Pancreatology 2011;11(suppl2):1419

DOI: 10.1159/000323479

Published online: April 5, 2011

Biomarkers of Pancreatic Cancer

ShinHamada TooruShimosegawa
Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan

Key Words
CA19-9 CEA DUPAN-2 S100P hENT1 MicroRNA

Abstract
Pancreatic cancer has a high mortality rate since early diagnosis is difficult and radical operation is challenging. Classical tumor markers are reliable parameters to determine disease progression during chemotherapy or recurrence after
surgery, but they are not adequate to identify suspected disease or for screening. Endoscopic brushing cytology or biopsy from the stenotic duct is widely performed for the histological evidence of pancreatic cancer, but still suffers from
low sensitivity. Recently, several molecules were found to be
specifically expressed in pancreatic cancer, and these novel
molecular markers are reported to improve the sensitivity of
cytology or biopsy. In some cases, novel markers are tested
for the diagnosis of cystic neoplasms. In addition, advances
in endoscopic ultrasonography-guided fine needle aspiration biopsy enabled sampling of the cancer tissue before surgery or treatment, which delineates the individualized therapeutic strategy against pancreatic cancer, via the assessment of prognosis- or therapy resistance-related factors.
Furthermore, novel transcriptomic or metabolomic biomarkers in the clinical samples collected by non-invasive
methods, e.g. blood or saliva samples, are now applied for
the diagnosis of pancreatic cancer. These methods will be
beneficial for the screening and early detection of pancreatic cancer.
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2011 S. Karger AG, Basel and IAP

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Introduction

Pancreas cancer is one of the main causes of cancerrelated death, since most of the patients present at advanced clinical stages, and even in operable cases the
prognosis is unfavorable [1]. Lack of an adequate screening method for pancreatic cancer hampers early detection of curable disease. Specific markers in the blood
samples of pancreatic cancer patients have been identified by antibody-based detection of cell surface antigen
released from cancer cells, such as CA19-9 [2]. Those classical tumor markers have contributed to the management
of pancreatic cancer treatment as clinical indicators of
disease progression during chemotherapy or recurrence
after surgery. Despite their clinical usefulness, classical
tumor markers are not effective for the early detection of
small pancreatic cancers, since elevated classical tumor
marker levels indicate the presence of a significant number of cancer cells.
Previously, suspicious pancreatic cancer cases were
mainly diagnosed based on imaging studies due to difficulties in obtaining cancer tissue. Recent development
of the endoscopic pancreatic juice cytology, endoscopic
brushing cytology or biopsy from the stenotic duct provided histological evidence for pancreatic cancer, but sensitivity was not satisfactory [3]. Based on these circumstances, novel molecular markers which can improve the
sensitivity of cytology and biopsy were extensively studied. Pathological examination identified several moleTooru Shimosegawa
1-1, Seiryo-machi
Aobaku, Sendai City, Miyagi 980-8574 (Japan)
Tel. +81 22 717 7171, Fax +81 22 717 7177
E-Mail tshimosegawa@int3.med.tohoku.ac.jp

Disease monitoring

Classical tumor markers:

CA19-9, CEA and DUPAN-2

Pancreatic cancer cell

Cancer-specific molecules:
e.g. S100P, hTERT

Diagnostic application

Novel markers in biofluids:

microRNA, metabolites

Prognostic factors:
hENT1, ABC transporters

Screening method

Fig. 1. Biomarkers of pancreatic cancer

Individualized therapy

and clinical applications.

cules specifically expressed in pancreatic cancer, such as

the calcium-binding protein S100P [4], and some of them
indeed improved the diagnostic sensitivity combined
with cytology or biopsy. Also, in cystic lesions of the pancreas, novel markers are assessed to determine the nature
of pancreatic cysts.
The advent of endoscopic ultrasonography-guided
fine needle aspiration biopsy (EUS-FNA) dramatically
changed the diagnosis of pancreatic cancer, with EUSFNA providing the ideal sensitivity and feasibility for
cancer diagnosis [5]. This method enabled not only accurate diagnosis, but also the collection of cancer tissue
before surgery or chemotherapy even in inoperable cases.
Recently, expression levels of multiple molecules were
found to correlate with a poor prognosis or resistance to
chemotherapy, such as ATP-binding cassette (ABC)
transporters [6]. Recent studies have tried to examine the
expression status of multiple molecules within the FNA
specimen [7], and further evaluation will lead to the establishment of individualized therapeutic strategies
based on the prediction of prognosis or response to chemotherapy.
For early detection and effective screening of pancreatic cancer, non-invasive methods to obtain clinical samples have gained renewed interest in order to target novel
biomarkers, such as transcriptomic or metabolomic biomarkers [8, 9]. Their clinical accuracy and effectiveness
should be examined carefully, but these non-invasive approaches seem promising to establish a screening system

identifying patients who are possibly at high risk for pancreatic cancer or have asymptomatic curable disease.
Biomarkers of pancreatic cancer and their application
in the clinical setting are summarized in figure 1. In the
following section, potential utility of biomarkers in pancreatic cancer treatment and in future applications as
novel diagnostic or therapeutic tools are discussed.

Current Knowledge and Future

Perspectives of Biomarkers

Pancreatology 2011;11(suppl2):1419

Utility of Classical Tumor Markers in the Clinical

Setting

In pancreatic cancer treatment, several tumor markers

are employed, such as CA19-9 or carcinoembryonic antigen (CEA). CA19-9 is a carbohydrate antigen which belongs to sialyl-Lewis (a) [10]. CEA is a glycophosphatidylinositol-anchored protein [11], which is widely used as a
tumor marker of gastrointestinal tract cancers. These
markers indicate false-positive results in a small subset of
benign diseases by chance, but continuous elevation in
these markers strongly suggests progressive disease during chemotherapy or recurrence after operation. Of note,
patients with a Lewis-negative (a/b) status (approximately 10% of the population) are not able to synthesize
CA19-9 from the precursor carbohydrate antigen DUPAN-2. In such cases, DUPAN-2 is a better parameter in
monitoring than CA19-9 [12].
Prediction of the patients prognosis using these tumor
markers has been studied, and several reports have sug15

gested a positive correlation between these tumor markers and clinical outcome. In patients with locally advanced or metastatic unresectable pancreatic cancer, elevated serum CA19-9 and CEA levels correlate with poor
prognosis by multivariate analysis [13]. Another study
has indicated the usefulness of tumor markers to determine the efficacy of a chemotherapeutic regimen, which
may affect the choice of chemotherapeutic agents [14]. In
this study, serum CA19-9 levels were routinely measured
and the results were used as one of the parameters assessing the efficacy of chemotherapy.
Tumor markers not only assist in the treatment of advanced pancreatic cancer, they also play a beneficial role
during the follow-up of intraductal papillary mucinous
neoplasms (IPMN) of the pancreas. Usually, the branchtype IPMN without invasive growth has a favorable prognosis, but the detection of invasive cancer cells within
cystic lesions is difficult. Once the IPMN-derived invasive cancer has developed, the prognosis turns unfavorable. Furthermore, IPMN patients are predisposed to the
occurrence of concomitant ductal adenocarcinoma [15].
To identify the clinical features of invasive carcinoma
arising from the branch duct in IPMN patients, we assessed 159 patients with branch-duct IPMN [16]. In summary, 12 patients had invasive IPMN and 7 patients had
concomitant ductal adenocarcinoma. The analyses of
these patients clinical characteristics elucidated the contribution of tumor markers for the prediction of invasive
IPMN or concomitant ductal adenocarcinoma. Interestingly, serum CEA levels were independently associated
with invasive IPMN. Similarly, elevated CA19-9 levels
were associated with concomitant ductal adenocarcinoma.
These results indicate the indispensable role of the
classical tumor markers as useful clinical parameters to
determine the efficacy of therapeutic methods and in decision making during long-term follow-up of high-risk
patients, such as patients with branch-type IPMN.

Novel Biomarkers of Pancreatic Cancer and Cystic

Neoplasms

Endoscopic retrograde cholangiopancreatography

(ERCP) has been improved regarding mechanical and
technical aspects. For the diagnosis of pancreatic cancer,
endoscopic sampling of pancreatic juice, brushing cytology from the stenotic pancreatic or bile duct and direct
forceps biopsy is widely performed during ERCP. Although these interventions are sometimes complicated
16

Pancreatology 2011;11(suppl2):1419

by post-ERCP pancreatitis, these diagnostic methods

provided histological evidence of pancreatic cancer.
However, these strategies suffered from a low sensitivity,
and novel markers which complement these strategies
were explored.
Recently, the calcium-binding protein S100P was reported to be expressed exclusively in pancreatic cancer
cells [4]. The expression of S100P was also confirmed in
PanIN-2 or -3 lesions, indicating the possibility of earlier
detection in clinical applications. Expression levels of
S100P mRNA were higher in pancreatic juice obtained
from pancreatic cancer and IPMN patients than from
pancreatitis cases by quantitative real-time reverse transcription PCR [17]. In this report, microdissected epithelium from pancreatic cancer, IPMN and PanIN lesions
had higher expression levels of S100P mRNA than normal pancreatic duct epithelium, which might help to differentiate benign pancreatic duct stenosis from the malignant one. The clinical efficacy of S100P mRNA measurement in brushing cytology samples from patients
with pancreatic duct stenosis is currently assessed in our
department.
In addition, several approaches to improve the sensitivity of brushing cytology have also been made using
different markers. Immunocytochemical assessment of
the p53 protein in brushing cytology samples displayed
higher sensitivity than conventional Papanicolau staining [18]. Another group reported elevated expression of
hTERT (human telomerase reverse transcriptase) in
pancreatic juice samples from patients with ductal adenocarcinoma or malignant IPMN, even in cytologynegative cases [19]. These molecular markers themselves
have the possibility of false-positive results, and a combined diagnostic strategy including conventional cytology or biopsy will be beneficial for an accurate diagnosis.
However, cystic lesions of the pancreas are now frequently found at an asymptomatic state due to the improvement in imaging techniques. Accurate diagnosis of
these lesions is not easy due to the lack of adequate markers of lesions necessitating treatment. A recent report
suggested the usefulness of the assessment of glycan variants in the differentiation of cystic neoplasms (mucinous
cystic neoplasms and IPMN) from benign cystic lesions
(serous cystadenomas and pseudocysts) [20]. Although
the risk of tumor dissemination following cyst fluid sampling from cystic lesions of the pancreas remains to be
determined, improvements in the sampling method will
help to improve the diagnosis of cystic lesions in the pancreas.
Hamada/Shimosegawa

Biomarkers in EUS-FNA Specimens

In this decade, the arrival of EUS-FNA changed the

diagnostic strategy of pancreatic cancer. The advantage
of EUS-FNA is the sampling of sufficient cancer tissue
even in inoperable cases. Until now, numerous reports
have suggested the predictive value of multiple molecules
regarding prognosis or sensitivity to chemotherapeutic
agents, but most studies had a retrospective design. Analysis of these molecules in EUS-FNA samples will enable
to prospectively study pancreatic cancer with respect to
prognosis and therapeutic efficacy. In 53 EUS-FNA specimens, Salek et al. [7] assessed genetic alterations of wellknown genes which are frequently mutated in pancreatic
cancer, such as K-ras, p53, p16 and Smad4. Unfortunately,
this study failed to find any positive predictive factor for
pancreatic cancer patients, but confirmed the possibility
of genetic studies using EUS-FNA specimens.
Immunohistochemical assessment of pancreatic cancer tissue provided several candidate molecules for the
prediction of prognosis in pancreatic cancer patients. For
example, higher expression of CDCP1 (CUB domaincontaining protein 1), which is reported to facilitate anchorage-independent growth and migration of cancer
cells, is correlated with the overall survival of pancreatic
cancer patients [21]. Similarly, L1-CAM (L1-cell adhesion
molecule) expression is reported to correlate with perineural invasion of pancreatic cancer cells and poor survival [22]. On the other hand, higher expression of B7-H3,
a co-stimulatory molecule for immune responses, correlates with a better postoperative prognosis [23]. By assessing the expression status of these molecules in EUS-FNA
specimens in a prospective manner, accurate classification of pancreatic cancer patients will be achieved.
The fact that most of the pancreatic cancer patients
have inoperable disease due to distant metastases or locally advanced tumor emphasizes the importance of disease-controlling therapy, such as systemic chemotherapy
or chemoradiation. In patients with unresectable pancreatic cancer, gemcitabine is widely used as a first-line chemotherapeutic agent. Factors determining gemcitabine
sensitivity have been studied extensively, and a correlation between hENT1 (human equilibrative nucleoside
transporter 1) and gemcitabine sensitivity was established [24]. Pancreatic cancer cells highly express hENT1,
which contributes to gemcitabine uptake in cancer cells.
Another group reported that in addition to hENT1 higher expression of dCK (deoxycytidine kinase), which metabolizes gemcitabine to its active form, correlates with
gemcitabine efficacy [25]. Determination of these markCurrent Knowledge and Future
Perspectives of Biomarkers

ers in EUS-FNA specimens will help to predict response

to chemotherapy, which may affect the choice of regimens.

Novel Biomarkers for the Non-Invasive Diagnosis of

Pancreatic Cancer

The above-mentioned diagnostic methods include invasive procedures, e.g. tissue sampling by endoscopy,
which may cause complications. In addition, the demand
for less invasive diagnostic methods is increasing in these
decades. These situations encouraged the development of
non-invasive biomarkers in pancreatic cancer. Saliva, for
example, can be easily obtained in most patients, without
using a special technique. Recent reports suggested the
possible utility of saliva for the differentiation between
pancreatic cancer patients and patients with normal or
chronic pancreatitis. Zhang et al. [8] could differentiate
pancreatic cancer patients from those without cancer using transcriptome profiles in saliva supernatants with a
sensitivity of 90.0% and a specificity of 95.0%. In this report, 4 mRNA biomarkers were combined to discriminate pancreatic cancer cases; these biomarkers were selected from 12 mRNA biomarkers discovered in saliva
samples from pancreatic cancer patients. A similar approach has been made by another group, which assessed
metabolites in saliva by comprehensive analysis. Using
mass spectrometry, pancreatic cancer cases were successfully detected based on the pancreatic cancer-specific signature [9]. These methods will affect pancreatic cancer
diagnosis in the future.
In addition, small non-coding RNA is now attracting
increased attention as a regulator of various biological
processes, including cancer progression. Among them,
microRNAs play a central role in the regulation of cellular functions, such as migration, invasion and stem cell
functions. Altered microRNA expression has been reported for numerous cancers, including pancreatic cancer [26]. Interestingly, recent research has suggested that
these microRNAs can be detected in peripheral blood
samples, and therefore assist in cancer detection [27]. The
expression levels of microRNAs are affected by the cellular function of cancer cells, and several microRNAs
are highly expressed in pancreatic cancer cells. Among
those microRNAs, miR-200a and miR-200b are highly
expressed in pancreatic cancer cell lines, and their expression levels were significantly elevated in the sera from
pancreatic cancer patients [28]. This suggests that microRNA itself could be a biomarker for pancreatic cancer.
Pancreatology 2011;11(suppl2):1419

17

Although these new diagnostic methods should be

prospectively examined regarding reliability and concordance with existing modalities, treatment outcome and
screening may be improved using biomarkers obtained
using less invasive diagnostic procedures.

creatic cancer is still challenging. Future work should be

addressed to the development of diagnostic techniques
with a higher sensitivity to detect even asymptomatic
cases.

Disclosure Statement
Closing Remarks

There are no conflicts of interest.

Asymptomatic pancreatic cancer is hard to detect, but

possibly curable. Recent research identified novel biomarkers of pancreatic cancer, but screening for early pan-

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