Non-functional pancreatic neuroendocrine tumors (NF-PanNETs) show highly variable clinical behavior. Some tumors remain localized and slow-growing, whereas others progress rapidly or metastasize. Although nearly 90% of NF-PanNETs are diagnosed as WHO grade 1 or 2, patients within the same grade can have markedly different outcomes, highlighting the need for improved prognostic stratification.
In a study published in Science Bulletin , researchers led by Yupei Zhao’s team at Peking Union Medical College Hospital, in collaboration with Zhixiang Lin at The Chinese University of Hong Kong and Jianhui Wu at Peking University Cancer Hospital, investigated the cellular heterogeneity of NF-PanNETs. Using scRNA-seq from 10 patients, scATAC-seq from 4 patients, and bulk RNA-seq from 77 patients, the researchers identified an AGR2 high endocrine subcluster enriched in high-grade tumors. AGR2 high cells exhibited malignant features, including higher CNV scores, increased proliferative activity, and enrichment of the metastasis-like primary signature.
The clinical relevance of AGR2 was further evaluated in a two-center cohort of 167 resected NF-PanNETs. AGR2-positive tumors were associated with larger tumor size, higher WHO grade, and more frequent synchronous metastasis. Among patients without synchronous distant metastasis, AGR2-positive patients also had significantly shorter progression-free survival. These findings support simple AGR2 immunohistochemistry as a clinically informative prognostic marker for NF-PanNETs, including within the clinically heterogeneous grade 2 subgroup.
The researchers also investigated the mechanism underlying the AGR2 high cell state. Single-cell chromatin analysis identified FOXM1 as a key transcriptional regulator. Further experiments showed that FOXM1 directly regulates cell-division genes including CENPA, CENPN, PLK1, CDCA2, and TOP2A, thereby promoting the proliferative transcriptional program of AGR2 high cells.
Finally, FOXM1 disruption suppressed NF-PanNET tumor growth, while the FOXM1 inhibitors FDI-6 and thiostrepton showed therapeutic effects in tumor cells, patient-derived organoids, and xenograft models. Together, the study identifies AGR2 as a potential tool for prognostic stratification and FOXM1 as a potential therapeutic vulnerability in NF-PanNETs.
About the study
This multidisciplinary study was led by Peking Union Medical College Hospital in collaboration with The Chinese University of Hong Kong, Peking University Cancer Hospital and other participating institutions. Junya Peng, Rui Jiang, Jiajuan Tu, Wanli Liu and Lu Ping are co-first authors. Yupei Zhao, Wenming Wu, Zhixiang Lin, Jianhui Wu and Junya Peng are co-corresponding authors. Funding was provided by the National High Level Hospital Clinical Research Funding, the National Natural Science Foundation of China, the CAMS Innovation Fund for Medical Sciences, the Peking Union Medical College Hospital Outstanding Young Talent Development Program, the Beijing High-Level Innovation and Entrepreneurship Talent Support Program Young Backbone Talent Projects, the 1+1+1 CUHK-CUHK(SZ)-GDSTC Joint Collaboration Fund, the Research Grants Council, University Grants Committee, and a direct grant from The Chinese University of Hong Kong.
Science Bulletin
Experimental study