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Pancreatic cancer has an incidence that almost matches its mortality. Only a small number of risk factors and 33 susceptibility loci have been identified. so Moreover, the relative rarity of pancreatic cancer poses significant hurdles for research aimed at increasing our knowledge of the genetic mechanisms contributing to the disease. Additionally, the inability to adequately power research questions prevents small monocentric studies from being successful. Several consortia have been established to pursue a better understanding of the genetic architecture of pancreatic cancers. The Pancreatic disease research (PANDoRA) consortium is the largest in Europe. PANDoRA is spread across 12 European countries, Brazil and Japan, bringing together 29 basic and clinical research groups. In the last ten years, PANDoRA has contributed to the discovery of 25 susceptibility loci, a feat that will be instrumental in stratifying the population by risk and optimizing preventive strategies.

Background: IL6 and YKL-40 (also known as chitinase 3-like 1 protein, CHI3L1) are produced by pancreatic cancer cells and macrophages and activate inflammation. C-reactive protein (CRP) is synthesized mainly in hepatic cells and primarily stimulated by IL6. The aim of this study was to determine the prognostic value of combined detection of serum IL6, YKL-40, and CRP in patients with pancreatic cancer receiving palliative chemotherapy. Methods: In all, 592 patients with unresectable pancreatic cancer from five hospitals in Denmark were included in the BIOPAC biomarker study between 2008 and 2017. Pretreatment and longitudinal serum values of IL6 and YKL-40 were determined. Baseline CRP and CA19-9 values were available for the whole cohort. Patients were dichotomized as low versus high using cutoffs for IL6 of >4.92 pg/mL, YKL-40 of >95% age-corrected percentile, and CRP of >10 mg/L. The main outcome was overall survival. Results: Combined elevations of serum IL6, YKL-40, and CRP were associated with worse survival in contrast to an isolated high concentration of a single marker. Serum IL6, YKL-40, and CRP were higher in patients with advanced stage disease and in patients with poor performance status. Higher IL6 and YKL-40 levels at the time of tumor progression and serum IL6 measured over time were associated with shorter overall survival. Conclusions: Combined high baseline serum levels of IL6, YKL-40, and CRP are associated with poor survival. Impact: Assessment of systemic inflammation via measurements of IL6, YKL-40, and CRP may be important for pancreatic cancer prognostication.

The use of novel tools to understand tumour-fibrosis in pancreatic ductal adenocarcinoma (PDAC) and novel anti-fibrotic treatments are highly needed. We established a pseudo-3D in vitro model including humane pancreatic fibroblasts (PFs) and pancreatic cancer-associated fibroblasts (CAFs) in combination with clinical collagen biomarkers, as a translational anti-fibrotic drug screening tool. Furthermore, we investigated the prognostic potential of serum collagen biomarkers in 810 patients with PDAC. PFs and CAFs were cultured in Ficoll-media. Cells were treated w/wo TGF-ß1 and the anti-fibrotic compound ALK5i. Biomarkers measuring the formation of type III (PRO-C3) and VI (PRO-C6) collagens were measured by ELISA in supernatant at days 3, 6, 9, and 12. PRO-C3 and PRO-C6, and their association with overall survival (OS), were evaluated in serum with PDAC (n = 810). PRO-C3 and PRO-C6 were upregulated in CAFs compared to PFs (p < 0.0001.). TGF-ß1 increased PRO-C3 in both PFs and CAFs (p < 0.0001). The anti-fibrotic compound ALK5i inhibited both PRO-C3 and PRO-C6 (p < 0.0001). High serum levels of PRO-C3 and PRO-C6 in patients with PDAC were associated with short OS (PRO-C3: HR = 1.48, 95%CI: 1.29–1.71, p < 0.0001 and PRO-C6: HR = 1.31, 95%CI: 1.14–1.50, p = 0.0002). PRO-C3 and PRO-C6 have the potential to be used both pre-clinically and clinically as a measure of tumor fibrosis and CAF activity.

AIM: Academic and high volume hospitals have better outcome for pancreatic cancer (PC) surgery, but there are no reports on oncological treatment. We aimed to determine the influence of facility types on overall survival (OS) after treatment with chemotherapy for inoperable PC.MATERIAL AND METHODS: 2,657 patients were treated in Denmark from 2012 to 2018 and registered in the Danish Pancreatic Cancer Database. Facilities were classified as either secondary oncological units or comprehensive, tertiary referral cancer centers.RESULTS: The average yearly number of patients seen at the four tertiary facilities was 71, and 31 at the four secondary facilities. Patients at secondary facilities were older, more frequently had severe comorbidity and lived in non-urban municipalities. As compared to combination chemotherapy, monotherapy with gemcitabine was used more often (59%) in secondary facilities than in tertiary (34%). The unadjusted median OS was 7.7 months at tertiary and 6.1 months at secondary facilities. The adjusted hazard ratio (HR) of 1.16 (confidence interval 1.07-1.27) demonstrated an excess risk of death for patients treated at secondary facilities, which disappeared when taking type of chemotherapy used into account. Hence, more use of combination chemotherapy was associated with the observed improved OS of patients treated at tertiary facilities. Declining HR's per year of first treatment indicated improved outcomes with time, however the difference among facility types remained significant.DISCUSSION: Equal access to modern combination chemotherapy at all facilities on a national level is essential to ensure equality in treatment results.

Background: Older patients with cancer are at risk of physical decline and impaired quality of life during oncological treatment. Exercise training has the potential to reduce these challenges. The study aim was to investigate the feasibility and effect of a multimodal exercise intervention in older patients with advanced cancer (stages III/IV). Patients and Methods: Eighty-four older adults (≥65 years) with advanced pancreatic, biliary tract, or non-small cell lung cancer who received systemic oncological treatment were randomized 1:1 to an intervention group or a control group. The intervention was a 12-week multimodal exercise-based program including supervised exercise twice weekly followed by a protein supplement, a home-based walking program, and nurse-led support and counseling. The primary endpoint was change in physical function (30-second chair stand test) at 13 weeks. Results: Median age of the participants was 72 years (interquartile range [IQR] 68–75). Median adherence to the exercise sessions was 69% (IQR 21–88) and 75% (IQR 33–100) for the walking program. At 13 weeks, there was a significant difference in change scores of 2.4 repetitions in the chair stand test, favoring the intervention group (p

Background: Radical resection of duodenal adenocarcinoma (DA) offers the possibility of cure. The outcome after operation and adjuvant therapy is mainly based on small numbers due to the low incidence of the disease. We examined the long-term outcome after surgical treatment of DA. Material and methods: This was a retrospective cohort study including all patients undergoing curatively intended resection for histologically confirmed DA at a single University hospital. Long-term survival was examined by the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox proportional hazards regression analysis was applied to adjust for confounding. Results: A total of 96 patients were included. The median follow-up was 3.7 years (IQR 2.9–4.3), during which 18 patients (18.5%) had recurrence and 35 (36.5%) patients had died. The 3- and 5-year overall survival was 66.3% (55.6–76.9%) and 58.2% (46.2–70.2%), respectively. In the multivariable analysis, adjuvant therapy was associated with decreased mortality (HR 0.29, CI 0.11–0.76, P = 0.011) whereas positive lymph node ratio >0.20 was associated with increased mortality. Conclusion: Radical operation for DA has a median overall 5-year-survival of more than 50%. The indication for adjuvant chemotherapy remains to be addressed.

Simple Summary For 20 years, the CA 19-9 blood test has been the only broadly used biomarker of pancreatic ductal adenocarcinoma (PDAC). We lack easily available biomarkers to help differentiate patients between good, intermediate and poor survivors at the time of PDAC diagnosis. Using one of the largest studies of patients with PDAC, we found that a simple combination of blood tests, namely CRP, CA 19-9 and IL-6, into a single biomarker score was a better marker of one-year survival than the currently recommended CA 19-9 alone or any other combination of the four inflammatory biomarkers examined (CRP, CA 19-9, IL-6 and YKL-40). However, since this is the first study examining this inflammatory biomarker score, future validation studies are needed. Moreover, CRP outperformed CA 19-9 in the majority of patients, thus questioning the routine use of CA 19-9 in patients with PDAC. Abstract We examined whether elevated plasma C-reactive protein (CRP), carbohydrate antigen (CA) 19-9, interleukin-6 (IL-6) and YKL-40, individually or combined, can identify poor survivors among patients with pancreatic ductal adenocarcinoma (PDAC). We measured CRP, CA 19-9, IL-6 and YKL-40 in 993 patients at the time of PDAC diagnosis. The biomarker score was the sum of biomarker categories, coded 0, 1 and 2 for low, intermediate and high plasma concentrations, respectively. High vs. low levels of CRP, CA 19-9 and IL-6 were each independently associated with a two-fold increased risk of one-year mortality. CRP performed best in patients with advanced and CA 19-9 in patients with low cancer stages. YKL-40 was not associated with mortality and, therefore, was not included in the biomarker score. Compared to the biomarker score = 0, the multifactorially adjusted hazard ratios for one-year mortality were 1.56 (95% confidence interval: 0.99–2.44) for score = 1, 2.22 (1.41–3.49) for score = 2, 3.44 (2.20–5.38) for score = 3, 5.13 (3.21–8.17) for score = 4 and 6.32 (3.84–10.41) for score = 5–6 (p-value for trend = 3 × 10−31). This score performed better than any single biomarker or combination of biomarkers when examined in similarly sized or other categories. In conclusion, a combination score of elevated CRP, CA 19-9 and IL-6 identified patients with six-fold higher one-year mortality.

Rare truncating BRCA2 K3326X (rs11571833) and pathogenic CHEK2 I157T (rs17879961) variants have previously been implicated in familial pancreatic ductal adenocarcinoma (PDAC), but not in sporadic cases. The effect of both mutations in important DNA repair genes on sporadic PDAC risk may shed light on the genetic architecture of this disease. Both mutations were genotyped in germline DNA from 2,935 sporadic PDAC cases and 5,626 control subjects within the PANcreatic Disease ReseArch (PANDoRA) consortium. Risk estimates were evaluated using multivariate unconditional logistic regression with adjustment for possible confounders such as sex, age and country of origin. Statistical analyses were two-sided with p values

Although pancreatic ductal adenocarcinoma (PDAC) survival is poor, there are differences in patients’ response to the treatments. Detection of predictive biomarkers explaining these differences is of the utmost importance. In a recent study two genetic markers (CD44-rs353630 and CHI3L2-rs684559) were reported to be associated with survival after PDAC resection. We attempted to replicate the associations in 1856 PDAC patients (685 resected with stage I/II) from the PANcreatic Disease ReseArch (PANDoRA) consortium. We also analysed the combined effect of the two genotypes in order to compare our results with what was previously reported. Additional stratified analyses considering TNM stage of the disease and whether the patients received surgery were also performed. We observed no statistically significant associations, except for the heterozygous carriers of CD44-rs353630, who were associated with worse OS (HR = 5.01; 95% CI 1.58–15.88; p = 0.006) among patients with stage I disease. This association is in the opposite direction of those reported previously, suggesting that data obtained in such small subgroups are hardly replicable and should be considered cautiously. The two polymorphisms combined did not show any statistically significant association. Our results suggest that the effect of CD44-rs353630 and CHI3L2-rs684559 cannot be generalized to all PDAC patients.

Objectives: Few studies have evaluated the impact of risk factors and comorbidity on overall survival (OS) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim was to investigate the prognostic importance of Charlson's age-comorbidity index (CACI) and other risk factors on prognosis in a clinical real-world cohort of PDAC patients. Methods: A total of 1,159 patients with PDAC who had received at least one cycle of adjuvant or palliative chemotherapy were included from the Danish BIOPAC study. We analysed OS according to CACI, tobacco smoking, alcohol intake, performance status (PS), BMI and diabetes. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for OS using Cox proportional hazards regression. Results: At the end of follow-up, 994 (86%) patients had died. The median OS was 298 days for all patients (range 3–3010) and shortest in patients with stage IV. No association with short OS was seen for CACI > 2, diabetes, alcohol abuse, tobacco smoking, hypertension, and high BMI. Multivariate analysis showed that stage (IV vs. I: HR = 9.05, 95% CI 5.17–15.84), PS (2 vs. 0: HR = 3.67, 2.92–4.61) and treatment with angiotensin-converting enzyme inhibitors (yes vs. no: HR = 1.31, 1.06–1.61) were independent negative prognostic factors. Conclusions: We found that CACI, diabetes, tobacco smoking, alcohol abuse, hypertension, and high BMI were not associated with OS in a real-world cohort of patients with PDAC treated with chemotherapy. Only stage and PS were prognostic parameters.

Background Several intervention studies have demonstrated that exercise training has beneficial effects among cancer patients. However, older cancer patients are underrepresented in clinical trials, and only few exercise-based studies have focused specifically on older patients with cancer. In particular, research investigating the effects of exercise training among older patients with advanced cancer is lacking. The purpose of the current study is to investigate the effect of a 12-week multimodal and exercise-based intervention among older patients (≥65 years) with advanced pancreatic, biliary tract or lung cancer, who are treated with first-line palliative chemotherapy, immunotherapy or targeted therapy. Methods PACE-Mobil-PBL is a two-armed randomized controlled trial. Participants will be randomized 1:1 to an intervention group (N = 50) or a control group (N = 50). Participants in the intervention group will receive standard oncological treatment and a 12-week multimodal intervention, comprised of: (I) supervised exercise training, twice weekly in the hospital setting, (II) home-based walking with step counts and goal-setting, (III) supportive and motivational nurse-led counseling, and (IV) protein supplement after each supervised training session. Participants in the control group will receive standard oncological treatment. The primary outcome is physical function measured by the 30-s chair stand test. Secondary outcomes include measures of feasibility, activity level, physical capacity and strength, symptom burden, quality of life, toxicity to treatment, dose reductions, inflammatory biomarkers, body weight and composition, hospitalizations and survival. Assessments will be conducted at baseline, and after 6, 12 and 16 weeks. Discussion The current study is one of the first to investigate the effect of an exercise-based intervention specifically targeting older patients with advanced cancer. PACE-Mobil-PBL supports the development of health promoting guidelines for older patients with cancer, and the study results will provide new and valuable knowledge in this understudied field. Trial registration The study was prospectively registered at ClinicalTrials.gov on January 26, 2018 (ID: NCT03411200). Electronic supplementary material The online version of this article (10.1186/s12885-018-4835-2) contains supplementary material, which is available to authorized users.

Introduction: Pancreas cancer (PC) is one of the most stroma-rich cancers with up to 80% of the tumor mass being stroma. Consequently, PC is a highly resistant disease. Cancer-associated fibroblasts (CAFs) and the collagens they produce are major components of the PC stroma. The fibrillar fibroblast-derived type XI collagen has been suggested to be a specific CAF marker and quantifying type XI collagen synthesis could have biomarker potential in PC. Therefore, we developed two competitive enzyme-linked immunosorbent assays (ELISAs) targeting the pro-peptide of type XI collagen and validated them both in patients with PC. Methods: Two ELISAs were developed and technically validated based on monoclonal antibodies raised against type XI collagen at either the cleavage site A'253↓ (PRO-C11-253) or A'511↓ (PRO-C11-511). Levels of PRO-C11-253 and PRO-C11-511 were measured in a discovery cohort in serum samples from patients with PC (n = 40, stage I-IV), chronic pancreatitis (CP) (n = 12) and healthy controls (n = 20). Any biomarker potential from the discovery cohort was validated in pretreatment serum from 686 patients with PC (validation cohort, stage I-IV). Biomarker levels were evaluated for the association with stage and with overall survival (OS) by univariate and multivariate cox regression analysis adjusting for various clinical risk factors such as performance status, stage, liver metastasis and CA19-9. Results: PRO-C11-511 was significantly upregulated in PC and CP compared to healthy controls whereas no difference was seen with PRO-C11-253. Likewise, there was no association between levels of PRO-C11-253 and OS (HR (95% CI): 1.00 (0.42-2.35), p = 0.9958), whereas high levels of PRO-C11-511 (> 75 percentile) were significantly associated with poor OS (HR (95% CI): 3.33 (1.44-7.69), p = 0.0045). In the validation cohort, PRO-C11-511 was upregulated in late stages compared to early stages (stage IV vs. stage II: p = 0.0004, stage IV vs. stage III: p = 0.0101). Furthermore, high levels of PRO-C11-511 (> 75 percentile) were associated with poor OS (HR (95% CI): 1.68 (1.40-2.02), p < 0.0001) and remained significant after adjusting for the clinical risk factors (HR (95% CI): 1.41 (1.13-1.74), p = 0.0021). Conclusion: Quantifying pretreatment serum levels of pro-peptides of type XI collagen (PRO-C11-511) predicts poor OS in patients with PC. This was not the case for PRO-C11-253 highlighting that the processing of type XI collagen pro-peptides is important from a biomarker perspective. Thus, targeting specific epitopes can be highly disease specific. PRO-C11-511 that indirectly quantifies CAF activity, should be validated in future studies to expand on the clinical applicability as a predictive and monitoring biomarker. Citation Format: Neel Ingemann Nissen, Stephanie Kehlet, Astrid Z. Johansen, Inna M. Chen, Morten Karsdal, Julia S. Johansen, Hadi M. Diab, Lars N. Jørgensen, Nicholas Willumsen. Non-invasive biomarker potential of quantifying the pro-peptides of type XI collagen alpha 1 chain (PRO-C11) in patients with pancreas cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 652.

Background 25-hydroxyvitamin D and active analogues have shown to inhibit growth of pancreatic cancer (PC) cell lines. However, studies describing the relationship between serum levels of vitamin D and survival in PC patients have shown conflicting results. The aim of the study was to evaluate the association between pre-treatment 25-hydroxyvitamin D levels and survival in Danish patients with PC. Methods In the prospective BIOPAC study (NCT03311776), the pre-treatment serum 25-hydroxyvitamin D (S-25(OH)D) concentrations were determined in 1233 patients with PC included from July 2008 to December 2018, using the DiaSorin Liaison 25-hydroxyvitamin D TOTAL assay. Age (median 67 years), gender (male/female: 675/558), BMI ( 25/unknown: 96/663/356/118), Performance status (PS) (0/1/2 + 3/unknown: 422/498/135/177) and stage (I+II/III+IV/unknown: 408/758/67) were retrieved. Survival was estimated in three S-25(OH)D groups as: insufficient 50 nmol/L. For survival analysis, Kaplan-Meier plots, log-rank tests and the Cox regression model were used. Results Table . 699P Stage I+II III+IV S-25(OH)D levels Pt, No. mOS, months 95%CI Pt, No. mOS, months 95%CI Sufficient 205 26.2 21.2-34.1 383 7.2 6.2-8.1 Relatively insufficient 156 22.9 18.3-27.8 275 6.3 5.3-7.2 Insufficient 47 15.7 11.3-30.2 100 5.3 3.7-6.4 Abbreviations: Pt, No.: Patient number, mOS: median overall survival, CI: Confidence interval. Overall survival between the three S-25(OH)D groups in stages I and II, log rank p = 0.03, as well as in stages III and IV, log rank p = 0.02, were significantly different. In the multivariate Cox regression analysis, patients with sufficient S-25(OH)D levels had longer survival than those with insufficient levels (HR = 0.77, 95% CI 0.62-0.96; p = 0.02). PS 0 vs. 1 and vs. 2 + 3 (p Conclusions Patients with PC and sufficient pre-treatment serum 25-hydroxyvitamin D levels had significantly longer OS than those with insufficient levels across all stages. Clinical trial identification NCT03311776. Legal entity responsible for the study Julia Sidenius Johansen. Funding Axel Muusfeldt’s Foundation. Disclosure All authors have declared no conflicts of interest.

Background: Collagen is highly expressed in pancreatic cancer (PC) stroma. Collagen accumulation compromises penetration of macromolecules into tumor tissues and is associated with poorer outcome and increased tumor invasion. The aim of this biomarker study was to investigate the clinical utility of serum pro-peptide of type III collagen (PRO-C3) in patients (pts) with PC.Methods: A cohort from the Danish BIOPAC study (ClinicalTrials.gov ID: NCT03311776) including 851 consecutive subjects with histologically confirmed PC, ampullary carcinoma (n = 45), distal biliary tract cancer (n = 32) and benign lesions (n = 88) were enrolled. Serum PRO-C3 was determined by ELISA (Nordic Bioscience, PRO-C3 protocol). The main outcome was survival among pts with PC (male/female: 458/393; age \lt;50 vs. 50-69 vs. ≥70: 41/477/333; ECOG Performance Status (PS) of 0/1/2+: 315/340/110; stage 1 + 2/3/4: 234/142/456; diabetes yes/no: 207/629; smoking yes/no: 508/265; alcohol yes/no: 183/588; body mass index: low/normal/overweight: 62/426/254; Charlson Age-Comorbidity index (CACI) 0/1-2/3+: 34/296/504) in relation to PRO-C3 levels. Serum CA19-9, hyaluronic acid (HA), C-reactive protein (CRP), interleukin-6 (IL-6) and YKL-40 were measured. Hazard ratios (HRs) and 95\% confidence intervals (CIs) were estimated by Cox proportional hazards regression.

Precision oncology requires sensitive and specific clinical biomarkers. Carbohydrate Antigen 19-9 (CA19-9) is widely used in pancreatic ductal adenocarcinoma (PDA) but lacks sensitivity and specificity. Nearly all PDAs harbor somatic KRAS mutations, nominating circulating tumor DNA (ctDNA) KRAS as an alternative disease biomarker, however, variable clinical performance has limited its clinical utility. We applied an ultrasensitive, PCR mutation enrichment, next generation sequencing ctDNA KRAS assay in a large cohort of patients with unresectable PDA (N = 189) recruited to the BIOPAC study between 2008-2015. Baseline and longitudinal serum CA19-9 and plasma ctDNA KRAS were correlated with time to progression (TTP) and overall survival (OS). Baseline ctDNA KRAS detection rate was 93.7% (86.4% in patients with non-elevated CA19-9). ctDNA KRAS and CA19-9 were positively correlated yet independently associated with TTP and OS (ctDNA KRAS p = 0.0018 and 0.0014; CA19-9 p = 0.0294 and 0.0007, respectively). A generated model quantitating longitudinal ctDNA KRAS correctly assessed greater than 80% of patient responses. Quantitative detection of KRAS ctDNA is an informative prognostic biomarker, complementary to CA19-9 in patients with unresectable PDA. Longitudinal ctDNA KRAS may inform therapeutic decision making and provides a kinetically dynamic and quantitative metric of patient response.

Background: Reliable biomarkers in patients (pts) with pancreatic cancer (PC) are highly warranted. The aim of this prospective-retrospective biomarker study was to investigate the clinical value of cell-free DNA (cfDNA) in pts with PC.Methods: A total of 377 consecutive pts with histologically confirmed PC and 94 healthy controls were included. Total cfDNA levels were determined by a direct fluorescent assay in EDTA plasma samples obtained before operation (stage I and II) or start of palliative chemotherapy (stage III and IV). Serum CA19-9 (IMMULITE 2000, Siemens), hyaluronic acid (HA) (ELISA, R\amp;D), interleukin-6 (IL-6) (ELISA, R\amp;D) and YKL-40 (ELISA, Quidel) were measured. The main outcome was association of cfDNA with overall survival (OS) for pts with PC. Hazard ratios (HRs) and 95\% confidence intervals (CIs) were estimated by Cox proportional hazards regression.

Background: Neoplasm seeding is a serious complication after liver metastases biopsy. Reported incidences vary between 10% and 19% for colorectal cancer (CRC) and are unknown for breast cancer (BC). The aim of this retrospective study was to determine the frequency of tumor seeding after ultrasound-guided percutaneous biopsy of CRC and BC liver metastases. Material and methods: Unselected liver biopsies performed in the period of 2005–2012 at our institution were extracted from the National Pathology Registry. Medical records including imaging from patients with biopsy-verified BC and CRC liver metastases were retrospectively reviewed. The endpoint was the development of abdominal wall recurrence following liver biopsy. Results: Of total 2981 biopsies we identified 278 patients with CRC and 155 patients with BC biopsy-verified liver metastases. During the median follow-up of 25 months after biopsy (range 3–253 months), no seeding was recorded in patients with BC. Within the median follow-up of 34 months (3–111 months), seeding was registered in 17/278 (6%) of patients with CRC; three patients of 278 (1%) had undoubtedly biopsy-related seeding, which became apparent six, nine, and 26 months after biopsy, respectively; and in nine patients (3%) seeding occurred due to either biopsy or other interventions; and five patients had seeding, which were assessed as a consequence of other invasive procedures than biopsies. The median overall survival of the 17 patients with seeding was 70 months compared to 39 months of patients without seeding. Conclusions: The results showed no seeding in BC patients. Seeding rate after biopsy in CRC patients is not negligible, however, without affecting outcome.

Introduction: An estimated 90% of pancreatic cancers harbor somatic KRAS G12/G13 mutations. The presence of circulating tumor DNA (ctDNA) KRAS mutations at diagnosis has prognostic implications, however, recent studies on small numbers of patients demonstrate widely variable KRAS ctDNA sensitivity (27 – 71%). Accurate identification of both the presence of ctDNA KRAS mutations and quantification of the number of ctDNA KRAS mutant copies would be an improved therapeutic response biomarker over CA19-9 which is known to be uninformative in 5-10% of patients with pancreatic cancer. A diagnostic and prognostic tool with very high analytical and clinical sensitivity, along with quantification, is needed for therapeutic response monitoring. Patients and Methods: Pretreatment (baseline) and longitudinal plasma samples were prospectively collected from 239 patients with unresectable pancreatic cancer through the Danish Biomarkers in Patients with Pancreatic Cancer (BIOPAC) study. The median age at diagnosis was 67 years (range 42 – 89 years) and 51.9% (N = 112) of patients were male. The majority of patients were metastatic at diagnosis (79.6%; N=172). ctDNA KRAS G12A/C/D/R/S/V, and G13D mutations were PCR enriched, sequenced by next generation sequencing (NGS), quantified and standardized. This was achieved by generating standard curves from a sample set with known numbers of spike-in copies for mutant KRAS molecules. These sample sets were assayed in parallel with patient samples starting with PCR enrichment of mutant KRAS DNA followed by NGS. The number of mutant copies detected was standardized by normalizing the number of copies detected in the sample to a constant number of calculated genome equivalents (GEqs) of wild type DNA across all samples evaluated. Baseline KRAS mutant levels were assessed. Additional metrics analyzed include age, gender, stage, and CA19-9 levels. Results: Two-hundred and sixteen patients (90.4%) had baseline plasma samples which passed quality control metrics. Baseline serum CA19-9 levels were available for 160 patients and ranged from 2.5 – 608,500 U/mL (median 202 U/mL). Eighteen patients (11.3%) had serum CA19-9 levels below the diagnostic threshold ( Conclusion: In this large, prospective dataset of 216 patients with unresectable pancreatic cancer, ctDNA analysis was KRAS positive in 87.0% of patients. This detection rate closely matches the published prevalence of KRAS in pancreatic cancer (90%), and out performs previous studies, demonstrating the superior assay sensitivity. ctDNA analysis offers a viable tissue biopsy alternative for determining KRAS mutation status, especially in late stage patients. Given that approximately 48% of patients had CA19-9 levels below the prognostic threshold, quantification of KRAS mutant copy load may provide a more informative biomarker. Other clinical variables, baseline and longitudinal KRAS mutant levels, and patient outcomes will be examined and presented. Citation Format: Inna Chen, Victoria M. Raymond, Jennifer A. Geis, Sandeep Pingle, Eric A. Collisson, Vlada Melnikova, Mark G. Erlander, Julia A. Johansen, Fernando Blanco.{Authors}. Detection and quantification of ctDNA KRAS mutations from patients with unresectable pancreatic cancer. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr A20.

Background: The median overall survival (OS) time of patients with non-resectable pancreatic cancer varies widely. Diagnostic tools are presently lacking to predict patient outcome at diagnosis. The vast majority of pancreatic tumors harbor KRAS mutations. In this study, we evaluated whether quantitative baseline and longitudinal monitoring of KRAS mutations in plasma circulating tumor DNA (ctDNA) may be used to stratify patients for predicting outcome. Methods: The Danish BIOPAC study prospectively collected plasma from patients with non-resectable pancreatic cancer undergoing treatment with gemcitabine or FOLFIRINOX. Archival (3-5 years) plasma specimens were collected from 113 patients pre-treatment (baseline),on chemotherapy, as well as at multiple additional time intervals for up to 977 days from baseline. Interim analysis of ctDNA KRAS was conducted (after 105 deaths). Levels of ctDNA KRAS mutations were assessed in 35 patients with long OS (median 473 days; range 360-1134), 33 patients with medium OS (median 227 days; range 155-349) and 37 patients with short OS (median 94 days; range 21-146). PCR enrichment of KRAS G12A/C/D/R/S/V, and G13D mutations was performed, followed by massively parallel deep sequencing and quantification with standardization of reporting number of copies detected per 105 genome equivalents (GE). Results: In a prospective-retrospective biomarker study of 113 patients, interim analysis of ctDNA KRAS was conducted (after 105 deaths). 92 of 105 patients had evaluable baseline plasma samples. Number of mutant KRAS copies was higher in patients with short OS (median 661; range 0-190,490 copies/105 GE) versus with median OS (median 103; range 0 to 275,918 copies/105 GE) versus with long OS (median, 15; range, 0-1,369 copies/105 GE). Longitudinally, KRAS mutation levels remained mostly low with long OS (last time point median 9; range 0-70,451 copies/105 GE) vs. medium OS (median 155; range 0-314,103 copies/105 GE) or short OS where levels increased or remained high (median 803; range 0-138,508 copies/105 GE). As this dramatic difference in systemic KRAS levels may reflect distinct tumor phenotypes, the underlying tumor biology was further investigated by interrogating additional cancer mutational hotspots (using massively parallel deep sequencing) in plasma ctDNA of patients stratified by systemic KRAS and the OS. Conclusion: Shorter OS in patients with non-resectable pancreatic cancer tended to associate with high levels of ctDNA KRAS mutations at diagnosis and with post-treatment elevation of KRAS mutations. ctDNA KRAS mutation levels in patients with non-resectable pancreatic cancer observed at diagnosis or on treatment may predict patient outcome and could reflect distinct underlying tumor biology. Citation Format: Julia S. Johansen, Cecile Rose T. Vibat, Saege Hancock, Latifa Hassaine, Errin Samuelsz, Inna Chen, Eric A. Collisson, Dan Calatayud, Benny V. Jensen, Jane Preuss Hasselby, Timothy T. Lu, Jason C. Poole, Vlada Melnikova, Mark G. Erlander. Comparative levels of KRAS mutations circulating tumor DNA for association with overall survival in patients with non-resectable pancreatic cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5240. doi:10.1158/1538-7445.AM2015-5240