胰腺癌的吉西他滨耐药机制
Mechanisms of Gemcitabine Resistance in Pancreatic Cancer
DOI: 10.12677/acm.2026.162492, PDF,    科研立项经费支持
作者: 章 靓, 亓同钢*:山东大学齐鲁第二医院基础医学研究所,山东 济南
关键词: 吉西他滨化疗耐药胰腺癌分子机制Gemcitabine Chemotherapy Resistance Pancreatic Cancer Molecular Mechanisms
摘要: 胰腺癌作为致死率极高的恶性肿瘤,严重威胁着人类的健康。吉西他滨作为胰腺癌治疗的基石,其临床应用中普遍存在的耐药性极大限制了治疗效果。本文阐述了胰腺癌的治疗现状和吉西他滨的临床应用,回顾了关于吉西他滨的作用机制、代谢转运、化疗耐药的最新知识,重点从分子机制、肿瘤微环境、表观遗传学、干细胞等多方面介绍吉西他滨的耐药机制。在讨论各方面的耐药机制的同时,发现相关可干预的靶点,简单介绍了有前景的相关耐药规避策略。同时,讨论了新型治疗措施纳米颗粒,为治疗吉西他滨耐药的胰腺恶性肿瘤提供新思路。
Abstract: Pancreatic cancer, as a malignant tumor with an extremely high mortality rate, poses a grave threat to human health. As a cornerstone of pancreatic cancer treatment, the widespread occurrence of resistance in the clinical application of gemcitabine significantly limits therapeutic efficacy. This paper outlines the current state of pancreatic cancer treatment and the clinical application of gemcitabine. It reviews the latest knowledge on gemcitabine’s mechanism of action, metabolic transport, and chemotherapy resistance, focusing on the mechanisms of gemcitabine resistance from multiple perspectives, including molecular mechanisms, tumor microenvironment, epigenetics, and stem cells. Whilst discussing these diverse resistance mechanisms, the paper identifies relevant interventionable targets and briefly outlines promising strategies for circumventing resistance. Furthermore, it explores novel therapeutic approaches involving nanoparticles, offering fresh perspectives for treating gemcitabine-resistant pancreatic malignancies.
文章引用:章靓, 亓同钢. 胰腺癌的吉西他滨耐药机制[J]. 临床医学进展, 2026, 16(2): 1112-1121. https://doi.org/10.12677/acm.2026.162492

参考文献

[1] Bilimoria, K.Y., Bentrem, D.J., Ko, C.Y., Ritchey, J., Stewart, A.K., Winchester, D.P., et al. (2007) Validation of the 6th Edition AJCC Pancreatic Cancer Staging System. Cancer, 110, 738-744. [Google Scholar] [CrossRef] [PubMed]
[2] Bray, F., Laversanne, M., Sung, H., Ferlay, J., Siegel, R.L., Soerjomataram, I., et al. (2024) Global Cancer Statistics 2022: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 74, 229-263. [Google Scholar] [CrossRef] [PubMed]
[3] Rahib, L., Smith, B.D., Aizenberg, R., Rosenzweig, A.B., Fleshman, J.M. and Matrisian, L.M. (2014) Projecting Cancer Incidence and Deaths to 2030: The Unexpected Burden of Thyroid, Liver, and Pancreas Cancers in the United States. Cancer Research, 74, 2913-2921. [Google Scholar] [CrossRef] [PubMed]
[4] Conroy, T., Desseigne, F., Ychou, M., Bouché, O., Guimbaud, R., Bécouarn, Y., et al. (2011) FOLFIRINOX versus Gemcitabine for Metastatic Pancreatic Cancer. New England Journal of Medicine, 364, 1817-1825. [Google Scholar] [CrossRef] [PubMed]
[5] Von Hoff, D.D., Ervin, T., Arena, F.P., Chiorean, E.G., Infante, J., Moore, M., et al. (2013) Increased Survival in Pancreatic Cancer with Nab-Paclitaxel plus Gemcitabine. New England Journal of Medicine, 369, 1691-1703. [Google Scholar] [CrossRef] [PubMed]
[6] Gandhi, V., Legha, J., Chen, F., et al. (1996) Excision of 2’,2’-Difluorodeoxycytidine (Gemcitabine) Monophosphate Residues from DNA. Cancer Research, 56, 4453-4459.
[7] Huang, W., Zeng, X., Shi, Y. and Liu, M. (2016) Functional Characterization of Human Equilibrative Nucleoside Transporter 1. Protein & Cell, 8, 284-295. [Google Scholar] [CrossRef] [PubMed]
[8] Morinaga, S., Nakamura, Y., Watanabe, T., Mikayama, H., Tamagawa, H., Yamamoto, N., et al. (2011) Immunohistochemical Analysis of Human Equilibrative Nucleoside Transporter-1 (hENT1) Predicts Survival in Resected Pancreatic Cancer Patients Treated with Adjuvant Gemcitabine Monotherapy. Annals of Surgical Oncology, 19, 558-564. [Google Scholar] [CrossRef] [PubMed]
[9] Poplin, E., Wasan, H., Rolfe, L., Raponi, M., Ikdahl, T., Bondarenko, I., et al. (2013) Randomized, Multicenter, Phase II Study of CO-101 versus Gemcitabine in Patients with Metastatic Pancreatic Ductal Adenocarcinoma: Including a Prospective Evaluation of the Role of Hent1 in Gemcitabine or CO-101 Sensitivity. Journal of Clinical Oncology, 31, 4453-4461. [Google Scholar] [CrossRef] [PubMed]
[10] Sinn, M., Riess, H., Sinn, B.V., Stieler, J.M., Pelzer, U., Striefler, J.K., et al. (2015) Human Equilibrative Nucleoside Transporter 1 Expression Analysed by the Clone SP120 Rabbit Antibody Is Not Predictive in Patients with Pancreatic Cancer Treated with Adjuvant Gemcitabine—Results from the CONKO-001 Trial. European Journal of Cancer, 51, 1546-1554. [Google Scholar] [CrossRef] [PubMed]
[11] Rauchwerger, D.R., Firby, P.S., Hedley, D.W., et al. (2000) Equilibrative-Sensitive Nucleoside Transporter and Its Role in Gemcitabine Sensitivity. Cancer Research, 60, 6075-6079.
[12] Tsujie, M., Nakamori, S., Nakahira, S., Takeda, S., Takahashi, Y., Hayashi, N., et al. (2006) Schedule-Dependent Therapeutic Effects of Gemcitabine Combined with Uracil-Tegafur in a Human Pancreatic Cancer Xenograft Model. Pancreas, 33, 142-147. [Google Scholar] [CrossRef] [PubMed]
[13] Skrypek, N., Duchêne, B., Hebbar, M., Leteurtre, E., van Seuningen, I. and Jonckheere, N. (2012) The MUC4 Mucin Mediates Gemcitabine Resistance of Human Pancreatic Cancer Cells via the Concentrative Nucleoside Transporter Family. Oncogene, 32, 1714-1723. [Google Scholar] [CrossRef] [PubMed]
[14] Skrypek, N., Vasseur, R., Vincent, A., Duchêne, B., Van Seuningen, I. and Jonckheere, N. (2015) The Oncogenic Receptor ErbB2 Modulates Gemcitabine and Irinotecan/SN-38 Chemoresistance of Human Pancreatic Cancer Cells via hCNT1 Transporter and Multidrug-Resistance Associated Protein MRP-2. Oncotarget, 6, 10853-10867. [Google Scholar] [CrossRef] [PubMed]
[15] Ohhashi, S., Ohuchida, K., Mizumoto, K., et al. (2008) Down-Regulation of Deoxycytidine Kinase Enhances Acquired Resistance to Gemcitabine in Pancreatic Cancer. Anticancer Research, 28, 2205-2212.
[16] Saiki, Y., Yoshino, Y., Fujimura, H., Manabe, T., Kudo, Y., Shimada, M., et al. (2012) DCK Is Frequently Inactivated in Acquired Gemcitabine-Resistant Human Cancer Cells. Biochemical and Biophysical Research Communications, 421, 98-104. [Google Scholar] [CrossRef] [PubMed]
[17] Maréchal, R., Mackey, J.R., Lai, R., Demetter, P., Peeters, M., Polus, M., et al. (2010) Deoxycitidine Kinase Is Associated with Prolonged Survival after Adjuvant Gemcitabine for Resected Pancreatic Adenocarcinoma. Cancer, 116, 5200-5206. [Google Scholar] [CrossRef] [PubMed]
[18] Nakahira, S., Nakamori, S., Tsujie, M., Takahashi, Y., Okami, J., Yoshioka, S., et al. (2006) Involvement of Ribonucleotide Reductase M1 Subunit Overexpression in Gemcitabine Resistance of Human Pancreatic Cancer. International Journal of Cancer, 120, 1355-1363. [Google Scholar] [CrossRef] [PubMed]
[19] Ying, H., Kimmelman, A.C., Bardeesy, N., et al. (2025) Genetics and Biology of Pancreatic Ductal Adenocarcinoma. Genes & Development, 39, 36-63.
[20] Lai, E., Ziranu, P., Spanu, D., Dubois, M., Pretta, A., Tolu, S., et al. (2021) BRCA-Mutant Pancreatic Ductal Adenocarcinoma. British Journal of Cancer, 125, 1321-1332. [Google Scholar] [CrossRef] [PubMed]
[21] Calheiros, J., Silva, R., Barbosa, F., Morais, J., Moura, S.R., Almeida, S., et al. (2025) A First-in-Class Inhibitor of Homologous Recombination DNA Repair Counteracts Tumour Growth, Metastasis and Therapeutic Resistance in Pancreatic Cancer. Journal of Experimental & Clinical Cancer Research, 44, Article No. 129. [Google Scholar] [CrossRef] [PubMed]
[22] Lu, H., Lu, S., Yang, D., Zhang, L., Ye, J., Li, M., et al. (2019) MiR-20a-5p Regulates Gemcitabine Chemosensitivity by Targeting RRM2 in Pancreatic Cancer Cells and Serves as a Predictor for Gemcitabine-Based Chemotherapy. Bioscience Reports, 39, BSR20181374. [Google Scholar] [CrossRef] [PubMed]
[23] Chen, L., Huan, X., Gao, X., Yu, W., Xiao, G., Li, T., et al. (2022) Biological Functions of the DNA Glycosylase NEIL3 and Its Role in Disease Progression Including Cancer. Cancers, 14, Article No. 5722. [Google Scholar] [CrossRef] [PubMed]
[24] Visnes, T., Grube, M., Hanna, B.M.F., Benitez-Buelga, C., Cázares-Körner, A. and Helleday, T. (2018) Targeting BER Enzymes in Cancer Therapy. DNA Repair, 71, 118-126. [Google Scholar] [CrossRef] [PubMed]
[25] Gohil, D., Sarker, A.H. and Roy, R. (2023) Base Excision Repair: Mechanisms and Impact in Biology, Disease, and Medicine. International Journal of Molecular Sciences, 24, Article No. 14186. [Google Scholar] [CrossRef] [PubMed]
[26] Bapat, A., Fishel, M.L. and Kelley, M.R. (2009) Going Ape as an Approach to Cancer Therapeutics. Antioxidants & Redox Signaling, 11, 651-667. [Google Scholar] [CrossRef] [PubMed]
[27] Fishel, M.L. and Kelley, M.R. (2007) The DNA Base Excision Repair Protein Ape1/Ref-1 as a Therapeutic and Chemopreventive Target. Molecular Aspects of Medicine, 28, 375-395. [Google Scholar] [CrossRef] [PubMed]
[28] Kelley, M.R., Logsdon, D. and Fishel, M.L. (2014) Targeting DNA Repair Pathways for Cancer Treatment: What’s New? Future Oncology, 10, 1215-1237. [Google Scholar] [CrossRef] [PubMed]
[29] Pramanik, S., Chen, Y., Song, H., Khutsishvili, I., Marky, L.A., Ray, S., et al. (2022) The Human Ap-Endonuclease 1 (APE1) Is a DNA G-Quadruplex Structure Binding Protein and Regulates KRAS Expression in Pancreatic Ductal Adenocarcinoma Cells. Nucleic Acids Research, 50, 3394-3412. [Google Scholar] [CrossRef] [PubMed]
[30] Thayer, S.P., di Magliano, M.P., Heiser, P.W., Nielsen, C.M., Roberts, D.J., Lauwers, G.Y., et al. (2003) Hedgehog Is an Early and Late Mediator of Pancreatic Cancer Tumorigenesis. Nature, 425, 851-856. [Google Scholar] [CrossRef] [PubMed]
[31] Bailey, J.M., Swanson, B.J., Hamada, T., Eggers, J.P., Singh, P.K., Caffery, T., et al. (2008) Sonic Hedgehog Promotes Desmoplasia in Pancreatic Cancer. Clinical Cancer Research, 14, 5995-6004. [Google Scholar] [CrossRef] [PubMed]
[32] Jones, S., Zhang, X., Parsons, D.W., Lin, J.C., Leary, R.J., Angenendt, P., et al. (2008) Core Signaling Pathways in Human Pancreatic Cancers Revealed by Global Genomic Analyses. Science, 321, 1801-1806. [Google Scholar] [CrossRef] [PubMed]
[33] Bahra, M., Kamphues, C., Boas-Knoop, S., Lippert, S., Esendik, U., Schüller, U., et al. (2012) Combination of Hedgehog Signaling Blockage and Chemotherapy Leads to Tumor Reduction in Pancreatic Adenocarcinomas. Pancreas, 41, 222-229. [Google Scholar] [CrossRef] [PubMed]
[34] Huang, F., Zhuan-Sun, Y., Zhuang, Y., Wei, S., Tang, J., Chen, W., et al. (2012) Inhibition of Hedgehog Signaling Depresses Self-Renewal of Pancreatic Cancer Stem Cells and Reverses Chemoresistance. International Journal of Oncology, 41, 1707-1714. [Google Scholar] [CrossRef] [PubMed]
[35] Xu, M., Li, L., Liu, Z., Jiao, Z., Xu, P., Kong, X., et al. (2013) ABCB2 (TAP1) as the Downstream Target of SHH Signaling Enhances Pancreatic Ductal Adenocarcinoma Drug Resistance. Cancer Letters, 333, 152-158. [Google Scholar] [CrossRef] [PubMed]
[36] Arlt, A., Gehrz, A., Müerköster, S., Vorndamm, J., Kruse, M., Fölsch, U.R., et al. (2003) Role of NF-κB and Akt/PI3K in the Resistance of Pancreatic Carcinoma Cell Lines against Gemcitabine-Induced Cell Death. Oncogene, 22, 3243-3251. [Google Scholar] [CrossRef] [PubMed]
[37] Pan, X., Arumugam, T., Yamamoto, T., Levin, P.A., Ramachandran, V., Ji, B., et al. (2008) Nuclear Factor-κB p65/relA Silencing Induces Apoptosis and Increases Gemcitabine Effectiveness in a Subset of Pancreatic Cancer Cells. Clinical Cancer Research, 14, 8143-8151. [Google Scholar] [CrossRef] [PubMed]
[38] Dilly, J., Hoffman, M.T., Abbassi, L., Li, Z., Paradiso, F., Parent, B.D., et al. (2024) Mechanisms of Resistance to Oncogenic KRAS Inhibition in Pancreatic Cancer. Cancer Discovery, 14, 2135-2161. [Google Scholar] [CrossRef] [PubMed]
[39] Réjiba, S., Wack, S., Aprahamian, M. and Hajri, A. (2007) K-Ras Oncogene Silencing Strategy Reduces Tumor Growth and Enhances Gemcitabine Chemotherapy Efficacy for Pancreatic Cancer Treatment. Cancer Science, 98, 1128-1136. [Google Scholar] [CrossRef] [PubMed]
[40] Mendt, M., Kamerkar, S., Sugimoto, H., McAndrews, K.M., Wu, C., Gagea, M., et al. (2018) Generation and Testing of Clinical-Grade Exosomes for Pancreatic Cancer. JCI Insight, 3, e99263. [Google Scholar] [CrossRef] [PubMed]
[41] Manning, B.D. and Cantley, L.C. (2007) AKT/PKB Signaling: Navigating Downstream. Cell, 129, 1261-1274. [Google Scholar] [CrossRef] [PubMed]
[42] Liu, T., Fang, Y., Zhang, H., Deng, M., Gao, B., Niu, N., et al. (2016) HEATR1 Negatively Regulates Akt to Help Sensitize Pancreatic Cancer Cells to Chemotherapy. Cancer Research, 76, 572-581. [Google Scholar] [CrossRef] [PubMed]
[43] Pal, S.K., Reckamp, K., Yu, H. and Figlin, R.A. (2010) Akt Inhibitors in Clinical Development for the Treatment of Cancer. Expert Opinion on Investigational Drugs, 19, 1355-1366. [Google Scholar] [CrossRef] [PubMed]
[44] Roberts, P.J. and Der, C.J. (2007) Targeting the Raf-MEK-ERK Mitogen-Activated Protein Kinase Cascade for the Treatment of Cancer. Oncogene, 26, 3291-3310. [Google Scholar] [CrossRef] [PubMed]
[45] Guo, Y.J., Pan, W.W., Liu, S.B., Shen, Z., Xu, Y. and Hu, L. (2020) ERK/MAPK Signalling Pathway and Tumorigenesis (Review). Experimental and Therapeutic Medicine, 19, 1997-2007. [Google Scholar] [CrossRef] [PubMed]
[46] García-Gómez, R., Bustelo, X.R. and Crespo, P. (2018) Protein-Protein Interactions: Emerging Oncotargets in the RAS-ERK Pathway. Trends in Cancer, 4, 616-633. [Google Scholar] [CrossRef] [PubMed]
[47] Khotskaya, Y.B., Holla, V.R., Farago, A.F., Mills Shaw, K.R., Meric-Bernstam, F. and Hong, D.S. (2017) Targeting TRK Family Proteins in Cancer. Pharmacology & Therapeutics, 173, 58-66. [Google Scholar] [CrossRef] [PubMed]
[48] McDaid, H.M., Lopez-Barcons, L., Grossman, A., Lia, M., Keller, S., Pérez-Soler, R., et al. (2005) Enhancement of the Therapeutic Efficacy of Taxol by the Mitogen-Activated Protein Kinase Kinase Inhibitor CI-1040 in Nude Mice Bearing Human Heterotransplants. Cancer Research, 65, 2854-2860. [Google Scholar] [CrossRef] [PubMed]
[49] Kim, M., Yan, Y., Kortum, R.L., Stoeger, S.M., Sgagias, M.K., Lee, K., et al. (2005) Expression of Kinase Suppressor of Ras1 Enhances Cisplatin-Induced Extracellular Signal-Regulated Kinase Activation and Cisplatin Sensitivity. Cancer Research, 65, 3986-3992. [Google Scholar] [CrossRef] [PubMed]
[50] Chang, G.C., Hsu, S.L., Tsai, J.R., Wu, W., Chen, C. and Sheu, G. (2004) Extracellular Signal-Regulated Kinase Activation and Bcl-2 Downregulation Mediate Apoptosis after Gemcitabine Treatment Partly via a p53-Independent Pathway. European Journal of Pharmacology, 502, 169-183. [Google Scholar] [CrossRef] [PubMed]
[51] Zhao, Y., Shen, S., Guo, J., Chen, H., Yu Greenblatt, D., Kleeff, J., et al. (2006) Mitogen-Activated Protein Kinases and Chemoresistance in Pancreatic Cancer Cells. Journal of Surgical Research, 136, 325-335. [Google Scholar] [CrossRef] [PubMed]
[52] Mahato, R., Kumar, V., Sethi, B., et al. (2023) Gemcitabine Elaidate and ONC201 Combination Therapy Inhibits Pancreatic Cancer in a KRAS Mutated Syngeneic Mouse Model. Research Square, rs.3.rs-3108907.
[53] Zhang, H., Wu, H., Guan, J., Wang, L., Ren, X., Shi, X., et al. (2014) Paracrine SDF-1α Signaling Mediates the Effects of PSCs on GEM Chemoresistance through an IL-6 Autocrine Loop in Pancreatic Cancer Cells. Oncotarget, 6, 3085-3097. [Google Scholar] [CrossRef] [PubMed]
[54] Liu, Y., Li, F., Gao, F., Xing, L., Qin, P., Liang, X., et al. (2016) Periostin Promotes the Chemotherapy Resistance to Gemcitabine in Pancreatic Cancer. Tumor Biology, 37, 15283-15291. [Google Scholar] [CrossRef] [PubMed]
[55] Cao, F., Li, J., Sun, H., Liu, S., Cui, Y. and Li, F. (2015) HES 1 Is Essential for Chemoresistance Induced by Stellate Cells and Is Associated with Poor Prognosis in Pancreatic Cancer. Oncology Reports, 33, 1883-1889. [Google Scholar] [CrossRef] [PubMed]
[56] Delitto, D., Black, B.S., Sorenson, H.L., Knowlton, A.E., Thomas, R.M., Sarosi, G.A., et al. (2015) The Inflammatory Milieu within the Pancreatic Cancer Microenvironment Correlates with Clinicopathologic Parameters, Chemoresistance and Survival. BMC Cancer, 15, Article No. 783. [Google Scholar] [CrossRef] [PubMed]
[57] Firuzi, O., Che, P.P., El Hassouni, B., Buijs, M., Coppola, S., Löhr, M., et al. (2019) Role of c-MET Inhibitors in Overcoming Drug Resistance in Spheroid Models of Primary Human Pancreatic Cancer and Stellate Cells. Cancers, 11, Article No. 638. [Google Scholar] [CrossRef] [PubMed]
[58] Mitchem, J.B., Brennan, D.J., Knolhoff, B.L., Belt, B.A., Zhu, Y., Sanford, D.E., et al. (2013) Targeting Tumor-Infiltrating Macrophages Decreases Tumor-Initiating Cells, Relieves Immunosuppression, and Improves Chemotherapeutic Responses. Cancer Research, 73, 1128-1141. [Google Scholar] [CrossRef] [PubMed]
[59] Song, X., Liu, X., Chi, W., Liu, Y., Wei, L., Wang, X., et al. (2006) Hypoxia-Induced Resistance to Cisplatin and Doxorubicin in Non-Small Cell Lung Cancer Is Inhibited by Silencing of HIF-1α Gene. Cancer Chemotherapy and Pharmacology, 58, 776-784. [Google Scholar] [CrossRef] [PubMed]
[60] Yokoi, K. and Fidler, I.J. (2004) Hypoxia Increases Resistance of Human Pancreatic Cancer Cells to Apoptosis Induced by Gemcitabine. Clinical Cancer Research, 10, 2299-2306. [Google Scholar] [CrossRef] [PubMed]
[61] Deng, D., Patel, R., Chiang, C. and Hou, P. (2022) Role of the Tumor Microenvironment in Regulating Pancreatic Cancer Therapy Resistance. Cells, 11, Article No. 2952. [Google Scholar] [CrossRef] [PubMed]
[62] Wang, R., Cheng, L., Xia, J., Wang, Z., Wu, Q. and Wang, Z. (2014) Gemcitabine Resistance Is Associated with Epithelial-Mesenchymal Transition and Induction of HIF-1α in Pancreatic Cancer Cells. Current Cancer Drug Targets, 14, 407-417. [Google Scholar] [CrossRef] [PubMed]
[63] Shukla, S.K., Purohit, V., Mehla, K., Gunda, V., Chaika, N.V., Vernucci, E., et al. (2017) MUC1 and HIF-1α Signaling Crosstalk Induces Anabolic Glucose Metabolism to Impart Gemcitabine Resistance to Pancreatic Cancer. Cancer Cell, 32, Article No. 392. [Google Scholar] [CrossRef] [PubMed]
[64] Ding, J., Xie, Y., Liu, Z., Zhang, Z., Ni, B., Yan, J., et al. (2025) Hypoxic and Acidic Tumor Microenvironment-Driven AVL9 Promotes Chemoresistance of Pancreatic Ductal Adenocarcinoma via the AVL9-IκBα-SKP1 Complex. Gastroenterology, 168, 539-555.e5. [Google Scholar] [CrossRef] [PubMed]
[65] Eltzschig, H.K., Abdulla, P., Hoffman, E., Hamilton, K.E., Daniels, D., Schönfeld, C., et al. (2005) HIF-1-Dependent Repression of Equilibrative Nucleoside Transporter (ENT) in Hypoxia. The Journal of Experimental Medicine, 202, 1493-1505. [Google Scholar] [CrossRef] [PubMed]
[66] Morote-Garcia, J.C., Rosenberger, P., Nivillac, N.M.I., Coe, I.R. and Eltzschig, H.K. (2009) Hypoxia-Inducible Factor-dependent Repression of Equilibrative Nucleoside Transporter 2 Attenuates Mucosal Inflammation during Intestinal Hypoxia. Gastroenterology, 136, 607-618. [Google Scholar] [CrossRef] [PubMed]
[67] Singh, M., Yelle, N., Venugopal, C. and Singh, S.K. (2018) EMT: Mechanisms and Therapeutic Implications. Pharmacology & Therapeutics, 182, 80-94. [Google Scholar] [CrossRef] [PubMed]
[68] Arumugam, T., Ramachandran, V., Fournier, K.F., Wang, H., Marquis, L., Abbruzzese, J.L., et al. (2009) Epithelial to Mesenchymal Transition Contributes to Drug Resistance in Pancreatic Cancer. Cancer Research, 69, 5820-5828. [Google Scholar] [CrossRef] [PubMed]
[69] Zheng, X., Carstens, J.L., Kim, J., Scheible, M., Kaye, J., Sugimoto, H., et al. (2015) Epithelial-to-Mesenchymal Transition Is Dispensable for Metastasis but Induces Chemoresistance in Pancreatic Cancer. Nature, 527, 525-530. [Google Scholar] [CrossRef] [PubMed]
[70] Rodriguez-Aznar, E., Wiesmüller, L., Sainz, B. and Hermann, P.C. (2019) EMT and Stemness—Key Players in Pancreatic Cancer Stem Cells. Cancers, 11, Article No. 1136. [Google Scholar] [CrossRef] [PubMed]
[71] Takemura, K., Ikeda, K., Miyake, H., Sogame, Y., Yasuda, H., Okada, N., et al. (2025) Epithelial-Mesenchymal Transition Suppression by ML210 Enhances Gemcitabine Anti-Tumor Effects on PDAC Cells. Biomolecules, 15, Article No. 70. [Google Scholar] [CrossRef] [PubMed]
[72] Amponsah, P.S., Fan, P., Bauer, N., Zhao, Z., Gladkich, J., Fellenberg, J., et al. (2017) microRNA-210 Overexpression Inhibits Tumor Growth and Potentially Reverses Gemcitabine Resistance in Pancreatic Cancer. Cancer Letters, 388, 107-117. [Google Scholar] [CrossRef] [PubMed]
[73] Iliopoulos, D. and Drakaki, A. (2013) MicroRNA-Gene Signaling Pathways in Pancreatic Cancer. Biomedical Journal, 36, 200-208. [Google Scholar] [CrossRef] [PubMed]
[74] Jiao, F., Hu, H., Han, T., Yuan, C., Wang, L., Jin, Z., et al. (2015) Long Noncoding RNA MALAT-1 Enhances Stem Cell-Like Phenotypes in Pancreatic Cancer Cells. International Journal of Molecular Sciences, 16, 6677-6693. [Google Scholar] [CrossRef] [PubMed]
[75] Kim, K., Jutooru, I., Chadalapaka, G., Johnson, G., Frank, J., Burghardt, R., et al. (2012) HOTAIR Is a Negative Prognostic Factor and Exhibits Pro-Oncogenic Activity in Pancreatic Cancer. Oncogene, 32, 1616-1625. [Google Scholar] [CrossRef] [PubMed]
[76] Wang, L., Dong, P., Wang, W., Huang, M. and Tian, B. (2017) Gemcitabine Treatment Causes Resistance and Malignancy of Pancreatic Cancer Stemlike Cells via Induction of lncRNA HOTAIR. Experimental and Therapeutic Medicine, 14, 4773-4780. [Google Scholar] [CrossRef] [PubMed]
[77] Ferreira, H.J. and Esteller, M. (2018) CpG Islands in Cancer: Heads, Tails, and Sides. In: Vavouri, T. and Peinado, M.A., Eds., CpG Islands, Springer, 49-80. [Google Scholar] [CrossRef] [PubMed]
[78] Luan, J., Gao, X., Hu, F., Zhang, Y. and Gou, X. (2019) SLFN11 Is a General Target for Enhancing the Sensitivity of Cancer to Chemotherapy (DNA-Damaging Agents). Journal of Drug Targeting, 28, 33-40. [Google Scholar] [CrossRef] [PubMed]
[79] Tang, S., Thomas, A., Murai, J., Trepel, J.B., Bates, S.E., Rajapakse, V.N., et al. (2018) Overcoming Resistance to DNA-Targeted Agents by Epigenetic Activation of Schlafen 11 (SLFN11) Expression with Class I Histone Deacetylase Inhibitors. Clinical Cancer Research, 24, 1944-1953. [Google Scholar] [CrossRef] [PubMed]
[80] Yang, L., Wang, R. and Zhang, L. (2025) HSPB1/KDM1 a Facilitates ANXA2 Expression via Hypomethylated DNA Promoter to Inhibit Ferroptosis and Enhance Gemcitabine Resistance in Pancreatic Cancer. Naunyn-Schmiedebergs Archives of Pharmacology, 398, 15665-15681. [Google Scholar] [CrossRef] [PubMed]
[81] Liu, Z.D., Shi, Y.H., Xu, Q.C., Zhao, G., Zhu, Y., Li, F., et al. (2024) CSNK2A1 Confers Gemcitabine Resistance to Pancreatic Ductal Adenocarcinoma via Inducing Autophagy. Cancer Letters, 585, Article ID: 216640. [Google Scholar] [CrossRef] [PubMed]
[82] Bjånes, T.K., Jordheim, L.P., Schjøtt, J., Kamceva, T., Cros-Perrial, E., Langer, A., et al. (2020) Intracellular Cytidine Deaminase Regulates Gemcitabine Metabolism in Pancreatic Cancer Cell Lines. Drug Metabolism and Disposition, 48, 153-158. [Google Scholar] [CrossRef] [PubMed]
[83] Yin, T., Wei, H., Gou, S., Shi, P., Yang, Z., Zhao, G., et al. (2011) Cancer Stem-Like Cells Enriched in Panc-1 Spheres Possess Increased Migration Ability and Resistance to Gemcitabine. International Journal of Molecular Sciences, 12, 1595-1604. [Google Scholar] [CrossRef] [PubMed]
[84] Makena, M.R., Ranjan, A., Thirumala, V. and Reddy, A.P. (2020) Cancer Stem Cells: Road to Therapeutic Resistance and Strategies to Overcome Resistance. Biochimica et Biophysica Acta (BBA)—Molecular Basis of Disease, 1866, Article ID: 165339. [Google Scholar] [CrossRef] [PubMed]
[85] Papa, A., Basu, S., Sengupta, P., Banerjee, D., Sengupta, S. and Harfouche, R. (2012) Mechanistic Studies of Gemcitabine-Loaded Nanoplatforms in Resistant Pancreatic Cancer Cells. BMC Cancer, 12, Article No. 419. [Google Scholar] [CrossRef] [PubMed]
[86] Birhanu, G., Javar, H.A., Seyedjafari, E. and Zandi-Karimi, A. (2017) Nanotechnology for Delivery of Gemcitabine to Treat Pancreatic Cancer. Biomedicine & Pharmacotherapy, 88, 635-643. [Google Scholar] [CrossRef] [PubMed]
[87] Yang, M., Li, J., Gu, P. and Fan, X. (2021) The Application of Nanoparticles in Cancer Immunotherapy: Targeting Tumor Microenvironment. Bioactive Materials, 6, 1973-1987. [Google Scholar] [CrossRef] [PubMed]