Nodal and Activin belong to the TGF-β superfamily and are important regulators of embryonic stem cell fate. Here we investigated whether Nodal and Activin regulate self-renewal of pancreatic cancer stem cells. Nodal and Activin were hardly detectable in more differentiated pancreatic cancer cells, while cancer stem cells and stroma-derived pancreatic stellate cells markedly overexpressed Nodal and Activin, but not TGF-β. Knockdown or pharmacological inhibition of the Nodal/Activin receptor Alk4/7 in cancer stem cells virtually abrogated their self-renewal capacity and in vivo tumorigenicity, and reversed the resistance of orthotopically engrafted cancer stem cells to gemcitabine. However, engrafted primary human pancreatic cancer tissue with a substantial stroma showed no response due to limited drug delivery. The addition of a stroma-targeting hedgehog pathway inhibitor enhanced delivery of the Nodal/Activin inhibitor and translated into long-term, progression-free survival. Therefore, inhibition of the Alk4/7 pathway, if combined with hedgehog pathway inhibition and gemcitabine, provides a therapeutic strategy for targeting cancer stem cells.

Oncogene-induced replicative stress activates an Atr- and Chk1-dependent response, which has been proposed to be widespread in tumors. We explored whether the presence of replicative stress could be exploited for the selective elimination of cancer cells. To this end, we evaluated the impact of targeting the replicative stress-response on cancer development. In mice (Mus musculus), the reduced levels of Atr found on a mouse model of the Atr-Seckel syndrome completely prevented the development of Myc-induced lymphomas or pancreatic tumors, both of which showed abundant levels of replicative stress. Moreover, Chk1 inhibitors were highly effective in killing Myc-driven lymphomas. By contrast, pancreatic adenocarcinomas initiated by K-Ras(G12V) showed no detectable evidence of replicative stress and were nonresponsive to this therapy. Besides its impact on cancer, Myc overexpression aggravated the phenotypes of Atr-Seckel mice, revealing that oncogenes can modulate the severity of replicative stress-associated diseases.

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Esta es la versión de autor del artículo publicado en: This is an author produced version of a paper published in: Gut 64.12 (2015Gut 64.12 ( ): 1921Gut 64.12 ( -1935 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 Results:We found that hCAP-18/LL-37 was strongly expressed in the stroma of advanced primary and secondary PDAC tumours and is secreted by immune cells of the stroma (eg, tumour-associated macrophages) in response to TGF-β1 and particularly CSC-secreted Nodal/ActivinA. Treatment of pancreatic CSC with recombinant LL-37 increased pluripotency-associated gene expression, self-renewal, invasion, and tumourigenicity via formyl peptide receptor 2 (FPR2)-and P2X purinoceptor 7 receptor (P2X7R)-dependent mechanisms, which could be reversed by inhibiting these receptors. Importantly, in a genetically engineered mouse model of K-Ras-driven pancreatic tumourigenesis, we also showed that tumour formation was inhibited by either reconstituting these mice with bone marrow from CRAMP (i.e murine homolog of hCAP-18/LL-37) knockout mice or by pharmacologically inhibiting FPR2 and P2X7R. Conclusion:Thus, hCAP-18/LL-37 represents a previously unrecognized PDAC micro-environment factor that plays a critical role in pancreatic CSC-mediated tumourigenesis. SIGNIFICANCE OF THE STUDYWhat is already known on this subject?• Pancreatic ductal adenocarcinoma (PDAC) is the most lethal cancer with limited therapeutic options.• Pancreatic cancer stem cells (CSCs) are exclusively tumourigenic and highly resistant to chemotherapy.• Tumour-associated macrophages are important for the progression and metastatic spread of many solid tumours. What are the new findings?• The immuno-modulatory cationic antimicrobial peptide 18/leucine leucine-37 (hCAP-18/LL-37) is over expressed in the stroma of PDAC and acts on CSCs to potentiate their inherent biological properties.• Tumour-associated macrophages secrete hCAP-18/LL-37 in direct response to CSC-secreted NODAL/ACTIVINA/TGF-β1.• Small molecule targeting of the LL-37 receptors formyl peptide receptor 2 (FPR2) and P2X purinoceptor 7 receptor (P2X7R), present on pancreatic CSCs, negatively impacts tumour growth and circulating tumour cell numbers. How might it impact on clinical practice in the foreseeable future?• The discovery of the crucial role of hCAP-18/LL-37 in cancer stem cell biology represents an important advancement in our understanding of the PDAC tumour microenvironment.• Targeting pancreatic CSCs using inhibitors of the LL-37 receptors FPR2 and P2X7R may represent a specific therapeutic approach to block the tumour promoting cross-talk that exists within the tumour microenviro...