Neural Plasticity in Pancreatic Cancer and Pancreatitis Eduardo Henrique Pirolla, MD, PhD, FIAMBS Collaborative Professor/Research/Spaulding/MGH Laboratory/HMS Collaborative Mentor and Supervisor of Fellows of Spaulding/ MGH Laboratory/HMS Collaborator- Optional Lectures - PPCR – Harvard Public Health School Clinical Research PPCR Alumni Graduate 2010 - Harvard Medical School Doctor by the University of Sao Paulo Medical School MBA in Economy’s Health of School of Public Health of USP Harvard Medical School Postgraduate Member Staff Chief of Team Surgeon at Sirio Libanes Hospital and Albert Einstein Hospital F. Fregni, MD, PhD, MPH Associate Professor and Director of Lab Spaulding/ and Massachusetts General Hospital – Harvard Medical School Director of Principle and Practice of Clinical Research, Harvard School of Public Health

Neural Plasticity in Pancreatic Cancer and Pancreatitis Definition “Plastic” - ability to react and reshape system as response physical stimullation Cronic diseases → adaptive - reactic CNS / PNS Morphological / Functional alteration of nerves “Neural Plasticity”

Neural Plasticity in Pancreatic Cancer and Pancreatitis Intra-pancreatics nerves Increase size Increase density Alterations Pancreatitis Pancreatic cancer Switched autonomic and sensory fibers Infiltrated perineural (neuritis) Invaded cancer cells Neuropathic pain

Neural Plasticity in Pancreatic Cancer and Pancreatitis Synergizes Enhanced excitability sensory neurons Pancreatic neural plasticity Schwann cell toward Cancer CNS alterations Maintain Bidirectional interation Nerves  Non-neural pancreatic cells Damage Neurophatic pain Neutrons - mediators ↑ Cancer growth ↑ Inflamation

Neural Plasticity in Pancreatic Cancer and Pancreatitis “Extreme Examples” Interactions between nervous system and gastrointestinal tract → e.g. → Acute pancreatitis Pancreas Central Nerve System E.H. Pirolla et al, Spinal Cord (2014) 1-4. doi: 10.1038/sc 2014.109 I.E. Demir et al, Nature (2015) 649-59. doi: 10.1038/nrgastro.2015.166

Neural Plasticity in Pancreatic Cancer and Pancreatitis Anatomic / Physiologic studies Digestive hormone Pancreatic inervation Exocrine section Enteropancreatic reflex Neuroplastic in all Pancreatic disorders E.H. Pirolla et al, Spinal Cord (2014) 1-4. doi: 10.1038/sc 2014.109 I.E. Demir et al, Nature (2015) 649-59. doi: 10.1038/nrgastro.2015.166

Neural Plasticity in Pancreatic Cancer and Pancreatitis Distribution of the patient’s ASIA Classification according to serum pancreatic enzyme level and acute pancreatitis Pirolla EH et al. Nature G. Spinal Cord 2014

Neural Plasticity in Pancreatic Cancer and Pancreatitis Distribution of the patient’s level of spinal cord injury according to serum pancreatic enzyme level and acute pancreatitis Pirolla EH et al. Nature G. Spinal Cord 2014

Neural Plasticity in Pancreatic Cancer and Pancreatitis Distribution of the presence of adynamic ileum according to serum pancreatic enzyme level and acute pancreatitis Pirolla EH et al. Nature G. Spinal Cord 2014

Neural Plasticity in Pancreatic Cancer and Pancreatitis Distribution of the associated fracture according to serum pancreatic enzyme level and acute pancreatitis Pirolla EH et al. Nature G. Spinal Cord 2014

Neural Plasticity in Pancreatic Cancer and Pancreatitis Anatomy of pancreatic innervation

Neural Plasticity in Pancreatic Cancer and Pancreatitis Sympathetic and parasympathetic nerves Spinal Cord (Th6-Th9) Right vagal trunks (+) Right and left splancnic nerves (–)

Neural Plasticity in Pancreatic Cancer and Pancreatitis The cell bodies of the sensory fibres lie in the dorsal root ganglia

Neural Plasticity in Pancreatic Cancer and Pancreatitis Comparison of human and mouse pancreatic neuroplasticity in chronic pancreatitis and pancreatic cancer

Neural Plasticity in Pancreatic Cancer and Pancreatitis Neurophatic-neuroplastic alterations in human and experimental chronic pancreatitis

Neural Plasticity in Pancreatic Cancer and Pancreatitis Interactions between neurons, glial cells and cancer cells

Neural Plasticity in Pancreatic Cancer and Pancreatitis Characteristics features “Normal” human Chronic P/P Cancer Neural density Normal Increased Neural size Hypertrophy Neural distribution Small nerve trunks (intralolular stroma septae) More and large-size nerves (> than pancreatic tissue) Pancreatic Neuroplasticity

Neural Plasticity in Pancreatic Cancer and Pancreatitis Neurothrophic Attributis of Pancreatic Cancer Paracrine mediators Pancreatic cancer NGF Artemin / Neurlurin Growth-associate protein - 43 Pancreatic Neuropathy (Normal/cancer tissue) Pancreatic Pain

Neural Plasticity in Pancreatic Cancer and Pancreatitis “Scoring System” Immune Inflammatory Cells “ATTACK” Severity I (perineuritis): Immune cells around perineurium, not between nerve fiber bundles. Severity II (endoneuritis): Inflammatory cells between nerves fibers and trunk. Immune cells Degree of neural density Degree of pain CD8+ cytotoxis Macrophages T cells Mast cells > MT type (several GI disorders) Neuroimmune interaction Regulate IL-8 intracellular expression Neurogenic inflammation (substance P)

Neural Plasticity in Pancreatic Cancer and Pancreatitis Key Mechanism of Pain Histamine 5-hydroxytryptamine Cytokines Prostaglandins ↑ Mast cells MT type Mediators (hypersensitivity) Neuropathic pain G.I. disorders e.g. – ulcerative colites, IBS Pancreatic Cancer include – Neural invasion strong affinity P.C. cells and neurons

Neural Plasticity in Pancreatic Cancer and Pancreatitis Pancreatic Cancer and Neural Invasion Kinesin-Like protein KIF14 Rho GDP – dissociation inhibitor 2 Neural invasion → affect CNS spinal astroglial activity

Neural Plasticity in Pancreatic Cancer and Pancreatitis Nerves as Modulators of Disease Progression Research rate models of prostate cancer Adrenergic fiber depletion with 6-hydroxydopamine Surgical denervation of prostate via hypogastric nerves Decrease tumor and distant metastases

Neural Plasticity in Pancreatic Cancer and Pancreatitis Anatomy and Evolution Chronic Pancreatitis to Cancer Pirolla EH et al. Nature G. Spinal Cord 2014

Neural Plasticity in Pancreatic Cancer and Pancreatitis Conclusions Neural plasticity is an inherent feature of chronic pancreatitis and pancreatic cancer, and involves neuronal activation at the peripheral, spinal and supraspinal level. Neural plasticity, pancreatic neuritis, neural invasion and altered distribution of sympathetic and sensory nerve fibres constitute the pancreatic neuropathy in these diseases and correlate with the severity of neuropatic pain sensation Pain and neural invasion are prognostic in pancreatic cancer and so understanding the underlying mechanismsholds major translational relevance Patients with chronic pancreatitis exhibit central hyperalgesia and alterations in brain resting activity and brain resting activity and brain microstructure Current animal models of chronic pancreatitis and genetically engineered mouse models of pancreatic cancer largely fail to recapitulate the intrapancreatic neuropathy and plasticity of nerve trunks in the pancreas Schwann cells of peripheral nerves are activated in the preneoplastic stage of cancer, possess strong affinity to cancer cells and initiate nerve-cancer cell interactions Neural modulation for treatment of nerves (CNS/PNS/Splancnic nerves system) Nature, November 2015 Pirolla EH et al. 2016

Neural Plasticity in Pancreatic Cancer and Pancreatitis