Periampullary carcinomas (PACs) encompass a heterogeneous group of neoplasms (L. 2001) arising from four distinct anatomic sites proximal to the major duodenal papilla, namely - ampullary adenocarcinoma (AA), distal cholangiocarcinoma (DCC), duodenal adenocarcinoma (DA), and pancreatic head adenocarcinoma (PDAC) (Sarmiento, Nagomey et al. 2001, Albores-Saavedra, Schwartz et al. 2009, Kamarajah 2018, Hester, Dogeas et al. 2019). PACs are a rare malignancy whose incidence rate is difficult to establish as most reported studies only reflect the prevalence of surgically resected cancers (Yeo, Sohn et al. 1998, Riall, Cameron et al. 2006, He, Ahuja et al. 2014, Chandrasegaram, Chiam et al. 2015). However, on average, taken together, they represent 5% of all gastrointestinal malignancies (Sarmiento, Nagomey et al. 2001, Berberat, Künzli et al. 2009, Kamarajah 2018, Song, Kim et al. 2020). Due to their anatomical proximity, PACs share clinical characteristics and interventions, the most effective of which, regardless of the site of origin, is surgical resection by ‘pancreaticoduodenectomy’ (PD) (Ohtsuka and Miyazaki 2018). However, even after surgical resection, the long-term survival (≥ 5 years) rate in patients is unsatisfactory (~20%) (El Nakeeb, El Sorogy et al. 2018) and varies greatly among the subtypes of PACs (Bramhall, Allum et al. 1995, Neoptolemos, Russell et al. 1997, Poultsides, Huang et al. 2012).
For better clinical outcomes and therapeutic management, it is important to distinguish the site of origin of cancer and thus the tumor identity before deciding on the required intervention. However, the precise site of origin of PACs is usually challenging to determine before the surgical intervention. Thus, the correct preliminary diagnosis is often difficult, as in the case of PAC patients with locally advanced or metastatic disease that impedes the curative surgical resection. For this reason, during the past years, many studies (Ching and Rhodes 1989, Steinberg 1990, Lundin, Roberts et al. 1994, Ritts, Nagorney et al. 1994, Satake and Takeuchi 1994, Kau, Shyr et al. 1999) have established distinct molecular markers of PACs, specifically carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9), but also CA 242 (Haglund, Lundin et al. 1994), CA 50, CA 12-5, tissue polypeptide antigen (TPA) (Benini, Cavallini et al. 1988) and various mRNAs and miRNAs (Sandhu, Bowitz Lothe et al. 2015). These markers exhibit some diagnostic and prognostic value and can partially explain differing tumor type behavior and patient survival (Forsmark, Lambiase et al. 1994, Okusaka, Okada et al. 1998, Distler, Pilarsky et al. 2013, Park, Shin et al. 2021). However, this is far from enough to fully understand this malignancy and necessitates a more detailed molecular characterization of the disease.
Eukaryotic organisms exhibit highly specialized DNA-protein structures at the end of linear chromosomes, called telomeres; that help maintains genomic stability (Hernandez-Sanchez, Xu et al. 2016). Owing to the end-replication problem, telomeres are progressively shortened during successive cell divisions that cause cellular senescence, ultimately leading to cell mortality. Since cancer is a disease of cellular immortality, it is not surprising that cancer cells need to overcome this senescence by countering telomere shortening (Shay 1995). Cancer cells achieve this with the help of an enzyme called telomerase, which adds telomere repeat sequence to the 3’ end of the telomere, giving them infinite replicative potential (Feng, Funk et al. 1995). The catalytic subunit of telomerase is telomerase reverse transcriptase (TERT) which has been implicated to have a role in human cancer (Kirkpatrick and Mokbel 2001). Approximately 90% of all human cancers exhibit transcriptional activation of TERT (Holt, Wright et al. 1997) (Shay and Bacchetti 1997). Hundreds of TERT polymorphisms have been found in human cancers, (Mocellin, Verdi et al. 2012) including hot-spot mutation of the gene promoter causing several sequence variations (Bell, Rube et al. 2016, Dratwa, Wysoczańska et al. 2020), which act as pivotal players in the activation of TERT transcription (Yuan, Larsson et al. 2019). In addition, epigenetic modification of the TERT promoter via methylation has been reported in about 50% of all human cancers (Lee, Leao et al. 2019, Dratwa, Wysoczańska et al. 2020). Despite the available detailed descriptions of the specific mechanism behind telomere maintenance of many cancers, it is still poorly understood in PAC. Thus, we reasoned that the information on the telomeric status and TERT gene features of PAC will help in a better understanding of its molecular landscapes. Following this rationale, we inspected and report the relative telomere length (RTL), as well as the most frequent genetic and epigenetic alterations in the TERT gene, using Sanger sequencing and 450K methylation array. In addition, we inspected TERT gene expression by immunohistochemistry in AA and DA. Lastly, we also explored whether these parameters were correlated with clinicopathological features and patient prognosis. This study constitutes a pilot study in the field of telomere biology in AA and DA and reveals new information about the telomere maintenance in these cancers.