BACKGROUND:Acute Pancreatitis (AP) is a formidable disease with significant morbidity, mortality and healthcare expenditure. There is an emergent need to develop therapeutic agents for this disease as there are no targeted therapies available. We have recently demonstrated that pirfenidone can significantly decrease the severity of AP in animal models. Based on our preclinical findings, we decided to conduct a pilot trial to evaluate the safety, tolerability and efficacy of pirfenidone in patients with AP. METHODS:We have designed a multicenter, randomized, pilot clinical trial of 60 patients with blinded outcome assessment. All patients with AP, who present within 48 h of establishment of the diagnosis, will be screened for exclusion and inclusion criteria. Consenting patients will be randomized into pirfenidone or placebo within 48 h of the diagnosis of AP. The primary end points include decrease in PAN-PROMISE score after 72 h of initiation of drug, reduction in inflammatory markers, and development of serious adverse events. The secondary end points include changes in PAN-PROMISE score, discharge PASS score <60, development of composite outcome of new or worsening necrotizing pancreatitis on CT scan performed 5-7 days after admission, major infection or death, and readmissions and/or ER visits within 30 days and within 6 months after discharge. STATUS:Currently enrolling (NCT05350371). CONCLUSION:There is an urgent need to identify novel therapies for AP. This pilot clinical trial may become the basis of a larger study to analyze the efficacy of pirfenidone in patients with AP.

Acquired cystic disease associated renal cell carcinomas (ACD-RCC) are rare and their molecular and histopathological characteristics are still being explored. We therefore investigated the clinicopathologic and molecular characteristics of 31 tumors. The patients were predominantly male (n = 30), with tumors mainly leftsided (n = 17), unifocal (n = 19), and unilateral (n = 29) and a mean tumor size of 25 mm (range, 3-65 mm). Microscopically, several histologic patterns were present, including pure classic sieve-like (n = 4), and varied proportions of mixed classic sieve-like with papillary (n = 23), tubulocystic (n = 9), compact tubular (n = 4) and solid (n = 1) patterns. Calcium-oxalate crystals were seen in all tumors. Molecular analysis of 9 tumors using next generation sequencing showed alterations in SMARCB1 in 3 tumors (1 with frameshift deletion and 2 with copy number loss in chromosome 22 involving SMARCB1 region), however, INI1 stain was retained in all. Nonrecurrent genetic alterations in SETD2, NF1, NOTCH4 , BRCA2 and CANT1 genes were also seen. Additionally, MTOR p.Pro351Ser was identified in one tumor. Copy number analysis showed gains in chromosome 16 (n = 5), 17 (n = 2) and 8 (n = 2) as well as loss in chromosome 22 (n = 2). In summary, ACD-RCC is a recognized subtype of kidney tumors, with several histological architectural patterns. Our molecular data identifies genetic alterations in chromatin modifying genes ( SMARCB1 and SETD2 ), which may suggest a role of such genes in ACD-RCC development.

Chronic pancreatitis (CP) is a fibro-inflammatory disease of the pancreas with no specific cure. Research highlighting the pathogenesis and especially the therapeutic aspect remains limited. Aberrant activation of developmental pathways in adults has been implicated in several diseases. Hedgehog pathway is a notable embryonic signaling pathway, known to promote fibrosis of various organs when overactivated. The aim of this study is to explore the role of the hedgehog pathway in the progression of CP and evaluate its inhibition as a novel therapeutic strategy against CP. CP was induced in mice by repeated injections of l-arginine or caerulein in two separate models. Mice were administered with the FDA-approved pharmacological hedgehog pathway inhibitor, vismodegib during or after establishing the disease condition to inhibit hedgehog signaling. Various parameters of CP were analyzed to determine the effect of hedgehog pathway inhibition on the severity and progression of the disease. Our study shows that hedgehog signaling was overactivated during CP and its inhibition was effective in improving the histopathological parameters associated with CP. Vismodegib administration not only halted the progression of CP but was also able to resolve already-established fibrosis. In addition, inhibition of hedgehog signaling resulted in the reversal of pancreatic stellate cell activation ex vivo. Findings from our study justify conducting clinical trials using vismodegib against CP and, thus, could lead to the development of a novel therapeutic strategy for the treatment of CP. NEW & NOTEWORTHY Hedgehog signaling is activated in human and experimental models of CP. Inhibition of hedgehog signaling using an FDA-approved inhibitor, vismodegib, leads to the resolution of fibrosis and improves CP. This study has immense and immediate translational benefits.

Renal cell carcinoma with fibromyomatous stroma, recognized as a provisional entity in the current 2022 World Health Organization classification of renal neoplasms, is rare. Recent evidence suggests recurrent alterations in the mTOR pathway, supporting its recognition as a distinct entity. Herein, we report 2 renal cell carcinomas with fibromyomatous stroma with MTOR mutations occurring in 62- and 72-year-old women and review the literature to support its recognition as a distinct entity, focusing on the characteristic morphology, immunohistochemical staining patterns as well as genetic alterations.

Heparin Induced Thrombocytopenia (HIT) is a potentially life-threatening but uncommon disease process characterized by IgG antibodies that recognize platelet factor 4/heparin immune complexes causing thrombocytopenia and thrombosis. Although therapeutic plasmapheresis (PLEX) appears to be effective, protocols regarding how and when to institute PLEX remain elusive. At our institution, we put together a standardized approach to assess the interventional success across patients that included 1 plasmapheresis procedure per day over 4 days, processing one plasma volume and using thawed plasma as the replacement fluid. Treatment effectiveness was evaluated by pre- and post-interventional HIPA OD levels and platelet count. Treatment aim was to decrease the HIPA OD to less than 0.6 and obtain a normal platelet count. The aim of this study was to design a protocol for PLEX to address urgent need for patients with HIT for which heparin is planned for intraoperative cardiac surgery requiring cardiopulmonary bypass (CPB) anticoagulation. We retrospectively examined the medical records of 2 HIT-positive patients who underwent PLEX prior to cardiac surgery at our large quaternary care hospital. Both patients had a 4Ts score of 5, with a medium probability of disease. One patient's HIT was confirmed by a positive serotonin release assay (SRA). The second patient had persistently negative confirmatory test but was deemed clinical HIT. The first patient is a 53-year-old female, who was admitted for mitral valve replacement, aortic valve replacement, and tricuspid valve repair. She was confirmed HIT by positive SRA. Three sessions of PLEX were performed on consecutive days. Her HIPA (heparin induced platelet antibody) O.D. value decreased from 1.925 to 0.534 and platelet counts normalized. The second patient is a 73-year-old male, who was admitted for LVAD implantation and LV thrombus resection. Two sessions of PLEX were performed on consecutive days. His HIPA O.D. value deceased from 1.261 to < 0.4 (negative) and platelet counts normalized. For both patients, the last PLEX procedure was performed the day of surgery, and the cardiac surgical procedure was completed successfully. Based on these 2 patients, we have proposed a protocol for PLEX in HIT patients as follows: daily plasmapheresis x 4 days will be performed until the OD has decreased to less than 0.6 and platelet count has normalized. Each plasmapheresis will consist of the processing of one plasma volume, using thawed plasma as the replacement fluid. The last plasmapheresis will occur on the day of surgery prior to surgery. Further assessment will be performed if the targeted parameters have not been met by the 4th plasmapheresis procedure. In conclusion, we present 2 patients with HIT who benefitted from PLEX prior to cardiac surgery under CPB. We will adopt the protocol used for these 2 patients as our standard of practice moving forward.

Background: We have previously showed that gut microbiota-depleting oral antibiotics decrease tumor growth in C57BL/6J mice via the immune system (Sethi et al, Gastroenterology, 2018). The gut microbiota, however, includes thousands of species producing numerous metabolites. The search for individual bacterial species and metabolites that can promote cancer continues. Methods: We studied the effects of common microbiota modulation techniques in C57BL/6 mice procured from various commercial vendors and injected subcutaneously with cancer cells. 16S rRNA gene sequencing and metabolomics analyses were used to identify the putative cancer-promoting species and metabolites. Results: Mice procured from The Jackson Laboratory (JAX mice) form larger tumors at baseline compared to mice procured from the Charles River Laboratories (CR mice). JAX mice have tumor promoting microbiota that can be targeted by oral antibiotics unlike CR mice. This tumor-promoting microbiota gets transferred from JAX to CR mice via cohousing or fecal microbiota transplant. In a preclinical trial, oral vancomycin slowed the growth of cancer in avatar mice gavaged with stools of some pancreatic cancer patients but not of others. Statistical analyses reveal that the gut of JAX mice hosts a common human gram-positive gut commensal Ruminococcus gnavus that is associated with increased cancer growth in those mice. Monocolonization of germ-free mice with R gnavus directly increases tumor growth. Similarly, feeding R gnavus, but not a control bacterial species, brings the baseline tumor kinetics of CR mice up to that of JAX mice. Our experiments reveal that R gnavus needs sufficient dietary tryptophan (Trp) to promote tumor growth and in turn, catabolizes Trp into various metabolites including the Aryl Hydrocarbon Receptor (AHR) ligand Tryptamine, which we find, is also tumor-promoting per se. The tumor-modulating effects of oral vancomycin, tryptophan catabolites and R gnavus are abolished when murine AHR is stimulated by an exogenous ligand or when it is knocked out. Finally, we find that Ly6G+ cells are essential in effecting these bacteria-cancer interactions. Conclusions: We present initial evidence on how a common gut commensal hijacks an essential dietary amino acid to promote cancer via the AHR. We also demonstrate the essential but underappreciated role that the source of animal procurement plays in studies involving cancer models. Citation Format: Vrishketan Sethi, Junyi Tao, Saba Kurtom, Utpreksha Vaish, Farrukh Afaq, Shuan Zao, Xian Luo, Tejeshwar Jain, Prateek Sharma, Ejas Bava, Sundaram Ramakrishnan, Liang Li, Ashok Saluja, Vikas Dudeja. A common gut commensal utilizes tryptophan to promote cancer via the aryl hydrocarbon receptor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3046.

Chronic pancreatitis (CP) is an irreversible fibro-inflammatory disease of the pancreas with no current targeted therapy. Pirfenidone, an anti-fibrotic and anti-inflammatory drug, is FDA approved for treatment of Idiopathic Pulmonary Fibrosis (IPF). Its efficacy in ameliorating CP has never been evaluated before. We recently reported that pirfenidone improves acute pancreatitis in mouse models. The aim of the current study was to evaluate the therapeutic efficacy of pirfenidone in mouse models of CP. We used caerulein and L-arginine models of CP and administered pirfenidone with ongoing injury, or in well-established disease. We evaluated for fibrosis by Sirius-red staining for collagen, immunohistochemistry, western blotting, and qPCR for fibrosis markers to show the salutary effects of pirfenidone in CP. Our results suggest that treatment with pirfenidone ameliorated CP related changes in the pancreas (i.e., atrophy, acinar cell loss, fibrosis, and inflammation) not only when administered with ongoing injury, but also in well-established models of caerulein as well as L-arginine induced CP. It reduces the pro-fibrotic phenotype of macrophages (in-vivo and in-vitro), reduces macrophage infiltration into the pancreas and alters the intra-pancreatic cytokine milieu preceding changes in histology. The therapeutic effect of pirfenidone is abrogated in absence of macrophages. Furthermore, it reduces collagen secretion, cytokine levels and fibrosis markers in pancreatic stellate cells in-vitro. As it is FDA approved, our findings in mouse models simulating clinical presentation of patients to the clinic, can be used as the basis of a clinical trial evaluating the efficacy of this drug as a therapeutic agent for CP.

Abstract Abuse and addiction of opioids leading to overdose deaths has increased significantly in Michigan since 2014. Moreover, a recent study showed that a majority (92%) of clinicians at Henry Ford Health System (HFHS) had reported prescribing narcotics in a way that was out of their comfort zone. To tackle this menace, we needed to equip our physicians with the appropriate tools to monitor patient compliance. In 2017, our laboratory implemented a reflexive urine drug testing (UDT) strategy called the directed pain panel (DPP). This panel included testing for natural/semi-synthetic /synthetic opiates, benzodiazepines, and cocaine metabolites. In 2019, the DPP was enhanced by adding buprenorphine, fentanyl, and tramadol. It is beneficial to order the DPP as opposed to UDSC (Urine drug screen) because UDSC does not detect the synthetic narcotics methadone, fentanyl, tramadol, and buprenorphine. DPP also has better sensitivity for detection of oxycodone. The primary aim of the current study was to evaluate UDT orders for chronic pain patients and to focus our efforts on improving the lab testing available to our providers to manage patients safely and effectively. Therefore, we evaluated the utilization of our testing strategy by doing a survey among chronic pain physicians in addition to retrospectively analyzing total orders for DPP (chronic pain panel, directed, urine) and UDSC (drug screen, urine) for chronic pain patients at five locations in Michigan over a one-year period (8/2020-8/2021). We collaborated with key providers and accessed their test ordering history to assess compliance with ordering the preferred UDT panel. The DPP represented 68% of all UDTs ordered for this population, however there were still a significant number of UDSC orders (32%). When order location was evaluated, the majority of UDSC orders originated from two locations (80%). When provider ordering patterns were evaluated, most providers (65%) ordered the DPP > 50% of the time. In addition, 70% of all UDSC orders came from just two providers. This data showed that HFHS pain management clinicians favored ordering the DPP, however a small minority of ordering providers may benefit from targeted education regarding the advantages of the DPP. Hence, we educated the physicians who were ordering UDSC. They were willing to modify their practice to order DPP, instead of UDSC. This may pave the way for better patient compliance as well as reduced overdose and abuse of opioids.

Despite decades of research, there is no specific therapy for acute pancreatitis (AP). In the current study, we have evaluated the efficacy of pirfenidone, an antiinflammatory and antifibrotic agent that is approved by the FDA for treatment of idiopathic pulmonary fibrosis (IPF), in ameliorating local and systemic injury in AP. Our results suggest that treatment with pirfenidone in therapeutic settings (e.g., after initiation of injury), even when administered at the peak of injury, reduces severity of local and systemic injury and inflammation in multiple models of AP. In vitro evaluation suggests that pirfenidone decreases cytokine release from acini and macrophages and disrupts acinar-macrophage crosstalk. Therapeutic pirfenidone treatment increases IL-10 secretion from macrophages preceding changes in histology and modulates the immune phenotype of inflammatory cells with decreased levels of inflammatory cytokines. Antibody-mediated IL-10 depletion, use of IL-10-KO mice, and macrophage depletion experiments confirmed the role of IL-10 and macrophages in its mechanism of action, as pirfenidone was unable to reduce severity of AP in these scenarios. Since pirfenidone is FDA approved for IPF, a trial evaluating the efficacy of pirfenidone in patients with moderate to severe AP can be initiated expeditiously.

BACKGROUND:Exocrine pancreatic insufficiency (EPI) is frequently seen in patients with pancreatic cancer (PDAC) and is thought to contribute to nutritional complications. While EPI can be pharmacologically temporized with pancreatic enzyme replacement therapy (PERT), there is lack of clear evidence informing its use in PDAC. Here we aim to survey pancreatic surgeons regarding their utilization of PERT in the management of EPI for PDAC.METHODS:An online survey was distributed to the members of The Americas Hepato-Pancreato-Biliary Association (AHPBA) and The Pancreas Club.RESULTS:86.5% (180/208) of surgeons prescribe PERT for at least some resectable/borderline resectable PDAC cases. Only a minority of surgeons order investigations to confirm EPI before starting PERT (28.1%) or test for adequacy of therapy (28.3%). Few surgeons believe that PERT has an effect on overall survival (19.7%) or disease-free survival (6.25%) in PDAC.CONCLUSION:PERT is widely prescribed in patients with resectable/borderline resectable PDAC, but investigations establishing EPI and assessing PERT adequacy are underutilized. A substantial proportion of surgeons are unclear as to the effect of PERT on survival outcomes in PDAC. These data call for prospective studies to establish guidelines for optimal use of PERT and its effects on survival outcomes in PDAC.

ABSTRACT Heat shock protein 70 (Hsp70), a protein chaperone, is known to promote cell survival and tumor progression. However, its role in the tumor microenvironment (TME) is largely unknown. We specifically evaluated Hsp70 in the TME by implanting tumors in wild-type (WT) controls or Hsp70−/- animals, thus creating a TME with or without Hsp70. Loss of Hsp70 led to significantly smaller tumors; there were no differences in stromal markers, but interestingly, depletion of CD8 + T-cells abrogated this tumor suppressive effect, indicating that loss of Hsp70 in the TME affects tumor growth through the immune cells. Compared to WT, adoptive transfer of Hsp70−/- splenocytes exhibited greater antitumor activity in immunodeficient NSG and Rag 1−/- mice. Hsp70−/- dendritic cells showed increased expression of MHCII and TNF-α both in vitro and in vivo. These results suggest that the absence of Hsp70 in the TME inhibits tumors through increased dendritic cell activation. Hsp70 inhibition in DCs may emerge as a novel therapeutic strategy against pancreatic cancer.