Altered Expression of Tight Junction (TJ) Proteins and TJ Dilation Associated with Organ Failure (OF) in Acute Pancreatitis

AGA Abstracts

the meta-analysis. The primary endpoint of interest was overall survival assessed by hazard ratio. The pooled hazard ratio (HR) and 95% confidence intervals (CI) were calculated from the original study data by using the Mantel-Haenszel method (fixed effects model). Statistical heterogeneity was assessed using the forest plot and inconsistency statistic (I-squared). If any heterogeneity existed (I-squared > 50%), it was to be explored by subgroup analyses, meta-regression and sensitivity analyses. Results: A total of seven retrospective cohort studies, involving 3,807 pre-existing diabetic patients with PAC were included. Across studies, mean age was seventy-five years old and 49% of the patients were men. Sixty-one percent had BMI<25 and 86% of patients had ECOG score of 0-1 whereas the remaining had scores 2 or greater. Among the studies, thirty-five percent had either resectable or locally advanced disease and the remaining 65% had either unresectable or metastatic disease. Administration of metformin to pre-existing diabetic patients with PAC reduced the risk of overall mortality by 19% (HR 0.81, 95% Cl 0.75-0.86) when compared to those not taking metformin. Isquare of the study was 48.8%, which was below 50% indicting statistical homogeneity among the studies. Conclusions: Metformin exposure when compared to non-exposure is associated with an increase in overall survival in pre-existing diabetic patients diagnosed with PAC. Further randomized, controlled trials looking at the use of metformin in preexisting diabetic patients with resectable and locally advanced PAC are needed.

pass including needle size, puncture route, easiness of puncture and presence of visible core. Samples were placed on a micro-philter, processed as biopsies, formalin fixed and paraffin embedded. Pathology evaluation included for every sample: diagnosis, presence of histologic core, recognizable gland architecture, degree of differentiation, immunohistochemistry and whether it was necessary to reach a final diagnosis. Results A total 121 passes (22G=109;25G=12;average1.92passes per lesion) were performed on 31 pancreatic masses or suspicious areas (43:30). A visible core was obtained in 120 passes (120/121;99.1%) and permitted full histologic study in the 120(120/120;100%) but it was representative of the expected lesion only in 118(118/120;98.3%). A diagnosis was obtained with a mean 1.03passes (range1-2); 97% in the first pass and reaching 100% in the second pass. A final diagnosis considering all passes was obtained in the 63 lesions(63/63; 100%). A duodenal route was used in 54 passes without problems of needle reinsertion but the needle appeared bent in some cases. Immunohistochemistry was necessary to reach a complete final diagnosis in 16 of the 43 masses(37.2%) including one anaplastic carcinoma, 6 undifferentiated adenocarcinomas (one of them a signet ring cell), one renal cell carcinoma metastasis, one pseudopapillary tumor, 6 NETs (one of them typified as an insulinoma) and one pancreatic GIST. Conclusions This novel EUS-guided core biopsy needle provides samples adequate for histologic diagnosis in almost every pass reducing overall number of passes to reach a diagnosis and avoiding the need for an on-site pathologist. Having a biopsy core that allows for imunohistochemical profiling helps reach a final diagnosis in a significant number of cases.

Su1252 SUITABLE LIQUID BIOPSY SAMPLES FOR DETECTING KRAS MUTATIONS IN PATIENTS WITH PANCREATIC CANCER Soichiro Ako, Kazuhiro Nouso, Hideaki Kinugasa, Chihiro Dohi, Hiroshi Matsushita, Sho Mizukawa, Shinichiro Muro, Yutaka Akimoto, Daisuke Uchida, Takeshi Tomoda, Kazuyuki Matsumoto, Shigeru Horiguchi, Koichiro Tsutsumi, Hironari Kato, Hiroyuki Okada

EUS-guided fine needle biopsy

[Background] The detection of cancer-specific DNA in body fluid, known as a liquid biopsy, has been a matter of interest in the field of oncology. Most of the studies used plasma samples; however, the potential of other body fluid such as serum or urine has not been precisely evaluated to date. KRAS mutations in pancreatic cancer is 75%-90% so that they have been considered as useful diagnostic markers and prognostic markers as well. [Aim] We attempted to clarify suitable liquid biopsy samples for detecting KRAS mutations in patients with pancreatic cancer. [Methods] Forty patients who were diagnosed as having pancreatic cancer between September 2013 and February 2016 were enrolled in this study. DNA was extracted from the tissue, plasma, serum and urine and the KRAS mutations (G12D, G12V and G12R) in each samples were analyzed using droplet digital PCR. The amount of DNA in the samples was also measured. This study was approved by our institutional review board, and was conducted according to the Helsinki Declaration. [Results] The median age was 71 years (range: 49-92 years), and 26 patients (65%) were male. Median size of primary tumor was 30 mm (range: 14-69 mm). The number of patients in stage I, II, III, and IV were 2 (5%), 21 (52%), 6 (15%), and 11 (28%), respectively. The median follow-up period was 9.8 months (range 0.3-33.4 months). The amount of DNA isolated from the serum was 129 ng/ml (median), which was much higher than those from plasma and urine (17.9ng/ml and 8.4ng/ml, respectively). Droplet digital PCR analysis revealed that at least one KRAS mutation was observed in 93% of cancer tissues, in 48% of serum and plasma samples, and in 58% of urine samples. No statistical difference of the detection rates was observed among serum, plasma and urine samples (p = 0.80). The most prevalent mutation in serum, plasma and urine was G12D (40%, 38% and 43%, respectively), but any of those were not contributed to the prognosis. The next prevalent mutation was G12V mutation in all materials (13% and 10% and 21%, respectively). All patients with G12V in serum and/or plasma were Stage IV, and showed significantly poor overall survival (MST: 2.4 months) compared to those without G12V (MST: 10.4 months, p = 0.03). Whereas, the mutation in tissue or urine did not correlated to the prognosis of the patients. [Conclusions] Serum and possibly urine samples were good materials for liquid biopsy as plasma. The presence of KRAS mutations in liquid samples can be a good prognostic biomarker for the patients with pancreatic cancer.

Core specimen on micro-philter

Su1254 ALTERED EXPRESSION OF TIGHT JUNCTION (TJ) PROTEINS AND TJ DILATION ASSOCIATED WITH ORGAN FAILURE (OF) IN ACUTE PANCREATITIS Pooja Goswami, Ujjwal Sonika, Imteyaz A. Khan, Tapas Nag, Vishnubhatla Sreenivas, Anoop Saraya

Su1253 HISTOLOGY CORE OBTAINED WITH A NOVEL EUS-GUIDED FRONT-END BIOPSY NEEDLE ON PANCREATIC LESIONS: SPECIMEN QUALITY AND CLINICAL IMPACT Andres Sanchez Yague, Jennifer Hinojosa-Guadix, Teresa Pereda, Angel GonzalezCanoniga, Cristina Lopez Muñoz, Andres Sanchez-Cantos

Aims: Acute pancreatitis (AP) gets worsened with infection and organ failure (OF) which lead to higher mortality of up-to 10-60%. It has long been speculated, that compromised gut integrity leads to bacterial translocation and can cause infection of sterile pancreatic necrosis. But this hypothesis is yet to be proven in humans. Methods: This prospective study was conducted in the department of Gastroenterology and HNU, A.I.I.M.S. New Delhi. Twenty- six consecutive subjects which include mild (n=1) moderate (n=8) and severe acute pancreatitis patients (n=7) fulfilling the study criteria along with 10 controls that underwent gastro-duodenoscopy for dyspepsia were studied. Localization of claudin 2 and claudin 4 were studied by IHC and their mRNA expression by RT-PCR. Assessment of IP was done with lactulose mannitol ratio (LM ratio) by HPLC. The ultrastructural changes of TJ were studied by TEM in duodenal biopsy. Statistical analysis was done with STATA 13.0. Results:

Introduction Endoscopic-ultrasound (EUS) guided Fine-needle aspiration (FNA) is used to reach a pathology diagnosis in pancreatic lesions. Most common samples obtained with standard and reverse bevel technology needles acquire cytology and cell-block that provide a sample adequate for a diagnosis but mostly inadequate for immunohistochemistry. Histology needles obtain cores adequate for immunohistochemistry but it is seldom necessary. Aims To evaluate the quality and the clinical impact of having histology samples obtained with a needle designed to obtain core biopsy. Material and methods We included samples from pancreatic lesions obtained through EUS-guided FNA using the SharkCoreTM (Medtronic, Dublin) needle from March 2015 to November 2016. We recorded technical data for every

AGA Abstracts

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at diagnosis and at least 1 year prior for 216 PC and 143 CoC patients. Precursor adipocytes (Ad) isolated from VAT and SAT of healthy renal transplant donors were differentiated in presence of exosomes (from 4 PC and 2 CoC cell lines). Results: The time line of change in weight and fasting glucose levels are depicted in figure 1 and figure 2 respectively. These data demonstrate that PC patients start losing weight as early as 18 months prior to the diagnosis of PC which weight loss immediately preceding diagnosis and after diagnosis was seen in CoC. Similar trend was seen for fasting glucose levels which begins to rise about 18 months prior to the diagnosis of PC. No significant change in fasting glucose levels were seen in CoC. CT data showed 8% greater loss of SAT than VAT in PC compared to 5% greater loss of VAT than SAT in CoC (P=0.008). PC (but not CoC) exosomes induced 220% increase in lipid content of VAT Ad vs no exosome (p=0.01). In contrast, PC and CC exosomes, respectively, reduced lipid content in SAT Ad by 40% and 30% vs no exosome (p<0.01 each). RNA sequencing (confirmed by qPCR) revealed differentially regulated pathways in VAT and SAT Ad differentiated with PC exosomes, with adipogenesis upregulated in VAT and lipolysis, browning and inflammation upregulated in SAT. Conclusion: Weight loss and rise in fasting glucose begins as early as 1.5 year prior to diagnosis of PC. In contrast to type 2 diabetes where fasting glucose improves with weight loss, a paradoxical rise in fasting glucose occurs with weight loss in PC. This paradoxical phenomenon could be explained by differential effects of PC on visceral and subcutaneous adipose tissues, with relative preservation of the metabolically active VAT (leading to worsening glycemia) with preferential loss of SAT (leading to weight loss).

Figure 1 Time line of weight loss in pancreatic cancer and colon cancer prior to the diagnosis of cancer (second order regression line shown)

Figure 1 Time line of rise in fasting glucose levels in pancreatic cancer and colon cancer prior to the diagnosis of cancer (second order regression line shown)

Su1256 A MULTICENTER, OPEN-LABEL, RANDOMIZED CONTROLLED TRIAL OF PANCREATIC ENZYME REPLACEMENT THERAPY IN UNRESECTABLE PANCREATIC CANCER Tomotaka Saito, Hiroyuki Isayama, Yousuke Nakai, Kenji Hirano, Ryunosuke Hakuta, Yukiko Ito, Dai Mohri, Dai Akiyama, Natsuyo Yamamoto, Hiroshi Yagioka, Osamu Togawa, Kazunaga Ishigaki, Tsuyoshi Takeda, Kei Saito, Gyotane Umefune, Takeo Watanabe, Kaoru Takagi, Tsuyoshi Hamada, Naminatsu Takahara, Rie Uchino, Suguru Mizuno, Hirofumi Kogure, Saburo Matsubara, Minoru Tada, Kazuhiko Koike Objective: Although pancreatic cancer (PC) patients are potentially prone to exocrine pancreatic insufficiency (EPI), there are few evidences about pancreatic enzyme replacement therapy (PERT) in PC patients, especially those receiving chemotherapy. Our previous prospective cohort study of PERT in patients with advanced PC suggested administration of pancrelipase during systemic chemotherapy might improve nutritional status (Pancreas 2016, in press. UMIN-CTR:000011378). Therefore, we conducted this randomized controlled trial to evaluate the role of PERT in patients with unresectable PC receiving systemic chemotherapy (UMIN-CTR:000016542). Methods: This is a multicenter, open-label, randomized controlled trial in seven Japanese hospitals. Inclusion criteria were patients receiving 1st line systemic chemotherapy for unresectable PC with pathological confirmation, ≥20 years of age, and adequate organ function. Exclusion criteria were prior history of PERT and prior therapy for PC including surgical resection, and poor oral intake. Eligible patients were randomly assigned in 1:1 ratio to pancrelipase group or non-pancrelipase group. Patients in the pancrelipase group took oral pancrelipase of 48,000-lipase units per meal at the time of introduction of chemotherapy. To evaluate the prevalence of EPI in PC patients, NBT-PABA test was performed at baseline on both groups. The primary endpoint was change in the nutritional status at 8 weeks (Body mass index [BMI]), serum albumin and serum total cholesterol). The secondary endpoints were change in other nutritional status at 8 and 16 weeks and overall survival. The change in the nutritional marker was evaluated as one at 8 weeks divided by that at baseline. Results: Between May 2014 and May 2016, a total

Su1255 PARANEOPLASTIC WEIGHT LOSS AND RISE IN BLOOD GLUCOSE PRECEDING SYMPTOMS OF PANCREATIC CANCER (PC): OPPORTUNITY FOR EARLY DETECTION Raghuwansh P. Sah, Sajan Jiv Singh Nagpal, Anil Sharma, Amrit K. Kamboj, Naoki Takahashi, Debabrata Mukhopadhyay, Suresh T. Chari Background: Prognosis and survival of patients with pancreatic cancer (PC) continues to remain dismal. Lack of effective therapy and late presentation are recognized as major limitations. More than 80% patients are unresectable at presentation. We have previously described paraneoplastic diabetes in PC. Weight loss occurring in PC patients has also been observed. We believe that better characterization of paraneoplastic metabolic effects of diabetes and weight loss seen in PC and understanding of their mechanisms will enable development of strategies for early detection of PC. Here we aim to characterize the timeline of weight loss and rise in blood glucose prior to the diagnosis of PC and explore the mechanisms of the paradoxical worsening glycemia paralleling weight loss. Methods: Weight and fasting glucose levels at various 6 monthly time points from the diagnosis of cancer were extracted from electronic databases of patients with PC and colon cancer (CoC). Visceral (VAT) and Subcutaneous Adipose Tissue (SAT) were measured at L3-L4 in abdominal CTs

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AGA Abstracts

AGA Abstracts

Distribution and intensity of Claudin 4 protein were significantly reduced in intracellular junction (ICJ) of villous duodenal biopsy (p <0.03 and p <0.01), similar changes were reported in crypts ICJ for claudin-4 (P <0.01 and p <0.01). However, claudin-2 distribution and intensity were significantly over-expressed in ICJ of crypt only (p<0.01 and p<0.01), no such changes could be reported in villi. RT-PCR revealed significantly increased relative expression of Claudin-2 in patients of AP compare to control (p<0.01). On differentiating AP into mild -moderate and severe category, there was significant over-expressed relative expression of claudin-2 in severe cases compare to mild-moderate (p<0.01). During functional studies, intestinal permeability (LM ratio) was significantly higher in acute pancreatitis patients compare to controls (0.98 ± 0.4 vs. 0.18 ± 0.14, p < 0.03) and lactulose concentration was also higher in AP patients compare to control (p<0.01). Pentalaminar structure of TJ was dilated in 7(43.7% ) and dilatation was also more prevalent in severe AP compare to mild-moderate AP (p=0.02). Other than TJ, few changes were also noted in intestinal mucosa i.e. increase in inter-villous width, shortening of villi, desmosomes multiplication, and mitochondrial de-compensation in AP. There was an association between Claudin-2 relative expression and TJ dilation in patients with organ failure (p=0.01 and <0.01 and p <0.01 & p=0.01). Conclusion: Changes in claudin -2 and claudin-4 expression and dilated TJ were more prevalent and persistent in patients who developed severe disease. So, altered TJ protein and dilated TJ could be associated with increased IP which initiate cascade of events responsible for severe disease. Baseline comparision of clinical and experimental parameters of AP cases and controls included in study