Mutation of K-RAS, CDKN2A, SMAD4 and TP53 in Pancreatic Cancer: Role of Liquid Biopsy in Preoperative Diagnosis

BACKGROUND Pancreatic cancer is the 4th cancer-related cause of death in Western countries and it is expected to become the 2nd leading cause of death by 2030 [1]. Approximately 80% of patients are unresectable at diagnosis [2] including a 41.4% of patients found unresectable at exploratory laparoscopy/tomy [3]. Moreover up to 38% of eventually resected patients will need a vascular resection in order to achieve a radical pancreatectomy [4], just over half of which because of a histological invasion [2]. Last but not least, successfully resected patients will recur within 12 months in more than 40% of cases with dismal prognosis [5]. Those early recurrent patients will show local spread or metastatic disease within 12 months with a post-recurrence survival and overall survival more than halved compared to patients recurring beyond one year from resection [5]. Laparotomy may be therefore useless in such patients. In this setting neoadjuvant treatment plays a key-role. It has the potential advantages to deliver systemic therapy to all patients with an increased efficacy of radio- and chemotherapies distributed in a virgin field, identify patients with aggressive tumor biology that could recur shortly after surgery and thus would not benefit form an operation. Moreover neoadjuvant therapy could downstage the tumor avoiding major vessels resections, decrease positive margins resections and decrease post-operative pancreatic fistulas [6]. Unfortunately imaging is no longer reliable in predicting resectability after neoadjuvant treatment [7]. The total mean direct cost of a patient with a resectable disease is $134,700, while for metastatic or unresectable patients this cost is $49,000-65,300 [8]. A properly staged patient provides a better resource allocation.

Liquid biopsy provides an non-invasive signature of the tumor, it is based circulating genetic material coming from cellular turnover and thus especially from the tumor [9]. Analyzing mutations on cell-free nucleic acids gives translational information on tumor biology and therefore on its clinico-pathological features and likely on its progression. Pancreatic cancer progression has long been studied. What is clear is that activating K-RAS mutations are an early event in most lesions, followed by inactivating mutations in CDKN2A, TP53 and SMAD4 [10]. Those 4 mountain genes are predictive of progression pattern in an autoptic study: patients with 2 or less genes mutations were more likely to develop oligometastatic failure and to harbor earlier disease stage at diagnosis compared to those with 3 or more mutated genes [11]. K-RAS mutations have been associated to a worse overall survival in particular when found in peripheral blood by liquid biopsy [12]. CDKN2A mutations have been associated to lymphatic invasion and widespread metastatic recurrence [13]. TP53 mutations have been associated to poor differentiation and locoregional recurrence [13]. Finally SMAD4 mutations have been associated to portal vein invasion, perineural invasion and lymph vessel invasion [14]. Besides evidences on those mountain genes there is a growing body of evidence of several stage and prognosis predictors: MET protein over expression significantly correlated with increased TNM stage and worsened survival [15]; EDIL3 expression was significantly up-regulated in PDAC in both cell lines and clinical specimens and correlated with patients' TNM stage, T classification and overall survival times [16]; BRCA1/BRCA2 mutation predict significantly shorter disease-free and overall survival [17]; High RAB27A expression was significantly associated with vascular invasion and tumor stage [18].

Those data have been validated on samples of the tumor and thus usually on specimens since only 53,3% of ultrasound guided biopsies provides enough material for histopathology and/or immunohistochemistry [19]. Recent evidences show that pancreatic cancer is one of the 4 cancers, along with colorectal, gastroesophageal and breast cancer, in which detectable ctDNA levels are present either in localized either in metastatic stages [20]. As seen in previous studies, the concordance between plasma and primary tumor mutations is as high as 100% in pancreatic cancer [9, 21].

The study of those mutations on liquid biopsy would provide non-invasive informations on preoperative staging and pattern progression and therefore a more accurate therapeutic planning.

AIM OF THE PROJECT This study is a pilot study. Genomic data will be described along with the clinical features of the disease for each patient.