positive cells within the PDG and main duct epithelium, suggesting that these cells now behaved like true stem cells. Precancerous PanIN lesions, PDAC, and metastatic implants all expressed GFP. Expression of Tff2 was maintained in early PanINs, but downregulated in high grade PanINs and tumor tissue. Single-cell analysis determined that Tff2 knockout and cancer-prone cells both upregulate the mTOR/Akt signaling pathway.

Conclusions: These data suggest that Tff2-expressing cells in PDGs are the compartment of origin for epithelial cells in regeneration and cancer.

Modulation of the PDAC Tumor Microenvironment: “The Extravesicular Link”

T. Kashuv, 1 H.K. Charles Jacob, 2 A.R. Ferrantella, 2 J. Tao, 2 S. Kurtom, 2 U. Vaish, 2 S. Lavania, 2 A.K. Saluja, 2 V. Dudeja, 21Department of Biochemistry and Molecular Biology, University of Miami, Miami, FL; 2Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive cancers with one of the lowest survival rates. In recent years, extracellular vesicles (EVs) of endocytic origin ranging from 30-100 nm have emerged as key players in this intercellular communication between cancer cells and their microenvironment. Through horizontal transfer of biomolecules, exosomes facilitate the transfer of oncogenic traits from highly aggressive cancer cells to normal and indolent ones, allowing for accelerated tumorigenesis. The following research focuses on the characterization of the proteome and phosphoproteome of EVs secreted from PSCs and Cancer cells grown both in isolation and in co-culture conditions.

Methods: A pancreatic cancer cell line was generated from a KPC GEMM mouse using a CD326 enrichment strategy and fresh stellate cells were isolated from normal C57BL6 mice. Cells were grown in exosome depleted media and EVs were isolated using an Extra-PEG based strategy. TEM and western blotting were used to confirm isolation of a pure population of EVs. A CD9 based enrichment was done and proteins were digested and subjected to mass spectrometry on an Easy-nLC 1000 coupled online with an LTQ-Orbitrap Velos Pro.

Results: A total of 721, 400, and 540 proteins and 489, 543, and 512 phosphoproteins were identified from KPC, stellate, and co-culture conditions, respectively, with 267 of the proteins commonly identified amongst all three. We discovered that IGF transport, assembly of collagen fibrils, ECM initiation and degradation, and platelet and neutrophil degranulation pathways were enriched in the EV fractions.

Conclusions: To our knowledge, this is the first report of a proteomic and phosphoproteomic characterization of EVs released from the co-culture of cancer and stromal cells. This study provides evidence of proteins that could mediate stromal cancer cross-talk affecting the initiation of ECM remodeling. Inhibition of EVs release might provide a better solution to control ECM remodeling and desmoplastic transformation.

Use of Nasopancreatic Drainage for Severe Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Case Series

S. Kawaguchi, 1 M. Kikuyama, 2 T. Ohtsu, 1 S. Terada, 1 S. Endo, 11Department of Gastroenterology, Shizuoka General Hospital, Shizuoka, Japan; 2Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan.

Background: Post-endoscopic retrograde cholangiopancreatography pancreatitis (ERCP; PEP) has a poor prognosis in severe cases. We previously reported the use of nasopancreatic drainage (NPD) for patients with severe PEP who had an incurable pain (Intern Med. 2018;57:2657-62). Increased white blood cell count and an elevated inflammatory reaction led to the diagnosis of bacterial infection in the pancreatic juice. To resolve these conditions, pancreatic duct drainage could be an effective treatment. We performed NPD placement through the duodenal papilla in severe PEP.

Methods: Among 3326 ERCPs performed between January 2012 and December 2018, 10 patients with severe PEP who had an incurable pain in spite of using analgesics >3 times in half a day underwent NPD (5-Fr pigtail; Olympus) placement. PEP was assessed as severe according to the Japanese severity score. ERCPs were performed for cholangitis due to common bile duct stones, primary sclerosing cholangitis, bile duct cancer, and acute recurrent pancreatitis due to pancreatic divisum in 6, 2, 1, and 1 patient, respectively.

Results: NPD placement was successful in all the patients, and pain was relieved within 1 day, 4 days, and longer in 6, 2, and 2 patients, respectively. The duration of the NPD placement was 8 to 21 days. All the patients were discharged or underwent pancreatoduodenectomy. Pancreatic juice obtained at NPD in 8 patients was cultured, and 6 patients had positive results.

Conclusions: Our results suggest that NPD can relieve severe PEP with severe pain. Bacteria-induced protease-activated receptor-2 activation may be associated with PEP. To confirm its efficacy, further studies with more patients are required; however, NPD placement for the treatment of PEP should only be performed by expert endoscopists.

Impact of Sarcopenia and Body Composition Change in Patients With Unresectable Pancreatic Cancer Receiving Systemic Chemotherapy

M. Kawahira, S. Arima, K. Oda, Y. Fujino, M. Hinokuchi, Y. Komaki, H. Iwaya, S. Tanoue, F. Sasaki, S. Hashimoto, S. Kanmura, A. Ido.

Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.

Background: Sarcopenia is the loss of muscle mass and strength due to aging and chronic diseases. We examined the prevalence of sarcopenia and body composition changes during chemotherapy among unresectable pancreatic cancer patients.

Methods: Twenty patients (≥55 years old) were enrolled between April 2018 and May 2019. The body composition underwent bioelectrical impedance analysis before and three months after chemotherapy. Sarcopenia was diagnosed by the consensus of the Asian Working Group for Sarcopenia.

Results: The median age was 74 years old (range, 56–85 years old), 11 (55%) were males, and 12 (60%) had metastatic disease. The primary tumor site was the pancreas head in 9 (45%) and the body/tail in 11 (55%). Biliary drainage was performed in 6 (30%). Chemotherapy was gemcitabine and nab-paclitaxel combination in 14, gemcitabine monotherapy in 5, and mFOLFOX therapy in 1. The median body mass index was 22.2 kg/m2, the skeletal muscle mass index (SMI) was 7.9 kg/m2 for males and 5.5 kg/m2 for females, and the grip strength was 32 kg for males and 17 kg for females. No males were diagnosed with sarcopenia, but three females were diagnosed. One male and two females had presarcopenia, defined as a low muscle mass only. The median progression-free survival (PFS) in sarcopenia/presarcopenia and non-sarcopenia patients was 5.5 and 3 months, respectively. In 8 patients whose body composition changes were observed for 3 months after starting chemotherapy, the mean loss of weight and BMI was 1.9 kg and 0.83 kg/m2, respectively. The mean change in the SMI was +0.47 kg/m2, whereas the body fat mass decreased by 2.73 kg.

Conclusions: Sarcopenia was more prevalent in females than in males. The PFS did not differ significantly by sarcopenia presence. Long-term follow-up is needed to clarify the relationship between the clinical course and body composition changes during systemic chemotherapy.

Effect of Y-chromosome Gene Expression on Pancreatic Ductal Adenocarcinoma Progression

K. Kawakubo, 1 K.N. Von Alt, 1 T. Hank, 1 M. Mino-Kenudson, 2 K.D. Lillemoe, 1 A.L. Warshaw, 1 C. Fernández-del Castillo, 1 A.S. Liss, 1Departments of 1Surgery and 2Pathology, Massachusetts General Hospital, Boston, MA.

Background: Loss of Y chromosome genes is associated with increased risk of cancer-related death in males. One-third of pancreatic ductal adenocarcinomas (PDAC) were reported to have a loss of these genes. However, their effect on PDAC progression is still unknown. We investigated effect of Y-chromosome gene expression on the pathogenesis of PDAC.

Methods: RNA sequencing (RNA-seq) was utilized to investigate Y-chromosome gene expression in 45 patient-derived xenograft (PDX) tumors and 20 PDX-derived cell lines from PDAC. KDM5D expression was evaluated by western blotting. We investigated the effect of KDM5D on pancreatic cancer progression by shRNA-knockdown and examined their ability to form orthotopic tumors in NSG mice.

Results: Among the Y-chromosome-specific genes, 7 were not expressed in 69% and 50% of males from PDX tumors and cell lines, respectively. Loss of expression of KDM5D, which encodes a histone demethylase for trimethylated histone 3 lysine 4 (H3K4me3), was verified by western blotting. KDM5D expression level was elevated in 3 of 4 cell PDX-derived cell lines relative to a normal pancreatic ductal epithelial cell line. The expression of KDM5D-specific shRNAs efficiently reduced KDM5D protein levels in four cell lines, but did not alter global levels of H3K4me3. This shRNA-mediated knockdown resulted in a 10-60% reduction in PDAC cell growth in vitro. However, these growth differences were not observed in vivo when cells were grown as orthotopic tumors.

Conclusions: KDM5D-knockdown had minimal effect on PDAC cell growth. Additional studies are needed to elucidate the contribution of Y-chromosome gene expression towards PDAC.

Usefulness of Contrast-enhanced Harmonic Endoscopic Ultrasonography and Carcinoembryonic Antigen Level in Pancreatic Juice for Prediction of Malignant Intraductal Papillary Mucinous Neoplasm

Y. Kawaji, 1 S. Hirono, 2 J. Nuta, 1 T. Tamura, 1 K. Hatamaru, 1 Y. Yamashita, 1 M. Itonaga, 1 M. Kitano, 11Second Department of Internal Medicine and 2Second Department of Surgery, Wakayama Medical University, Wakayama, Japan.

Background: Regarding preoperative diagnosis of intraductal papillary mucinous neoplasm (IPMN), further accurate malignant predictors are needed. The aims of this study were to identify the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) and carcinoembryonic antigen (CEA) level in pancreatic juice for malignant IPMN evaluation.

Methods: A total of 145 IPMN patients including 77 branch duct type and 68 mixed type IPMNs who underwent surgical resection at our hospital from July 1999 to October 2017 were retrospectively studied. The risk factors for malignant IPMN were analyzed. The diagnosability of B-mode EUS, CH-EUS and CEA level in pancreatic juice were compared.

Results: The median age was 71 years and 46.2% were female. Benign and malignant IPMNs were 52 (35.9%) and 93 (64.1%) cases, respectively. The median size of IPMN and mural nodule were 27 mm and 8 mm, respectively. In the multivariate analyses, the significant risk factors were the CEA level in pancreatic juice ≥30 ng/mL (odds ratio 29.47, P < 0.0001) and size of mural nodule ≥5 mm in CH-EUS (odds ratio, 4.11; P = 0.035). When the size of mural nodule ≥5 mm in CH-EUS, the specificity and positive predictive value for malignant IPMN were 71.4% and 85.7%, respectively. These values tended to be higher than those of the size of mural nodule ≥5 mm in B-mode EUS, in which the specificity and positive predictive value were 50.0% and 79.4%, respectively. If the CEA level in pancreatic juice ≥30 ng/mL, the sensitivity and negative predictive value for malignant IPMN were 93.5% and 70.0%, respectively. These tended to be higher than those of the size of mural nodule ≥5 mm in CH-EUS (the sensitivity and negative predictive value were 52.2% and 31.3%, respectively).

Conclusions: CH-EUS and CEA level in pancreatic juice were useful for prediction of malignant IPMN.

IL-6 Drives Metabolic Reprogramming and Induces Stemness in Pancreatic Cancer

K. Kesh, V.K. Gupta, N. Sharma, R. Hadad, B.C. Durden, V.T. Garrido, A.K. Saluja, S. Banerjee.

Division of Surgery, Department of Surgery, University of Miami, FL.

Background: Pancreatic Ductal Adenocarcinoma (PDAC) is one of the most devastating human malignancies with poor survival rate owing to chemoresistance and relapse. Small population of 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.

Method: CD133 negative MIA PaCa-2 cells populations were sorted with magnetic sorting techniques. MIA PaCa-2 cells were implanted subcutaneously with pancreatic stellate (PSC) in athymic nude mice for tumor initiation experiment. KPC cells along with CAF cells were implanted in orthotropic condition for IL-6 receptor neutralizing experiment. PDAC were cultured with PSC condition media or recombinant IL-6 and stem ness markers expression were investigated. Cytometry Bead Array (CBA) were used for cytokine profiling. Metabolic alteration along with TIC gene expression were measured using flow cytometry and Seahorse.

Result: Presence of PSC increased tumor initiation frequency in mice. PDAC cells when cultured with PSC-CM exhibited increase glucose uptake along with an enrichment of CD133+ population. An analysis of the conditioned media using CBA reveled that PSC-CM is enriched with cytokine IL-6 and TNF-α. Treatment of PDAC cells with recombinant IL6 increased expression of self-renewal genes SOX2, OCT4, Nanog along with biochemical marker ALDH. In addition, TIC marker CD133 and invasion marker gene MMP7 expression also increased upon IL-6 induction. Moreover, IL-6 treatment increased glucose uptake and lactate secretion. Small molecule inhibitor Stattic (inhibitor of STAT3) inhibit glucose uptake and stemness gene expression. In vivo administration of anti-IL-6 receptor antibody reduces tumor volume. Our study shows that stromal IL-6 altered metabolic reprogramming in cancer cells as well as increased cancer stemness and invasion.

Conclusions: Stromal cell secreted IL-6 altered metabolic reprogramming and increased cancer stemness in PDAC cells. In future, the underlying mechanisms of IL-6 driven metabolic alteration and its impact on stemness and metastasis will be investigated.

The Obesity Paradox in Pancreatitis Explained by Triglyceride Saturation Making Lipolysis Energetically Unfavorable

B. Khatua, 1 C. de Oliveira, 1 A. Guerra, 1 S. Kostenko, 1 M. Martinez, 1 M. Lowe, 2 V.P. Singh, 11Department of Medicine, Mayo Clinic, Scottsdale, AZ; 2Department of Pediatrics, Washington University Saint Louis, MO.

Background: Studies from the western hemisphere, unlike the east often report BMIs >30 to be associated with mild AP. We thus investigated the impact of saturation on the interaction between long chain unsaturated triglycerides and human pancreatic lipase (PNLIP), the main pancreatic lipase.

Methods: Mixed triglycerides (300 μM) of linoleic (L), oleic (O), and Palmitic (P) were used. Cellular responses (Cai and Mψ) of LLL, OOO, LLP, PLP, LOP, OOP, OPO, POP were measured and FA generation was quantified by adding these to acinar cell medium. Interaction and kinetics of PNLIP with TGs were measured by Isothermal Titration of Calorimetry (ITC)

Results: Fatty acid generation from LLP was reduced to 42 ± 4% while that from LOP and PLP were reduced to 19 ± 8% and 11 ± 4% respectively vs LLL. Linoleate generated 30% less from LLP lipolysis vs LLL. A second palmitate in PLP did not increase palmitate generation and reduced LA generation from the sn-2 position to 8.4%. Generation of linoleate (4.3 ± 1μM) and oleate (4.4 ± 1.2 μM) were dramatically reduced from LOP. Similarly, palmitate at the Sn1/3 or Sn2 position interfered with OA generation from its triglycerides. On ITC, TG interaction with PNLIP had a biphasic pattern, with an immediate endothermic interaction (<20s) followed by an exothermic reaction. The magnitude of both exo- and endothermic interactions followed a similar pattern, (LLL>LLP>LOP) as their lipolysis. Enzyme kinetic parameters also mirrored the above findings LLL>LLP>LOP. The lipase inhibitor orlistat (50 μM) blunted PNLIP-TG interaction, signifying specificity.

Conclusions: Overall, unsaturated triglycerides are more prone to lipolysis by pancreatic lipase and thus may worsen pancreatitis outcomes. Saturated fatty acids like palmitate present in visceral adipose tissue may interfere with this lipolysis and may limit the adverse outcomes even when the triglyceride is in excess. Thus, visceral fat compositions, and not just amount dictate pancreatitis severity, explaining the obesity paradox.

Acute Obstructive Suppurative Pancreatic Ductitis (AOSPD) in Pancreatic Malignancies

M. Kikuyama, R. Shimizuguchi, T. Kamisawa, S. Kuruma, K. Chiba, K. Yoshimoto, J. Nakahodo.

Gastroenterology, Tokyo Metropolitan Cancers and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.

Background: Acute obstructive suppurative pancreatic ductitis (AOSPD) is a suppurative pancreatic duct infection with main pancreatic duct (MPD) or accessory pancreatic duct obstruction in the absence of a pancreatic pseudocyst or necrosis, which is experienced usually in chronic pancreatitis. The diagnosis is confirmed by the finding of pancreatic duct obstruction on ERCP with evidence of infection, such as a positive pancreatic juice culture or drainage of purulent pancreatic juice.

Methods: We studied five patients with pancreatic ductal adenocarcinoma (PDAC) and in one with chronic myeloid leukemia (CML), who suffered from AOSPD.

Results: Of the 281 PDAC and 39 CML patients who we treated in the past 2 years in our hospital, five with PDAC (1.8%) and one with CML (2.6%) experienced AOSPD. Each patient had fever, abdominal pain, and increased blood C-reactive protein. Pancreatography found that each patient had a MPD stricture and an upstream dilatation. Four had a disruption of the MPD in the upper stream of the stricture. Nasopancreatic drainage was successfully performed in all patients. Pancreatic juice culture was positive for Klebsiella pneumonia, Enterobacter agerogenes, or Enterococcus cloacae in four patients.

Conclusions: AOSPD should be considered in pancreatic malignancy with fever and abdominal pain. Prompt diagnosis of AOSPD could avoid shortening of survival of patients with an already poor prognosis by infection.

Clinical Validation of the 2017 International Consensus Guidelines on Intraductal Papillary Mucinous Neoplasm of the Pancreas

E.J. Kim, 1 J.S. Kang, 1 T. Park, 2 Y. Han, 1 S. Lee, 3 H. Lim, 3 H. Kim, 1 S. Choi, 1 W. Kwon, 1 J.Y. Jang, 11Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; 2Department of Statistics and Interdisciplinary Program in Biostatistics, Seoul National University, Seoul, Korea; 3Department of Mathematics and Statistics, Sejong University, Seoul, Korea.

Background: The 2017 international consensus guidelines (ICG) for intraductal papillary mucinous neoplasm (IPMN) of the pancreas were recently released. Important changes included the addition of worrisome features such as elevated serum carbohydrate antigen 19-9 (CA 19-9) and rapid cyst growth (>5 mm over 2 years). We aimed to clinically validate the 2017 ICG and compare the diagnostic performance between the 2017 and 2012 ICG.

Methods: This was a retrospective cohort study. During January 2000–January 2017, patients who underwent complete surgical resection and had pathologic confirmation of branch-duct or mixed-type IPMN were included. To evaluate diagnostic performance, the areas under the receiver operating curves (AUCs) were evaluated.

Results: A total of 448 patients were included. The presence of mural nodule (hazard ratio [HR], 9.12, 95% confidence interval [CI], 4.60–18.09; P = 0.001), main pancreatic duct dilatation (>5 mm) (HR, 5.32; 95% CI, 2.67–10.60; P = 0.001), thickened cystic wall (HR, 3.40; 95% CI, 1.51–7.63; P = 0.003), and elevated CA 19-9 level (>37 unit/mL) (HR, 5.25; 95% CI, 2.05–13.42; P = 0.001) were significantly associated with malignant IPMN. Malignant lesions showed a cyst growth rate >5 mm over 2 years more frequently than benign lesions (60.9 vs 29.7%, P = 0.012). The AUC was higher for the 2017 ICG than the 2012 ICG (0.784 vs 0.746).

Conclusions: The new 2017 ICG for IPMN is clinically valid, with a superior diagnostic performance to the 2012 ICG. The inclusion of elevated serum CA 19-9 level and cyst growth rate to the 2017 ICG is appropriate.

Peroxiredoxin-2 Inhibits Pancreatic Neuroendocrine Tumor Proliferation by Suppressing ROS Related Signaling Pathway

E.J. Kim, H. Lee, J.H. Cho, K.O. Kim, Y.J. Kim, Y.S. Kim.

Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea.

Background: Pancreatic neuroendocrine tumors (pNETs) are one of the rare neoplasms accounting for less than 2% of pancreatic malignancies. Peroxiredoxin (PRX) which are major cellular antioxidants have been indicated in multiple oncogenic signaling pathways. In this study, the role of peroxiredoxin-2 in human pNET cell line was investigated.

Methods: QGP-1, a human pNET cell line and human pancreatic cancer cell lines (BxPC3 and CFPAC) were used for the analyses. The expression of PRX-2 was analyzed at transcript and protein levels by qRT-PCR and western blot. Baseline ROS levels were detected by DCF-DA with FACS. To validate the resistance to the oxidative stress, MTT assay with H2O2 was analyzed. After specific silencing of PRX2 with siRNA, ROS related signaling pathway, migration assay using the scratch-wound assay and proliferation assay were analyzed. Tumor spheroid culture was done to acquire cancer stem cell-like cells from QGP-1 cell line.

Results: Baseline ROS level revealed that there was no definite difference of ROS levels between QGP-1 and other pancreatic cancer cell lines. PRX-2 level was remarkably high in QGP-1 cell lines within both cytosol and nucleus fractions. MTT assay with H2O2 revealed moderate resistance to oxidative stress of QGP-1 cell line compared to the other pancreatic cancer cell lines. Silencing of PRDX2 by siRNA induced phosphorylation of ERK, AKT and JNK. There was no difference in the level of expression of E-cadherin and N-cadherin after siPRDX2. The scratch-wound assay showed no definite change after PRDX2 silencing in QGP-1 cell line. However, proliferation assay revealed that proliferation was increased by siPRDX2 in QGP-1 compared to other pancreatic cancer cell lines.

Conclusions: These results suggest that presence PRX2 may play a suppressive role in proliferation of pNETs by suppressing ROS related signaling pathway.

GLRLM Features in CT Texture Analysis Are Prognostic Factors: Evaluation of Pancreatic Cancer Heterogeneity

H.S. Kim, 1 J. B. Lim, 2 J.S. Park, 11Pancreas-biliary Cancer Clinic, Department of Surgery, and 2Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

Background: Pancreatic cancer is an extremely lethal disease. Resistance to chemotherapy is a critical factor influencing the prognosis (recurrence or metastasis) after surgery for pancreatic cancer. Tumor heterogeneity is an important indicator of the progression of chemoresistance. Although texture analyses can allow quantification of tumor heterogeneity, only a few studies reported the use of texture analysis in cases of pancreatic cancer. Therefore, we analyzed tumor heterogeneity in preoperative computed tomography (CT) scans by performing texture analysis using the gray-level run-length matrix (GLRLM) and analyzed the correlation of survival with the f obtained in these analyses.

Methods: We analyzed 116 consecutive patients who underwent surgical resection during 2001-2017 and had preoperative contrast-enhanced CT data available for analysis (prior to surgery). An ROI was drawn on all the slices with a visible tumor and normal pancreas on the arterial phase CT scans and the correlation of pathological characteristics and GLRLM features was analyzed. We then performed Kaplan—Meier survival curve analysis among pancreatic cancer patients.

Results: The gray-level non-uniformity (GLN) values in GLRLM features for tumors were higher than those for normal pancreas. High GLN values represent a non-uniform texture, i.e., heterogeneity. Kaplan–Meier survival curve analysis using these GLRLM features showed that recurrence-free survival was shorter in the group with high GLN135 values (P = 0.025).

Conclusions: Tumor heterogeneity is a significant prognostic factor. Our analyses of the correlation between pathological outcomes and GLRLM features in pancreatic cancer patients showed that GLN values were a powerful indicator of prognosis.

Enhancing Mural Nodule in the Main Pancreatic Duct of Main and Mixed Type IPMN of the Pancreas: Does Size Matter on Malignancy Risk?

T.H. Kim.

Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, South Korea.

Objective: Most guidelines recommend surgical resection of all main-duct (MD) and mixed-type intraductal papillary mucinous neoplasms (IPMNs) in fit patients. However, there is little evidence on the malignancy risk of MD and mixed-type IPMNs with enhancing mural nodules (MN) in just main pancreatic duct (MPD). We conducted to identify the clinical features and morphologic features associated with malignancy in patients with MD and mixed IPMN that had enhancing MNs in the MPD.

Methods: We enrolled retrospectively 50 patients with MD and mixed type IPMNs that had enhancing MNs in the MPD on contrast enhanced MRI. Clinical characteristics, particularly preoperative radiologic imaging with regard to morphology of the MPD (diffuse vs segment, mural nodule size, MPD diameter 5–9 vs >10 mm) were correlated with histopathology. We analyzed risk factors for malignant MD and mixed type IPMN in this group.

Results: MD and mixed-IPMNs with low-grade (n = 2) or moderate-grade (n = 17) dysplasia were classified as benign (38%); those with high-grade dysplasia (n = 18) or invasive carcinoma (n = 13) were classified as malignant (62%). On the ROC curve, the cutoff value of mural nodule size on MRI for predicting malignant IPMNs is 5 mm (sensitivity of 90%, specificity of 55%, AUC = 0.770). Univariate analysis revealed that diffuse type of MPD (P = 0.04), Serum CA 19-9 (P = 0.05), and mural nodule size >5 mm (P = 0.0001). Multivariate analysis revealed that only mural nodule size >5 mm (odds ratio, 18.7; 95% CI, 3.4–103.3; P = 0.0008) was an independent risk factor for malignancy in main and mixed type IPMNs with enhancing MNs on MRI.

Conclusions: In patients with MD and mixed type IPMNs who have enhancing MNs in the MPD on contrast enhanced MRI, enhancing MN size >5 mm may be associated with malignancy. These data support management algorithm of main and mixed type IPMN in 2017 International Consensus Guideline.

Clinicopathological Predictive Factors for Early Recurrence in Resectable Pancreatic Cancer

R. Kimura, Y. Miyasaka, Y. Mori, K. Nakata, T. Ohtsuka, M. Nakamura.

Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Background: Pancreatic cancer (PC) has one of the unfavorable prognosis among digestive cancer and is extremely difficult to cure. The current standard of care for resectable PC is surgery-first followed by adjuvant chemotherapy. Patients often experience early recurrence after curative resection for PC. We aimed to evaluate the use of preoperative clinicopathological parameters as predictive factors for early recurrence of resectable PC.

Materials and Methods: We reviewed 215 patients who underwent pancreatic resection for resectable PC, treated by the surgery-first approach in a Kyushu University Hospital between 2007 and 2016. We defined recurrence within 6 months after surgery as early recurrence. We divided the patients into early recurrence group and non-early recurrence group. We compared the clinicopathological factors among the two groups.

Results: Of the patients who underwent surgical resection, 45 (21.0%) had postoperative recurrence within 6 months after surgery. In univariate and multivariate analysis, patients in the early recurrence group had a significantly larger tumor size (≥30 mm) and higher R1 resection rate. We classified patients into a high-risk group (2 risk factors), a middle-risk group (1 risk factor) and low-risk group (no risk factors). Overall survival (OS) of the patients in the high-risk group (median: 11.8 months, 5y-OS: 14.1%) were significantly worse than that of the patients in no risk group (median: 48.3 months, 5y-OS: 48.2%) and middle risk group (median: 19.8 months, 5y-OS: 18.7%) (P < 0.001).

Conclusions: Our results showed that large tumor and R1 resection are independent predictive factors of early recurrence and poor prognosis after resection for resectable PC. Multidisciplinary therapy including neoadjuvant treatment should be considered in patients with large tumor close to resection margin.

Alternative Lengthening of Telomeres Predicts Metastatic Disease and Poor Survival in Patients With Pancreatic Neuroendocrine Tumors

Y. Kinowaki,1 Y. Matsuda,2 Y. Fukumura,3 A. Kudo,4 T. Akashi,1 M. Kitagawa.51 Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan; 2 Onco-Pathology, Department of Pathology and Host-Defense, Faculty of Medicine, Kagawa University, Takamatsu, Japan; 3 Department of Human Pathology, Juntendo University, Tokyo, Japan; Departments of 4 Hepatobiliary-Pancreatic Surgery and 5 Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.

Background: Pancreatic neuroendocrine tumors (PanNET) are a heterogeneous group of neoplasms with increasing incidence and unpredictable behavior. Alternative lengthening of telomeres (ALT), a telomerase-independent telomere maintenance mechanism, occurs frequently in PanNET, and plays a key role in pathogesis of PanNET. In this study, we assessed the ALT status and compared it with clinicopathologic factors.

Methods: Pancreatic tissue samples were obtained from 139 Japanese patients (aged 19 to 80 years; average, 57 years; median, 60 years; 74 male and 65 female) who underwent surgical treatment at Tokyo Medical and Dental University Hospital, Tokyo, Japan between 2001 and 2018. Telomeric fluorescence in situ hybridization was performed using 42 samples. We analyzed the correlation between ALT and clinicopathological features of the tumors, including disease-free and overall survival.

Results: ALT was detected in 17/42 (40.5%) of PanNET cases, and was significantly correlated with tumor size (P = 0.0004), WHO grade (P = 0.0068), and lymph node metastasis (P = 0.0291). The ALT statuses were not correlated with sex, tumor location, lymphovascular invasion, hormone production, and liver metastasis. The ALT-positive group had poor disease-free survival values (P = 0.0324) compared with those of the ALT-negative group. The median disease-free survival duration of ALT-positive and -negative groups were 1208 and 1756 days, respectively, but there was no statistically significant difference in the overall survival between both groups.

Conclusions: ALT-positive PanNET was associated with a more aggressive subtype. Further analysis will be needed to clarify the mechanisms of tumorigenesis in PanNET.

Scoring System for Cytological Diagnosis of Pancreatic Cancer Using EUS-FNA Samples

Y. Kiso,1 Y. Matsuda,2 S. Esaka,1 Y. Hamashima,1 H. Shirahata,1 M. Kakizaki,1 T. Ishizaki,3 T. Arai,11 Department of Pathology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan; 2 Oncology Pathology, Department of Pathology and Host-Defense, Faculty of Medicine, Kagawa University, Kagawa, Japan; 3 Research Team for Human Care, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.

Background: It is often difficult to diagnose pancreatic cancer by EUS-FNA due to small amount of samples or well-differentiated adenocarcinoma with weak cytological atypia. It has been demanded to improve the sensitivity and specificity of cytological diagnosis for pancreatic cancer. We clarified the useful indices to distinguish malignancy from benign to establish novel scoring system for cytological diagnosis of pancreatic EUS-FNA specimens.

Methods: The present study was conducted using 142 of Papanicolaou staining specimens obtained by EUS-FNA from 124 patients which were pathologically diagnosed as malignancy (n = 111, invasive ductal adenocarcinoma, intraductal papillary mucinous carcinoma) or benign (n = 31, pancreatitis, low grade atypical epithelium) by tissue specimens. We decided 20 cytological indices based on our previous study (Esaka, J Jpn Soc Clin Cytol, 2018). Reviewers who were three medical doctors (two pathologists and a senior resident) and four cytotechnologists evaluated the presence or absence of 20 indices in blind manner. Statistical analysis was performed using χ2 and Fisher's exact tests, ROC curve, Youden Index, and logistic regression test.

Results: Cytotechnologists showed relatively uniform judgements, while medical doctors showed variety of judgements in the determination of hypercellularity. From the results of all seven reviewers, 13 indices out of 20 (unclear cell boundary, irregular nuclei, irregular structure, irregular cell polarity, high N/C ratio, hyperchromatin, nuclear membrane thickening, irregular molding, anisonucleosis, decreased cell adhesion, prominent nucleoli, necrotic background, two cell pattern) were useful to distinguish malignant from benign (P < 0.0001). When we adopted scoring system using the 13 useful indices, cutoff value 8/9 showed the highest sensitivity and specificity to distinguish malignant from benign (98% and 97%, respectively).

Conclusions: Our new scoring system showed high sensitivity and specificity to differentiate malignant and benign using pancreatic EUS-FNA samples. Further validation or prospective study is necessary to establish scoring system for cytological diagnosis of pancreatic cancer.

Strategy for SMA Margin-negative Dissection Without Severe Diarrhea for Pancreatic Uncinate Process Cancer

H. Kitagawa,1 K. Hashida,1 K. Hamai,1 K. Kawamoto,1 H. Terakawa,2 N. Ozaki,31 Department of Surgery, Kurashiki Central Hospital, Okayama, Japan; Departments of 2 Gastroenterological Surgery and 3 Functional Anatomy, Kanazawa University, Kanazawa, Japan.

Background: SMA margin is the most important margin to achieve R0 resection for pancreatic head cancer. This margin is cut margin at the region of superior mesenteric arterial nerve plexus (PLsma) or the pancreatic head nerve plexus II (PLphII) defined in Japan Pancreas Society Classification of Pancreatic Carcinoma (JPS Classification). Involvement to these PLs is frequently observed in pancreatic head cancer. When cancer involved very near to the SMA, optimal dissection of these PLs around SMA is still being debated. Therefore, we examined histological structure and anatomical interaction of these PLs by cadaveric study to allow to minimize the dissection of PLsma.

Results: Around SMA, areolar structure mainly consists of fibers formed concentric circles 2-3 mm thick, which corresponds to the PLsma. PLsma continue along SMA to the peripheral direction. PLphII indicates the region from PLsma to the uncinate process of pancreas, which is macroscopically fibrous thick part and histologically including the fiber tissue, vessels and adipose tissues as well. The PLphII continue and gradually fuse to the PLsma on the right to posterior side around the origin of IPDA. PLphII contains regional lymph nodes which corresponds to No. 14 lymph node station of JPS Classification.

Conclusions: Surgical procedure: Based on these results, our surgical plan is follows. Basic dissection for T1 or T2 (tumor limited to the pancreas): dissect longitudinally along the SMA from the lower level of uncinate process to 1cm upper level of the origin of IPDA preserving PLsma 3 mm in thickness. Advanced dissection for T3 (tumor extends beyond the pancreas): dissect more than 3 mm away from cancer. If the cancer infiltrates closer to the adventitia of SMA, dissect en bloc with circumferential dissection of PLsma of 3 cm longitudinally along SMA around the origin of IPDA. We have no case complicated severe diarrhea without local recurrence.

Usefulness of Selective Arterial Calcium Injection Tests for Functional Pancreatic Neuroendocrine Neoplasms

M. Kitago,1 Y. Nakano,1 M. Shinoda,1 S. Nakatsuka,2 K. Isao,3 H. Yagi,1 Y. Abe,1 G. Oshima,1 S. Hori,1 Y. Endo,1 T. Yokose,1 K. Abe,1 Y. Kitagawa,1 Departments of 1Surgery, 2 Diagnostic Radiology, and 3 Nephrology, Endocrinology and Metabolism, Keio University School of Medicine, Tokyo, Japan.

Background: The use of the selective arterial calcium injection (SACI) test has resulted in increased performance of curative resection surgery for patients with functional pancreatic neuroendocrine neoplasms (F-PNENs). Aim: To identify which patients with F-PNENs would benefit from the SACI test by investigating the preoperative findings.

Methods: Patients who underwent pancreatectomy for F-PNENs between January 1992 and September 2016 were retrospectively evaluated in this study. We reviewed their preoperative findings on the SACI test as well as on CT, MRI, and CT angiography (CTA).

Results: A total of 14 patients underwent the SACI test and curative resection for F-PNENs. The detection rate of F-PNENs was 78.6% for CT, 91.7% for MRI, 100% for CT and MRI, and 100% for CTA. We classified the patients into three groups according to their preoperative findings: group A had a single pancreatic tumor detected using either CT or MRI; group B had multiple pancreatic tumors; and in group C, the tumor location was consistent between CT, MRI, and CTA, but the SACI test revealed another tumor on calcium injection. In group A consisting of 10 patients, CTA and the SACI test also revealed the tumor, which was positive on calcium injection. In group B consisting of 3 patients, we could detect the responsible tumor among the multiple tumors by using the SACI test. Moreover, all patients in group B had MEN-I. In group C consisting of 1 patient, the SACI test revealed another tumor on calcium injection, whose location was different from the location detected using CT, MRI, and CTA.

Conclusions: The SACI test should be performed for multiple F-PNENs on CT or MRI. The SACI test or CTA might not be needed if CT or MRI reveals a single tumor.

Total Pancreatectomy With Islet-Auto Cell Transplant (TPIAT) in Pediatric Patients: Outcomes Improve With Patient and Family-Centered Education

M. Klosterman,1 M. Zerofsky,1 S. Rhee,1 J. Ostroff,2 R. Long,1 J. Buchanan,1 A. Borucki,1 K. Sun,1 G. Szot,3 A. Posselt,3 E. Perito,1Departments of 1 Pediatrics, 2 Medicine, and 3 Transplant Surgery; University of California, San Francisco, San Francisco, CA.

Background: Chronic pancreatitis (CP) in pediatric patients can cause debilitating pain, poor quality of life, and diabetes. TPIAT aims to treat CP-related pain, preserve islet function, and restore quality of life. Given the complexity of the surgery and recovery, we determined the outcomes of patient and family centered education (PFCE), to prepare children and families for TPIAT.

Methods: Single-center, retrospective review of 18 pediatric patients (3–22 yrs) with CP who underwent TPIAT 2013-2019. 10 patients received pre-TPIAT PFCE; 8 did not. PFCE included counseling, for primary caregivers and the child, about the peri-operative clinical course, diabetes education, nutrition education, pain management and coping strategies.

Results: Demographics and operative characteristics did not differ in the PFCE and non-PFCE groups. Median age at TPIAT was 13.3 yrs; 89% had CP-related mutations (PRSS1, CFTR, SPINK1); 67% were female, 22% Hispanic. Median operative time was 8.3 hrs (IQR, 7.9–8.4 hrs). Median islet equivalents per kilogram body weight (IEQ/kg) was 6892 (IQR, 4294–8436). During the TPIAT hospitalization, children who received PFCE (n = 10) had a significantly shorter median length of stay (16.5 d [IQR, 15–19] vs 30 d [IQR, 25.5–46]; P = 0.002), trended towards fewer days in the ICU (5.5 d [IQR, 5–7] vs 9 d [IQR, 5–10]; P = 0.06) and fewer days on patient controlled analgesia (8 d [IQR, 4–9] vs 12 d [IQR, 8–19]; P = 0.10). Postoperative days to goal enteral nutrition did not differ between groups (overall median days = 4, IQR, 2–5). Among 1 year or more post-TPIAT (n = 15), the PFCE group (n = 7) had fewer ER visits and hospitalizations in the year following TPIAT (median = 2 [IQR, 0–3] vs 4 [IQR, 2.5–7]; P = 0.04) and no PFCE recipients were taking opioids (n = 0 vs n = 3; 37.5%; P = 0.07).

Conclusions: PFCE was associated with improved outcomes after TPIAT with shorter ICU and hospital stays, fewer ER visits/hospitalizations during follow-up and no opioid use at 1 year.

Clinical and Morphological Background of Parenchyma-preserving Split-pancreas Technique in Chronic Pancreatitis Patients

V.N. Klymenko,1 A.V. Klymenko,2 A.A. Steshenko,2 V.A. Tumanski,3 V.A. Kabachenko,3Departments of 1 Hospital Surgery, 2 Faculty Surgery, and 3 Pathological Anatomy and Forensic Medicine, Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine.

Background: resectional nature of surgical interventions in patients with chronic pancreatitis (CP) (Beger, Frey and Wipple procedures) are mainly based upon severe morphological changes in pancreatic head. But still there is a lack of comparative studies to look at simultaneous morphological changes in the area of pancreatic body and tail.

Methods: 64 CP patients underwent parenchyma-preserving (non-resectional) surgery - longitudinal total pancreatic wirsungo-duodeno-papillotomy with isolated longitudinal pancreatico-jejuno-duodenostomy (split-pancreas technique). Histological and immunohistochemical methods were used. Alcoholic CP was in (59/64; 92.2%) patients.

Results: Absolute identical morphological changes were found in the head, body and tail of the pancreas: significant periductal fibrosis with areas of immune infiltration forming a thick connective tissue sheath around the Wirsung’s duct. Significant expression of type IV collagen as well as penetration of α-SMA-positive stellate cells from periductal fibrosis zone into interlobular stroma of the pancreas with formation of interlobular fibrous septa of different severity were observed. In the long term period (5 years) in all the CP patients after the surgery abdominal pain stopped. In the CP patients without exocrine (37/64; 57.8%) and endocrine (51/64; 79.7%) insufficiency before the surgery syndrome of malnutrition and pancreatogenic diabetes did not develop after a split-pancreas technique and quality of life corresponded to the one of healthy people. In the CP patients after manifestation of exocrine (27/64; 42.2%) and endocrine (13/64; 20.3%) insufficiency before the surgery the severity did not progress and remained at the same level as before the surgery.

Conclusions: identical morphological changes in the area of head, body and tail of the pancreas were observed in all the patients with CP and they are the result of long-existing and not treated pancreatic ductal hypertension. All that gives us a reason to promote the idea that CP patients strongly need parenchyma-preserving split-pancreas type of surgery.

APACT: Phase III, Multicenter, International, Open-Label, Randomized Trial of Adjuvant nab-Paclitaxel Plus Gemcitabine (nab-P/G) Versus Gemcitabine (G) for Surgically Resected Pancreatic Adenocarcinoma

A. Ko,1 M. Reni,2 H. Riess,3 U. Pelzer,3 E.M. O’Reilly,4 J. Winter,5 D.Y. Oh,6 C.P. Li,7 G. Tortora,8,9 H.M. Chang,10 C.D. Lopez,11 J. Tabernero,12 E. Van Cutsem,13 P. Philip,14 D. Goldstein,15 J.D. Berlin,16 S. Ferrara,17 M. Li,17 B. Lu,17 A. Romano,17 H. Marks,17 A. Biankin,18 M.A. Tempero,11 Department of Hematology and Oncology, University of California, San Francisco, Helen Diller Comprehensive Cancer Center, San Francisco, CA; 2 Medico Specialista in Oncologia, IRCCS Ospedale San Raffaele, Milan, Italy; 3 Oncology and Hematology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; 4 Medical Oncology, Memorial Sloan Kettering Cancer Center, New York City, NY; 5 Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA; 6 Hemato Oncology, Seoul National University