Introduction
Globally, pancreatic cancer ranks as the seventh leading cause of death from cancer. It is 4 times more common in highly developed countries. Ninety per cent of malignant tumours in this organ are identified as ductal adenocarcinoma, making it the most prevalent type [1–3]. Unfortunately, pancreatic cancer is usually diagnosed when it is already unresectable locally or when distant metastases are present. At the time of diagnosis, only 10% of patients can undergo tumour resection [4]. All patients with pancreatic cancer, regardless of the stage, have a 5-year survival rate of approximately 8%. Surgical resection extends this rate to about 20%, and when postoperative chemotherapy is included, the rate reaches 30%. The most frequently occurring malignant tumour of this organ (90%) is ductal adenocarcinoma (PDAC) [5]. Surgery is the most effective method of treating pancreatic cancer. The extent of surgical resection is determined by the tumour’s position. Pancreatoduodenectomy is the procedure of choice when a tumour is located within the head of the pancreas. Distal resections are performed in the body and tail of this organ. Pancreaticoduodenectomy is a procedure that involves the removal of the head of the pancreas, duodenum, and distal parts of the stomach as well as the gallbladder with the common bile duct (the Whipple procedure). Mortality following pancreatic surgery in reference units has decreased to 5%; however, it still poses a high risk of complications including pancreatic fistula [6]. In order to improve the unfavourable survival statistics of patients with pancreatic cancer, new diagnostic methods for pancreatic cancer ought to be researched and developed to enable an earlier diagnosis. Markers of the initial stage of carcinogenesis in pancreatic cancer are still being searched for. This requires in-depth research, which will help develop more targeted therapies in the future [7].
Persistent inflammation may result in the development of cancer, subsequently either promoting or hindering the proliferation of cancerous cells. The pro- and anticancer balance could be altered by the cells influenced by inflammation and inflammatory-responsive factors [8]. The anti-cancer impact of acute inflammation may stem from its ability to identify and eliminate cancer cells during the initial phase of the disease [9]. For certain cancers, including pancreatic, colorectal, and breast cancer, inducing a regulated acute inflammatory response may be utilised as a therapeutic strategy. On the other hand, during chronic inflammation, cells may facilitate carcinogenesis by promoting their own proliferation and fostering resistance [10]. Inflammation results in the stimulation of immune cells to secrete cytokines and chemokines. Cytokines in contact with pancreatic cells can activate inflammatory routes such as NF-B (nuclear factor kappa-light-chain-enhancer of activated B cells) and JAK-STAT (janus kinase-signal transduction and transcription). This activation subsequently enhances the functionality of pro-inflammatory enzymes and leads to the generation of pro-inflammatory mediators, including interleukin 1 (IL-1) and tumour necrosis factor (TNF-) [11, 12]. TNF-, which originates from activated macrophages and T lymphocytes, has been observed to possess a proinflammatory impact that can lead the onset of cancer development by inflicting damage to DNA [13]. Understanding the principles that connect inflammation to cancer development could yield substantial benefits in oncology practice through the advancement of new diagnostic and treatment approaches for patients with pancreatic cancer.
Aim of the research
The main goal of our study was to assess the relationship between the location of pancreatic cancer and the levels of selected inflammatory cytokines, and to examine the differences in the concentration of the assessed cytokines depending on the location of the tumour. Additionally, we evaluated the diagnostic value of inflammatory cytokines by employing receiver operating characteristic (ROC) curve analysis. We also investigated the associations between cytokines and specific clinicopathological parameters, as well as the outcomes of chosen laboratory tests.
Material and methods
The Bioethics Committee of the Medical University of Bialystok gave their approval for the study to be conducted (authorisation number APK.002.237.2020). Upon receiving comprehensive disclosure regarding the objectives of our investigation and potential associated risks, all suitable participants furnished their written assent to partake in the research study.
Patients
The study group comprised 42 patients (22 women and 20 men) qualified for surgery due to PDAC in the 2nd Department of General and Gastroenterological Surgery of the University Teaching Hospital in Bialystok between 2020 and 2022. The patients, both men and women, did not undergo preoperative radiotherapy or chemotherapy. The criterion for exclusion of patients with pancreatic cancer were other coexisting neoplastic diseases. Material for research was collected from all patients before surgery.
The patients were divided into 2 groups depending on the location of the tumour: n = 24 pancreatic head, n = 18 body and tail. The histopathological examination determined the final diagnoses.
Histopathological examination
The tissue samples collected during the procedure were preserved in a 4% buffered formalin solution and then embedded in paraffin at 56°C. The paraffin-embedded tissue blocks were sectioned into approximately 4-µm-thick slides using a Microm H340 microtome, followed by staining with haematoxylin and eosin. Then, 2 independent pathologists assessed the obtained sections using an Olympus CX22 microscope at magnifications of 200× and 400×.
Histopathological analysis were assessed in regards to the histological tumour type based on the World Health Organisation (WHO) grade for histological malignancy [14], and to stage the tumour based on the TNM classification system of the Union for International Cancer Control [15], which includes assessments of the tumour’s depth of invasion (pT), the presence of lymph node metastases (pN), distant metastases (pM), and vascular infiltration.
Blood collection
Blood samples were taken from fasting patients, each providing 5.5 ml using the S-Monovette® serum collection system from Sarstedt, Germany. Following collection, the samples were subjected to centrifugation at 1500 γ for 10 min at a temperature of +4°C using the MPW 351 from MPW Med. Instruments in Warsaw, Poland, allowing for the isolation of serum from blood cells, with the serum being subsequently drawn off from the top. To inhibit oxidation of the samples, butylated hydroxytoluene at a concentration of roughly 0.5 M (20 µl for every 2 ml of plasma or serum) was introduced. The prepared samples were preserved at –80°C until analysed for inflammatory cytokines.
Inflammatory cytokines
Concentrations of 37 cytokines: cutaneous T cell-attracting chemokine (CTACK), eotaxin, basic fibroblast growth factor (basic FGF), granulocyte colony stimulating factor (G-CSF), growth related oncogene-a (GRO-), hepatocyte growth factor (HGF), interleukin-1, -1ra, -2R, -4, -6, -7, -8, -9, -10, -12, -16, -17, -18 (IL-1ra, -2R, -4, -6, -7, -8, -9, -10, -12, -16, -17, -18), inducible protein-10 (IP-10), leukaemia inhibitor factor (LIF), monocyte chemoattractant protein-1 (MCP-1); macrophage colony-stimulating factor (M-CSF), macrophage migration inhibitory factor (MIF), monokine induced by γ interferon (MIG), macrophage inflammatory protein-1 (MIP-1), macrophage inflammatory protein-1 (MIP-1), -nerve growth factor (-NGF), platelet-derived growth factor (PDGF-BB), regulated on activation normal T-cell expressed and secreted (RANTES), stem cell factor (SCF), stem cell growth factor β (SCGF-), stromal cell-derived factor-1 (SDF-1), TNF-, tumour necrosis factor- (TNF-), and tumour necrosis factor-related apoptosis-inducing ligand (TRIAL) were measured using a customised Bio-Plex Pro Human Cytokine Screening Panel, 48-Plex (#12007283). Bio-Plex technology utilises a bead-based multiplex approach similar to an ELISA test. In this method, antibodies specific to the target biomarker are covalently attached to magnetic beads. When these particles are mixed with a specimen containing the target biomarker, they bind to form a compound. After a series of rinsing steps to purge non-specifically bound proteins, a secondary antibody tagged with biotin is added to establish a sandwich-like structure. This construction is finalised by the addition of streptavidin bound to phycoerythrin (SA-PE). The outcome is quantified using a dedicated instrument, like the Bio-Plex 200 system, offering efficacy comparable to traditional ELISA assays.
Statistical analysis
The analysis of the data was performed with GraphPad Prism version 8.4.3 (GraphPad Software, based in La Jolla, USA). To determine whether the data followed a normal distribution, the Shapiro-Wilk test was applied. Where data showed normal distribution, the difference between 2 groups was compared using Student’s t-test. Conversely, the Mann-Whitney U test was applied for data that did not follow a normal distribution. The findings are expressed as the median along with the range from minimum to maximum values, and a p-value of less than 0.05 was considered to indicate statistical significance. The association between inflammatory cytokines and clinicopathological features of the subjects was investigated using Spearman’s rank correlation coefficient. For assessing the diagnostic power of inflammatory cytokines, receiver operating characteristic (ROC) analysis was conducted, calculating the area under the curve (AUC) and establishing the best threshold values that achieve the highest sensitivity and specificity.
The determination of the study’s sample size was informed by an earlier experiment that included 15 patients, utilising the online ClinCalc software for calculation. The sample size estimation took into account the concentration levels of IL-6 and TNF- as key variables. A significance threshold was established at 0.05, with the study power set at 0.9. The ClinCalc software for calculating sample size yielded the required number of participants for one group, which was determined to be a minimum of 30 patients.
Results
Clinical findings
The study group consisted of 42 patients with pancreatic adenocarcinoma. The participants were divided into 2 groups (head, body, and tail) depending on the location of the tumour. Pancreatic head cancer was found in 57.1% of patients, and pancreatic body and tail cancer in 42.9% of patients. Normal body mass index (BMI) was found in 52.4% of patients, 34.7% were overweight, and 15.9% were in the Class 1 obesity range. Weight loss of more than 10 kg in the last 3 months was observed in 38.1% of the patients. The grade of tumour differentiation in the majority of patients (78.6%) was G2 (moderately differentiated). A pT3 and pT4 tumour were present in approximately 76.2% of the patients. Lymph node involvement (N1+N2) was present in 45% of the patients, and 35.7% had distant metastasis (M1). In the majority (90.5%) of patients, vascular infiltration was present. It is defined as ‘’tumour present within an lial-lined space either surrounded by a rim of muscle or containing red blood cells’’. Detailed characteristics of the patients are presented in Tables 1 and 2.
Inflammatory cytokines
The levels of all analysed cytokines – CTACK, eotaxin, basic FGF, G-CSF, GRO-, HGF, IL-1, IL-1ra, IL-2R, IL-4, IL-6, IL-7, IL-8, IL-9, IL-10, IL-12, IL-16, IL-17, IL-18, IP-10, LIF, MCP-1, M-CSF, MIF, MIG, MIP-1, MIP-1, -NGF, PDGF-BB, RANTES, SCF, SCGF-, SDF-1, TNF-, TNF-, and TRIAL was higher in the group of patients with cancer located in the pancreatic head. The levels of eotaxin (p = 0.002), basic FGF (p = 0.316), G-CSF (p = 0.0408), IL-2R (p = 0.0487), IL-6 (p = 0.0001), IL-9 (p = 0.0002), IL-17 (p = 0.0153), IP-10 (p = 0.0228), MIP-1 (p = 0.0117), MIP-1 (p = 0.0021), RANTES (p = 0.0228), SCGF- (p = 0.223), TNF- (p = 0.0398), and TNF- (p = 0.002) was statistically significantly higher in the group of patients with tumours located in the head in comparison to the patients with tumours in the body and tail of the pancreas (Table 3, Figure 1).
ROC analysis
ROC analysis revealed that every cytokine under study (eotaxin, basic FGF, G-CSF, IL-2R, IL-6, IL-9, IL-17, IP-10, MIP-1, MIP-1, RANTES, SCGF -, TNF-, TNF-) may show usefulness in differentiating patients with cancer located in the head, body, and tail of the pancreas. The AUC for eotaxin was 0.7396, while the p-value was 0.0453; for basic FGF these values were 0.7552 and 0.0330, respectively; for G-CSF 0.7526 and 0.0348, for IL-2R 0.7266 and 0.0583; for IL-6, 0.9198 and 0.0005; for IL-9 0.8958 and 0.0009; for IL-17 0.7839 and 0.0177; for IP-10 0.7708 and 0.0236; and for MIP-1 the AUC was 0.7969 and the p-value was 0.0131. The AUC for MIP-1 was 0.8385 with a p-value of 0.0047, and for RANTES the AUC was 0.7708 with a p-value of 0.0236. The AUC for SCGF- was 0.7857 while the p-value was 0.0233; for TNF- these values were 0.7448 and 0.0408; for TNF- the AUC was 0.9245 and the p-value was 0.0004 (Table 4).
Correlations
All statistically significant relationships are presented in Figures 2 and 3. Our analysis of clinical and other parameters revealed negative correlations between IL-1ra (p = 0.027, R = –0.404) and TNF- (p = 0.022, R = –0.403) and tumour location. We observed a correlation between LIF (p = 0.023, R = 0.481) and TNF- (p = 0.037, R = 0.446) and tumour size. TNF- (p = 0.037, R = –0.451) and a negative correlation with tumour grade (G). Interestingly, we demonstrated a negative correlation between IL-16 (p = 0.047, R = –0.401) and the depth of tumour invasion (pT) and between IL-9 (p = 0.011, R = –0.469) and the presence of distant metastases (pM). Negative correlations were also present between IL-1 ra (p = 0.006, R = –0.552), IP-10 (p = 0.047, R = –0.410), -NGF (p = 0.033, R =–0.469), and the presence of lymph node metastases (pN). Positive correlations were found between IL-16 (p = 0.019, R = 0.400), MIF (p = 0.016, R = 0.404), and weight loss (Figures 2 A, B). WBC was positively correlated with SDF-1 (p = 0.0149, R = 0.427), HGF (p = 0.006, R = 0.472), and with IL-6 (p = 0.009, R = 0.571). Neutrophil count was positively correlated with CTACK (p = 0.023, R = 0.406), HGF (p = 0.009, R = 0.461), IL-6 (p = 0.003, R = 0.624), MIF (p = 0.0212, R = 0.412), PDGF-BB (p = 0.021, R = 0.412), and SDF-1 (p = 0.010, R = 0.458). Moreover, HGF was also negatively correlated with RBC (p = 0.021, R = –0.407) and HCT (p = 0.016, R = –0.424). Significant associations were also found between Ca-19.9 and CTACK (p = 0.039, R = 0.542) and RANTES (p = 0.017, R = 0.613). -NGF was negatively correlated with HGB (p = 0.046, R = –0.430) (Figures 3 A, B).
Discussion
Approximately 60% to 70% of PDAC originate in the pancreatic head, while the remaining 30% develop in the body (15%) and tail (15%) [16]. The severity and type of symptoms of the tumour strictly depend on its location. Tumours situated in the pancreatic head can lead to a constriction of the primary bile duct, resulting in mechanical jaundice or acute pancreatitis. Peripherally located tumours (pancreas body and tail) can reach significant sizes before causing severe pain or high obstruction of the gastrointestinal tract [17]. Cancerous changes in this location pose a very difficult diagnostic problem. Initially, the only symptoms are non-specific pain in the abdominal cavity, and in later stages diabetes, as well as weight loss may occur. These tumours are usually diagnosed belatedly when adjacent organs have already been affected or distant metastases have occurred [18].
Inflammation is crucial in the emergence and advancement of PDAC. Antigens specific to the tumour stimulate a reaction from the immune system. Within the pancreatic cancer microenvironment, a local immune reaction provokes inflammatory process, which is produced and sustained by cytokines, chemokines, reactive oxygen species, and small peptides. Cells involved in the inflammatory process have the potential to affect the metabolic processes of cancer cells, particularly glucose metabolism, and by altering this metabolic route, they may promote tumour progression and evasion of immune surveillance [19, 20].
Cytokines, which are small proteins released by cells, play a crucial role as regulators of inflammation [21]. Numerous studies have demonstrated a variation in the expression of different cytokines in cases of pancreatic cancer [7, 22]. Cytokines can be stratified based on their functional mechanisms into pro-inflammatory (IL-1, IL-2, IL-6, IL-12, TNF-, and chemokines such as IL-8 and MCP-1, and anti-inflammatory (e.g. IL-1ra, IL-4, IL-10) categories. Pro-inflammatory cytokines are synthesised and exert their effects on immunocompetent cells, initiating an inflammatory cascade. In contrast, anti-inflammatory cytokines modulate specific immune responses and curtail the propagation of inflammation [23]. Pro-inflammatory cytokines play a pivotal role in modulating the proliferation, activation, and differentiation of immune cells, in addition to directing immune cells to the loci of infection for the containment and eradication of intracellular pathogens, such as viruses [24]. As cancer develops and progresses, it has an impact on the cells of the immune system [25]. PDAC is characterised by elevated levels of inflammatory cytokines and angiogenic markers, which are integral to its pathogenesis and advancement [26]. Despite the immune system’s initial recognition and elimination of aberrant or neoplastic cells through the activation of inflammatory pathways, malignant cells evolve defence mechanisms to circumvent host immune responses, a process termed immunoediting. Moreover, a pronounced desmoplastic reaction is emblematic of pancreatic ductal adenocarcinoma within the tumour microenvironment. This is indicative of the activation of pancreatic stellate cells, leading to the encapsulation of over 50% of the tumour with a dense fibrous stroma. The stromal barrier not only obstructs the entry of immune cells but also restricts the administration of anti-cancer drugs [27–29]. Numerous studies indicate that anti-inflammatory cytokines, i.e. TGF and IL-10, and pro-inflammatory cytokines – IL-1, IL-6, IL-17, and TNF-, could be an essential factor in the progression of PDAC [30]. Our study demonstrates significantly higher levels of cytokines – eotaxin, basic FGF, G-CSF, IL-2R, IL-6, IL-9, IL-17, IP-10, MIP-1, MIP-1, RANTES, SCGF- , TNF-, and TNF- – in patients with pancreatic cancer located in the pancreatic head compared to patients with tumours in the body and tail of the pancreas. This clearly indicates an increased inflammatory response in patients with tumours in the head of the pancreas, which may be caused by hyperbilirubinaemia. Mechanical jaundice in the course of cancer of the pancreatic head is an indication for endoscopic biliary stenting, which also results in the body’s response and cytokine production. The prosthesis inserted during endoscopic retrograde cholangiopancreatography (ERCP) is a foreign body that can induce an inflammatory response [31].
Our study demonstrated that IL-1ra and TNF- were closely correlated with tumour location, reaching higher values in patients with a tumour located in the pancreatic head. Increased circulating IL-1Ra levels have been linked to insulin resistance and the development of type 2 diabetes [32].
It is widely accepted that PDAC located peripherally are often accompanied by hyperbilirubinemia, which may additionally explain the observed relationships. Research conducted by Oldfield et al. corroborates the utility of circulating IL-1Ra as a potentially efficacious biomarker for the early identification of PDAC in individuals at elevated risk, particularly those who have recently received a diabetes diagnosis [33].
Research has confirmed that IL-6, which is a cytokine that promotes inflammation, also contributes to cancer progression [34, 35]. In vitro investigations have elucidated that pancreatic cancer cell lines and cancer-associated fibroblasts (CAF) synthesise IL-6. This cytokine can function in an autocrine and paracrine capacity, culminating in enhanced cancer cell motility and invasiveness, alongside the facilitation of epithelial-mesenchymal transition [36, 37]. In individuals diagnosed with PDAC, heightened concentrations of IL-6 detected in serum, pancreatic juice, and tissue samples have been associated with prognostic implications regarding tumour stage and patient survival. This observation substantiates the possible utility of this interleukin as a predictive biomarker for malignant tumours. However, the sensitivity and specificity of this method are extremely variable. A higher level of IL-6 in patients with a tumour located in the head of the pancreas may indicate the advanced stage of the neoplastic disease. Elevated serum IL-6 positively correlated with an increased risk of cancer development, weight loss, and metastases [30].
Th17 CD4+ cells produce IL-17, which plays a significant role in the onset and development of tumours. The presence of IL-17 receptors has been observed on cancer cells that are experiencing the epithelial-mesenchymal transition (EMT), with this expression reliant on the activity of the KRAS oncogene [38–40]. Our research noted increased levels of IL-17 in patients whose tumours were situated in the head of the pancreas, indicating that a tumour in this position might be associated with more intense chronic inflammation. It may also indicate its connection with mechanical jaundice or diabetes.
TNF- serves as a principal modulatory protein integral to the orchestration of the host’s immune response, and it is implicated in the mediation of systemic inflammation and pyrexia [41]. TNF-, a type II transmembrane polypeptide, has transmission capabilities as a soluble factor following its liberation through proteolytic cleavage. Although TNF- was originally classified as a cytokine that promotes inflammation, contemporary research lends support to its multifaceted role in carcinogenesis, underscoring its dual functionality in the process. TNF- is involved in chronic inflammatory diseases. It has been suggested that this cytokine, at low concentrations, plays a foundational role in tumour promotion. Therefore, the tumour-promoting or inhibiting impact also depends on the regional levels and the site of manifestation [41]. TNF- facilitates the activity of mast cells and fosters polar angiogenesis by inducing the production of pancreatic VEGF by stellate cell fibroblasts, further contributing to metastasis via the activation of NF-B signalling pathways. In patients with PDAC, the presence of immune cells and human pancreatic tumour cells capable of synthesising and secreting TNF- has been documented, indicating that cells changed by cancer are consistently subjected to endogenous autocrine stimulation [42].
Levels of CTACK and RANTES positively correlated with the number of neutrophils and carbohydrate antigen 19.9 (Ca 19.9), a recognised diagnostic tumour marker in PDAC [43]. Ca 19.9 antigen is one of the most frequently studied biomarkers in patients affected by pancreatic cancer. It is used for diagnostic and prognostic purposes [44, 45]. The sensitivity of Ca 19.9 in the early-stage of PCAC is low; in more advanced cancer lesions it is disturbed by the inflammatory response of the host and by obstructive jaundice [46]. Without a doubt, the potential of this biomarker has been weakened due to false-negative results in patients with pancreatic cancer and false-positive results in benign pancreatic and bile duct diseases [47]. CTACK may become a new, alternative, auxiliary marker. Cutaneous T-cell-attracting chemokine, also known as CCL27, is one of the chemokines that are key in the functioning of the immune system [48]. It is expressed strongly in both normal and inflamed skin. However, the number of clinical trials examining the association of CTAC with abdominal cancers is limited. A 2020 study found that adding CTACK, among other agents, to the reference models with Ca19-9 improved the survival rate for patients with PDAC [49]. In their study, Ceriolo et al. demonstrated that pancreatic islets in patients with pancreatic cancer are positive for CTACK expression [50]. A 2022 study provided evidence of a potential link between genetically determined CTACK levels and increased risk of prostate, kidney, and pancreatic cancer, as well as melanoma and non-Hodgkin’s lymphoma [51].
In our study group, tumours resulted in jaundice in 65.2% of patients with pancreatic head cancer, while elevated bilirubin levels were rare in patients with peripheral tumours. It is a widely recognised phenomenon that bilirubin precipitates a systemic inflammatory response syndrome, potentially culminating in multiple organ dysfunction syndrome. The cardinal clinical presentations encompass haemodynamic instability, acute renal insufficiency, cardiovascular compromise, immunodeficiency, coagulopathies, metabolic derangements, and impairments in wound repair processes [52]. The compromised immune function observed in obstructive jaundice is a critical factor in the development of many complications. This occurrence is ascribed to the aforementioned perturbations in homeostasis within the enterohepatic axis and portal sequelae, in conjunction with systemic endotoxaemia [53]. The lack of bile in the intestines, disruption of the intestinal mucosa barrier, and increased endotoxin absorption, followed by endotoxaemia cause the production of pro-inflammatory cytokines (including TNF- or IL-6). Septic symptoms result mainly from the impairment of the immune system. Specifically, they stem from a deficiency in cell-mediated immunity (T cells) triggered by the secretion of cytokines (TNF-, IL-1, IL-6, interferon-), prostaglandins, and various other inflammatory agents. Conjugated primary bile salts have been theorised to form micelles that bind endotoxins and reduce endotoxin permeability through intestinal epithelial cells [54]. A recent study demonstrated a decrease in LPS-responsive pro-inflammatory cytokines secreted by monocytes in obstructive jaundice. Biliary drainage reversed this effect. Patients with malignant tumours had a weaker response to LPS than patients with benign tumours [55]. Consequently, our observation showed a marked rise in inflammatory cytokines in patients with hyperbilirubinaemia associated with tumours in the pancreatic head.
Perioperative nutritional interventions, including immunonutrition, represent a significant therapeutic modality that enhances clinical outcomes following major surgical procedures, such as pancreatic resections [56]. Immunonutrition consisting of arginine, omega-3 fatty acids, and ribonucleic acid has demonstrated efficacy in modulating immune responses, attenuating inflammatory pathways, and optimising bowel function post-operatively [57]. Provision of nutritional support is essential for patients undergoing pancreatoduodenectomy, as a substantial proportion of these individuals exhibit malnourishment secondary to their underlying disease pathology. In patients exhibiting a catabolic state and experiencing stress attributable to both the disease itself and surgical trauma, there is a concomitant impairment of immune response. Modulation of this immune response is pivotal to enhancing patient prognosis, a claim substantiated by numerous clinical investigations [58–61]. In our study, IL-16 (p = 0.019, R = 0.400) and MIF (p = 0.016, R = 0.404) were positively correlated with weight loss. This suggests that the implementation of preoperative nutrition may improve the patient’s condition and thus reduce inflammation and the occurrence of postoperative complications.
Conclusions
We demonstrated that the concentrations of cytokines (eotaxin, basic FGF, G-CSF, IL-2R, IL-6, IL-9, IL-17, IP-10, MIP-1, MIP-1, RANTES, SCGF-, TNF-, and TNF-) were statistically significantly higher in patients with ductal carcinoma of the pancreatic head compared to patients with cancer located in the body and the tail. Cytokines such as FGF, G-CSF, IL-2R, IL-6, IL-9, IL-17, IP-10, MIP-1, MIP-1, RANTES, SCGF-, TNF-, and TNF- differentiate, with high sensitivity and specificity, patients with cancer located in the head of the pancreas from patients with the peripheral location of this cancer.
The examination of clinical and chosen parameters showed negative correlations between IL-1ra and TNF- and tumour location. Significant correlations were also found between Ca 19.9 and CTACK and RANTES.
It is important to acknowledge certain constraints of our study, including the small patient cohort size. Consequently, additional research involving a more extensive patient population with PDAC is necessary. Therefore, our study is the first step for future research purchased on the assessment of the diagnostic usefulness of inflammatory cytokines.
The concentration of selected parameters of inflammatory cytokines were performed exclusively on blood serum, which permits only an estimation of the results. Our evaluation was limited to a selection of cytokines; thus, we cannot provide a complete description of the inflammatory disorders of the PDAC patients. However, the carefully selected group of patients with PDAC constitutes an undeniable advantage of our study.
Funding
Medical University of Bialystok.
Ethical approval
Approval number: APK.002.237.2020.
Conflict of interest
The authors declare no conflict of interest.
References
1. Conroy T, Desseigne F, Ychou M, Bouché O, Guimbaud R, Bécouarn Y, Adenis A, Raoul JL, Gourgou-Bourgade S, de la Fouchardière C, Bennouna J, Bachet JB, KhemissaAkouz F, Péré-Vergé D, Delbaldo C, Assenat E, Chauffert B, Michel P, Montoto-Grillot C, Ducreux M; Groupe Tumeurs Digestives of Unicancer; PRODIGE Intergroup. FOLFIRINOX versus Gemcitabine for Metastatic Pancreatic Cancer. N Engl J Med. 2011 May; 364(19): 1817-1825.
2.
Rahim Moossa A, Lewis MH, Mackie CR. Surgical treatment of pancreatic cancer. Pol J Surg. 2018 Apr; 90(2): 45-53.
3.
Kowalska M, Kamocki Z. Body composition of patients suffering from pancreatic cancer. Pol J Surg. 2022 May; 95(1): 1-5.
4.
Faris JE, Blaszkowsky LS, McDermott S, Guimaraes AR, Szymonifka J, Huynh MA, Ferrone CR, Wargo JA, Al- len JN, Dias LE, Kwak EL, Lillemoe KD, Thayer SP, Murphy JE, Zhu AX, Sahani DV, Wo JY, Clark JW, Fernandez-del Castillo C, Ryan DP, Hong TS. FOLFIRINOX in locally advanced pancreatic cancer: the Massachusetts General Hospital Cancer Center Experience. Oncologist. 2013 May; 18(5): 543-548.
5.
Hariharan D, Saied A, Kocher HM. Analysis of mortality rates for pancreatic cancer across the world. HPB (Oxford). [Internet]. 2008; 10(1): 58-62.
6.
Klotz R, Larmann J, Klose C, Bruckner T, Benner L, Doerr-Harim C, Tenckhoff S, Lock JF, Brede EM, Salvia R, Pola- ti E, Köninger J, Schiff JH, Wittel UA, Hötzel A, Keck T, Nau C, Amati AL, Koch C, Eberl T, Zink M, Toma- zic A, Novak-Jankovic V, Hofer S, Diener MK, Wei- gand MA, Büchler MW, Knebel P; PAKMAN Trial Group. Gastrointestinal complications after pancreatoduodenectomy with epidural vs patient-controlled intravenous analgesia: a randomized clinical trial. JAMA Surg. 2020 Jul; 155(7): e200794.
7.
Kruger D, Yako YY, Devar J, Lahoud N, Smith M. Inflammatory cytokines and combined biomarker panels in pancreatic ductal adenocarcinoma: enhancing diagnostic accuracy. PLoS One. 2019 Aug; 14(8): e0221169.
8.
Chatterjee S. Oxidative Stress, Inflammation, and Disease. Oxidative Stress and Biomaterials. Elsevier, Amsterdam 2016; 35-58.
9.
Schreiber RD, Old LJ, Smyth MJ. Cancer immunoediting: integrating immunity’s roles in cancer suppression and promotion. Science (1979). 2011 Mar; 331(6024): 1565-1570.
10.
Zhao H, Wu L, Yan G, Chen Y, Zhou M, Wu Y, Li Y. Inflammation and tumor progression: signaling pathways and targeted intervention. Signal Transduct Target Ther. 2021 Jul; 6(1): 263.
11.
Fan Y, Mao R, Yang J. NF-B and STAT3 signaling pathways collaboratively link inflammation to cancer. Protein Cell. 2013 Mar; 4(3): 176-185.
12.
Owen KL, Brockwell NK, Parker BS. JAK-STAT signaling: a double-edged sword of immune regulation and cancer progression. Cancers (Basel). 2019 Dec; 11(12): 2002.
13.
Ullman TA, Itzkowitz SH. Intestinal inflammation and cancer. Gastroenterology. 2011 May; 140(6): 1807-1816.e1.
14.
Bosman F, Carnerio F, Hruban R, Theise N. Summary for Policymakers. Climate Change 2013 – The Physical Science Basis. Intergovernmental Panel on Climate Change, Ed.; Cambridge University Press, Cambridge, UK 2010; 1-30.
15.
Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, Meyer L, Gress DM, Byrd DR, Winchester DP. The Eighth Edition AJCC Cancer Staging Manual: continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin. 2017 Mar; 67(2): 93-99.
16.
Luchini C, Capelli P, Scarpa A. Pancreatic ductal adenocarcinoma and its variants. Surg Pathol Clin. 2016 Dec; 9(4): 547-560.
17.
McGuigan A, Kelly P, Turkington RC, Jones C, Cole- man HG, McCain RS. Pancreatic cancer: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018 Nov; 24(43): 4846-4861.
18.
Chari ST, Maitra A, Matrisian LM, Shrader EE, Wu BU, Kambadakone A, Zhao YQ, Kenner B, Rinaudo JAS, Srivastava S, Huang Y, Feng Z; Early Detection Initiative Consortium. Early detection initiative: a randomized controlled trial of algorithm-based screening in patients with new onset hyperglycemia and diabetes for early detection of pancreatic ductal adenocarcinoma. Contemp Clin Trials. 2022 Feb; 113: 106659.
19.
Padoan A, Plebani M, Basso D. Inflammation and pancreatic cancer: focus on metabolism, cytokines, and immunity. Int J Mol Sci. 2019; 20(3): 676.
20.
Everhart J, Wright D. Diabetes mellitus as a risk factor for pancreatic cancer: a meta-analysis. JAMA 1995 May; 273(20): 1605-1609.
21.
Bel’skaya LV, Loginova AI, Sarf EA. Pro-inflammatory and anti-inflammatory salivary cytokines in breast cancer: relationship with clinicopathological characteristics of the tumor. Curr Issues Mol Biol. 2022 Oct; 44(10): 4676.
22.
Padoan A, Plebani M, Basso D. Inflammation and pancreatic cancer: focus on metabolism, cytokines, and immunity. Int J Mol Sci. 2019 Feb; 20(3): 676.
23.
Akdis M, Aab A, Altunbulakli C, Azkur K, Costa RA, Crameri R, Duan S, Eiwegger T, Eljaszewicz A, Ferstl R, Frei R, Garbani M, Globinska A, Hess L, Huitema C, Kubo T, Komlosi Z, Konieczna P, Kovacs N, Kucukse- zer UC, Meyer N, Morita H, Olzhausen J, O’Mahony L, Pezer M, Prati M, Rebane A, Rhyner C, Rinaldi A, Sokolowska M, Stanic B, Sugita K, Treis A, van de Veen W, Wan- ke K, Wawrzyniak M, Wawrzyniak P, Wirz OF, Zakzuk JS, Akdis CA. Interleukins (from IL-1 to IL-38), interferons, transforming growth factor , and TNF-: receptors, functions, and roles in diseases. J Allergy Clin Immunol. 2016 Oct; 138(4): 984-1010.
24.
Turner MD, Nedjai B, Hurst T, Pennington DJ. Cytokines and chemokines: at the crossroads of cell signalling and inflammatory disease. Biochim Biophys Acta 2014 Nov; 1843(11): 2563-2582.
25.
Kuol N, Stojanovska L, Apostolopoulos V, Nurgali K. Crosstalk between cancer and the neuro-immune system. J Neuroimmunol. 2018 Feb; 315: 15-23.
26.
Masamune A, Kikuta K, Watanabe T, Satoh K, Hirota M, Shimosegawa T. Hypoxia stimulates pancreatic stellate cells to induce fibrosis and angiogenesis in pancreatic cancer. Am J Physiol Gastrointest Liver Physiol. 2008 Oct; 295(4): 709-717.
27.
Yako YY, Brand M, Smith M, Kruger D. Inflammatory cytokines and angiogenic factors as potential biomarkers in South African pancreatic ductal adenocarcinoma patients: a preliminary report. Pancreatology. 2017 May; 17(3): 438-444.
28.
Watt J, Kocher HM. The desmoplastic stroma of pancreatic cancer is a barrier to immune cell infiltration. Oncoi- imunology 2013 Dec; 2(12): e26788.
29.
Heinemann V, Reni M, Ychou M, Richel DJ, Macarulla T, Ducreux M. Tumour-stroma interactions in pancreatic ductal adenocarcinoma: rationale and current evidence for new therapeutic strategies. Cancer Treat Rev. 2014 Feb; 40(1): 118-128.
30.
van Duijneveldt G, Griffin MDW, Putoczki TL. Emerging roles for the IL-6 family of cytokines in pancreatic cancer. Clin Sci (Lond). 2020 Aug; 134(16): 2091-2115.
31.
Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol. 2016 Oct; 30(5): 793-805.
32.
Herder C, Fćrch K, Carstensen-Kirberg M, Lowe GD, Haapakoski R, Witte DR, Brunner EJ, Roden M, Ta- bák AG, Kivimäki M, Vistisen D. Biomarkers of subclinical inflammation and increases in glycaemia, insulin resistance and beta-cell function in non-diabetic individuals: the Whitehall II study. Eur J Endocrinol. 2016 Nov; 175(5): 367-377.
33.
Oldfield L, Evans A, Rao RG, Jenkinson C, Purewal T, Psarelli EE, Menon U, Timms JF, Pereira SP, Ghaneh P, Greenhalf W, Halloran C, Costello E. Blood levels of adiponectin and IL-1Ra distinguish type 3c from type 2 diabetes: implications for earlier pancreatic cancer detection in new-onset diabetes. EBioMedicine. 2022 Jan; 75: 103802.
34.
Pop VV, Seicean A, Lupan I, Samasca G, Burz CC. IL-6 roles – molecular pathway and clinical implication in pancreatic cancer – a systemic review. Immunol Lett. 2017 Jan; 181: 45-50.
35.
Landskron G, De La Fuente M, Thuwajit P, Thuwajit C, Hermoso MA. Chronic inflammation and cytokines in the tumor microenvironment. J Immunol Res. 2014; 2014: 149185.
36.
Feng R, Morine Y, Ikemoto T, Imura S, Iwahashi S, Saito Y, Shimada M. Nab-paclitaxel interrupts cancer-stromal interaction through C-X-C motif chemokine 10-mediated interleukin-6 downregulation in vitro. Cancer Sci. 2018 Aug; 109(8): 2509-2519.
37.
Karakhanova S, Link J, Heinrich M, Shevchenko I, Yang Y, Hassenpflug M, Bunge H, von Ahn K, Brecht R, Mathes A, Maier C, Umansky V, Werner J, Bazhin AV. Characterization of myeloid leukocytes and soluble mediators in pancreatic cancer: Importance of myeloid-derived suppressor cells. Oncoimmunology. 2015 Apr; 4(4); e998519.
38.
McAllister F, Bailey JM, Alsina J, Nirschl CJ, Sharma R, Fan H, Fan H, Rattigan Y, Roeser JC, Lankapalli RH, Zhang H, Jaffee EM, Drake CG, Housseau F, Maitra A, Kolls JK, Sears CL, Pardoll DM, Leach SD. Oncogenic kras activates a hematopoietic-to-epithelial IL-17 signaling axis in preinvasive pancreatic neoplasia. Cancer Cell. 2014 May; 25(5): 621-637.
39.
Zhang Y, Zoltan M, Riquelme E, Xu H, Sahin I, Castro-Pando S, Montiel MF, Chang K, Jiang Z, Ling J, Gupta S, Horne W, Pruski M, Wang H, Sun SC, Lozano G, Chiao P, Maitra A, Leach SD, Kolls JK, Vilar E, Wang TC, Bai- ley JM, McAllister F. Immune cell production of interleukin 17 induces stem cell features of pancreatic intraepithelial neoplasia cells. Gastroenterology. 2018 Jul; 155(1): 210-223.e3.
40.
Loncle C, Bonjoch L, Folch-Puy E, Lopez-Millan MB, Lac S, Molejon MI, Chuluyan E, Cordelier P, Dubus P, Lom- berk G, Urrutia R, Closa D, Iovanna JL. IL17 functions through the novel REG3-JAK2-STAT3 inflammatory pathway to promote the transition from chronic pancreatitis to pancreatic cancer. Cancer Res. 2015 Nov; 75(22): 4852-4862.
41.
Steeland S, Libert C, Vandenbroucke RE. A new venue of TNF targeting. Int J Mol Sci 2018 May; 19(5): 1442.
42.
Egberts JH, Cloosters V, Noack A, Schniewind B, Thon L, Klose S, Kettler B, von Forstner C, Kneitz C, Tepel J, Adam D, Wajant H, Kalthoff H, Trauzold A. Anti-tumor necrosis factor therapy inhibits pancreatic tumor growth and metastasis. Cancer Res. 2008 Mar; 68(5): 1443-1450.
43.
Shaw VE, Lane B, Jenkinson C, Cox T, Greenhalf W, Halloran CM, Tang J, Sutton R, Neoptolemos JP, Costello E. Serum cytokine biomarker panels for discriminating pancreatic cancer from benign pancreatic disease. Mol Cancer. 2014 May; 13(1): 114.
44.
Goonetilleke KS, Siriwardena AK. Systematic review of carbohydrate antigen (CA 19-9) as a biochemical marker in the diagnosis of pancreatic cancer. Eur J Surg Oncol. 2007 Apr; 33(3): 266-270.
45.
van Manen L, Groen J V., Putter H, Vahrmeijer AL, Swijnenburg RJ, Bonsing BA, Mieog JSD. Elevated CEA and CA19-9 serum levels independently predict advanced pancreatic cancer at diagnosis. Biomarkers. 2020 Feb; 25(2): 186-193.
46.
Liu W, Liu Q, Wang W, Wang P, Chen J, Hong T, Zhang N, Li B, Qu Q, He X. Differential diagnostic roles of the serum CA19-9, total bilirubin (TBIL) and the ratio of CA19-9 to TBIL for benign and malignant. J Cancer. 2018 Apr; 9(10): 1804-1812.
47.
Azizian A, Rühlmann F, Krause T, Bernhardt M, Jo P, König A, Kleiß M, Leha A, Ghadimi M, Gaedcke J. CA19-9 for detecting recurrence of pancreatic cancer. Sci Rep. 2020 Dec; 10(1): 1332.
48.
Cogliano VJ, Baan R, Straif K, Grosse Y, Lauby-Secretan B, El Ghissassi F, Bouvard V, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Wild CP. Preventable exposures associated with human cancers. J Natl Cancer Inst. 2011 Dec; 103(24): 1827-1839.
49.
Lanki M, Seppänen H, Mustonen H, Salmiheimo A, Stenman UH, Salmi M, Jalkanen S, Haglund C. Pancreatic cancer survival prediction via inflammatory serum markers. Cancer Immunol Immunother. 2022 Sep; 71(9): 2287-2292.
50.
Ceriolo P, Fausti V, Cinotti E, Bonadio S, Raffaghello L, Bianchi G, Orcioni GF, Fiocca R, Rongioletti F, Pistoia V, Borgonovo G. Pancreatic metastasis from mycosis fungoides mimicking primary pancreatic tumor. World J Gastroenterol. 2016 Mar; 22(12): 3496-3501.
51.
Song J, Li A, Qian Y, Liu B, Lv L, Ye D, Sun X, Mao Y. Genetically predicted circulating levels of cytokines and the risk of cancer. Front Immunol. 2022 Jul; 13: 886144.
52.
Yang R, Zhu S, Pischke SE, Haugaa H, Zou X, Tonnes- sen TI. Bile and circulating HMGB1 contributes to systemic inflammation in obstructive jaundice. J Surg Res. 2018 Aug; 228: 14-19.
53.
Pavlidis ET, Pavlidis TE. Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobil Pancr Dis Int. 2018 Feb; 17(1): 17-21.
54.
Parlesak A, Schaeckeler S, Moser L, Bode C. Conjugated primary bile salts reduce permeability of endotoxin through intestinal epithelial cells and synergize with phosphatidylcholine in suppression of inflammatory cytokine production. Crit Care Med. 2007 Oct; 35(10): 2367-2374.
55.
Chowdhury AH, Camara M, Martinez-Pomares L, Zaitoun AM, Eremin O, Aithal GP, Lobo DN. Immune dysfunction in patients with obstructive jaundice before and after endoscopic retrograde cholangiopancreatography. Clin Sci (Lond). 2016; 130(17): 1535-1544.
56.
Takagi K, Domagala P, Hartog H, van Eijck C, Groot Koerkamp B. Current evidence of nutritional therapy in pancreatoduodenectomy: systematic review of randomized controlled trials. Ann Gastroenterol Surg. 2019 Nov; 3(6): 620-629.
57.
Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, Di Carlo V. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology. 2002 Jun; 122(7): 1763-1770.
58.
Furukawa A, Furukawa K, Suzuki D, Yoshitomi H, Takayashiki T, Kuboki S, Miyazaki M, Ohtsuka M. Effect of immunonutrition on infectious complications in low skeletal muscle mass patients after pancreaticoduodenectomy. Clin Nutr. 2021 Jan; 40(1): 103-109.
59.
Hamza N, Darwish A, O’Reilly DA, Denton J, Sheen AJ, Chang D, Sherlock DJ, Ammori BJ. Perioperative enteral immunonutrition modulates systemic and mucosal immunity and the inflammatory response in patients with periampullary cancer scheduled for pancreaticoduodenectomy: a randomized clinical trial. Pancreas. 2015 Jan; 44(1): 41-52.
60.
Shirakawa H, Kinoshita T, Gotohda N, Takahashi S, Nakagohri T, Konishi M. Compliance with and effects of preoperative immunonutrition in patients undergoing pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci. 2012 May; 19(3): 249-258.
61.
Tumas J, Jasiūnas E, Strupas K, Šileikis A. Effects of immunonutrition on comprehensive complication index in patients undergoing pancreatoduodenectomy. Medicina 2020 Jan; 56(2): 52.
