The usefulness of a multidisciplinary team approach in decision making for pancreatic serous cystic neoplasms

CONTEXT

Serous cystic neoplasms of the pancreas are regarded as benign entities with rare malignant potential and are frequently resected.

OBJECTIVE

The purpose of the study was to evaluate the usefulness of a multidisciplinary team (MDT) approach in decision making regarding the diagnosis and management of pancreatic serous cystic neoplasms.

METHODS

A retrospective study of a prospective database involving 43 patients with serous cystic neoplasms was carried out. Patients who underwent multidisciplinary team evaluation (Group 1) were compared with patients who did not (Group 2) as regards demographic, clinical, radiological, surgical and pathological data. Uni-multivariate analyses were carried out.

RESULTS

Uni-multivariate analysis showed that a multidisciplinary team approach was significantly related to the type of management, suggesting that MDT evaluation independently reduced the odds of surgery (odds ratio (OR) 0.1; 95% confidence interval (CI) 0.02-0.8; P=0.027). Age, second level imaging techniques, latero-lateral diameter, cranio-caudal diameter and Wirsung duct size differed between the two groups; however, the differences were not statistically significant.

CONCLUSIONS

A multidisciplinary team approach seems to be useful in proper decision making regarding the diagnosis and management of pancreatic serous cystic neoplasms.

Are there preoperative factors related to a "soft pancreas" and are they predictive of pancreatic fistulas after pancreatic resection?

PURPOSE

Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistula. We conducted this study to clarify if there are preoperative factors related to a soft pancreatic remnant and to establish if they are useful for predicting pancreatic fistula.

METHODS

This was a retrospective study of patients who underwent pancreatic resections at the Department of Surgical Sciences of the S. Orsola-Malpighi Hospital, Bologna, Italy. The factors considered were sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, characteristics of the pancreatic remnant, and preoperative diagnosis.

RESULTS

Data from 208 patients were recorded. The risk factors predictive of a soft pancreatic remnant were BMI >24 kg/m(2) (P = 0.011), a Wirsung duct size ≤3 mm (P < 0.001), and coexisting periampullary diseases (P < 0.001). Using these factors, we developed a risk score model that was validated by considering the pancreatic fistula rate. The overall and clinically relevant pancreatic fistula rate increased with increasing score values (P = 0.002 and P = 0.028, respectively). Using a score cut-off value of six points, patients with a score ≥6 were considered to be at high risk.

CONCLUSIONS

Body mass index >24 kg/m(2), a Wirsung duct size <3 mm, and preoperative diagnosis represented the preoperative factors related to a soft pancreas. These factors proved useful in the building of a risk score model to predict the incidence of pancreatic fistula.

Systematic review of laparoscopic versus open surgery in the treatment of non-parasitic liver cysts

We conducted a systematic review of the literature on the electronic databases Medline, Embase, Ovid and Cochrane to identify studies from 1990 to 2011 regarding the surgical management of non-parasitic liver cysts treated with laparoscopy (LT) and/or laparotomy (OT) to identify short-term and long-term outcomes of the relative treatments. Two reviewers independently extracted data regarding the following parameters: first author, year of publication, type of journal, study design, number of patients operated on, male/female ratio, mean age, mean size of the cysts treated, laparoscopic conversion rate, morbidity, mortality and recurrence in both groups (LT and OT). A qualitative analysis was carried out using the Pearson Chi square test and the Fischer's exact test where necessary. The data analysis was conducted by dividing the sample into three periods in relation to the development of laparoscopic surgery: period 1 (P1), 1990-1995 "pioneering" period of laparoscopy; period 2 (P2), 1996-2000 period of the "development of laparoscopy"; period 3 (P3), 2001-2011 period of "diffusion of laparoscopy." Thirty studies involving 948 patients comparing LT with OT were included in the final pooled analysis. Twenty-two studies were retrospective (73.3 %) and only 8 (26.7 %) were prospective. The number of publications increased during the three periods analysed. The correlation between the type of journal and the year of publication showed an increase (p = 0.048) in journals dedicated to LT during the three periods. In P1, the preferred approach was open surgery (66.3 %) with only 11 cases treated with LT. The conversion rate was 18.1 %. The overall complication rate was 33.3 % with a substantial equivalence between the two approaches (27.2 % for laparoscopic surgery and 36.6 % for laparotomic). The overall recurrence rate was 18.1 % with 36.3 % in the laparoscopic group and 9.2 % in the laparotomic group. In P2, the preferred approach was laparoscopic (56.7 %). The conversion rate was 2.3 %. The overall complication rate was 5.8 % but with some differences between the two approaches (10.3 % for the laparoscopic approach and 0 % for open surgery). The overall recurrence rate was 14.4 % with 17.4 % in the laparoscopic group and 10.4 % in the laparotomic group. In P3, the preferred approach was laparoscopic (69.9 %). The overall recurrence rate was 11.1 %; it was 6.1 % for the laparoscopic approach while it was 11.5 % for laparotomic. In all three periods analysed, the laparoscopic approach showed a statistically significant reduction in operative time (p = 0.009) and hospital stay (p = 0.001) and a significant (p < 0.05) reduction rate in symptomatic recurrences in patients with polycystic liver disease (25 %) as compared with simple liver cysts (7.5 %). The current data in the literature show that the laparoscopic approach may be the treatment of choice in patients with symptomatic non-parasitic cysts of the liver, providing the short-term advantages of minimally invasive surgery. Recurrence rates were acceptable and comparable to those of conventional surgery. Long-term outcomes should be verified by additional randomised controlled trials and long-term follow-ups.

Laparoscopic distal pancreatectomy in Italy: a systematic review and meta-analysis

BACKGROUND

The use of laparoscopic distal pancreatectomy (LDP) increased in the past twenty years but the real diffusion of this technique is still unknown as well as the type of centers (high or low volume) in which this procedure is more frequently performed.

DATA SOURCE

A systematic review was performed to evaluate the frequency of LDP in Italy and to compare indications and results in high volume centers (HVCs) and in low volume centers (LVCs).

RESULTS

From 95 potentially relevant citations identified, only 5 studies were included. A total of 125 subjects were analyzed, of whom 95 (76.0%) were from HVCs and 30 (24.0%) from LVCs. The mean number of LDPs performed per year was 6.5. The mean number of patients who underwent LDP per year was 8.8 in HVCs and 3.0 in LVCs (P<0.001). The most frequent lesions operated on in HVCs were cystic tumors (62.1%, P<0.001) while, in LVCs, solid neoplasms (76.7%, P<0.001). In HVCs, malignant neoplasms were treated with LDP less frequently than in LVCs (17.9% vs 50.0%, P<0.001). Splenectomy was performed for non-oncologic reason frequenter in HVCs than in LVCs (70.2% vs 25.0%, P=0.004). The length of stay was shorter in HVCs than in LVCs (7.5 vs 11.3, P<0.001). No differences were found regarding age, gender, ductal adenocarcinoma treated, operative time, conversion, morbidity, postoperative pancreatic fistula, reoperation and margin status.

CONCLUSIONS

LDPs were frequently performed in Italy. The "HVC approach" is characterized by a careful selection of patients undergoing LDP. The "LVC approach" is based on the hypothesis that LDPs are equivalent both in short-term and long-term results to laparotomic approach. These data are not conclusive and they point out the need for a national register of laparoscopic pancreatectomy.

WHO 2010 classification of pancreatic endocrine tumors. is the new always better than the old?

BACKGROUND

In 2010, the World Health Organization released a new classification system for endocrine pancreatic tumors. The new categories replaced those in the old classification.

METHODS

To test the safety and accuracy of the new classification in stratifying patients, we retrospectively evaluated 64 consecutive patients, surgically R0 resected for pancreatic endocrine tumors.

RESULTS

In our experience, only 19/31 (61.3%) patients classified as having well-differentiated tumors were included in the new neuroendocrine tumor G1 category while the remaining 12 (38.7%) shifted into the G2 category. Moreover, 10/33 (30.3%) patients classified as affected by a malignant endocrine neoplasm in the old system were considered as G1 tumors in the new one. These differences were statistically significant (P < 0.001) and changed the risk category in 22 (33.3%) patients with well-differentiated pancreatic endocrine tumors. Multiple multivariate models were produced and the poor stratification of the new system was found to be in the G2 category which presents too wide a range of the Ki 67 index (2 to 20%). We built a model in which the G2 category was divided into two subcategories: tumors with a Ki 67 index ≥2 and <5% and tumors with a Ki index ≥5 and <20%, partially modifying the new classification. In this model, the modified classification showed a superiority with respect to the European Neuroendocrine tumor Society-Tumor-Node-Metastasis staging system in stratifying patients for recurrence, with a relative risk of 19 (P < 0.001).

CONCLUSION

The new G2 category seems too large because it includes both benign, low and high grade malignant tumors.

Natural history of branch-duct intraductal papillary mucinous neoplasms of the pancreas: a case report

CONTEXT

The natural history of incidental branch-duct intraductal papillary mucinous neoplasm of the pancreas is still unknown.

CASE REPORT

The case of a 74-year-old man who had been diagnosed 14 years previously with an incidental branch-duct intraductal papillary mucinous neoplasm of the pancreatic head, 30 mm in size, without mural nodules and dilatation of the main pancreatic duct is herein reported. After an exploratory laparotomy at the time of diagnosis (when he was 60 year-old), the patient was enrolled in a surveillance program. Fourteen years after the diagnosis, the cystic lesion showed an increase in size, Wirsung duct dilatation and the presence of several mural nodules. A total pancreatectomy was performed and a diagnosis of mixed-intraductal papillary mucinous neoplasm diffused throughout the entire pancreas with high grade dysplasia, and a micro-invasive carcinoma (<1 mm) of the pancreatic head was reached.

CONCLUSION

The present case confirmed that the natural history of branch-duct intraductal papillary mucinous neoplasms is unpredictable. Thus, an appropriate surveillance program is required for prompt identification of the signs predictive of a malignant transformation of branch-duct intraductal papillary mucinous neoplasms. In high-volume centers, surgery should seriously be considered in young patients who are fit for surgery.

Interventional radiology procedures after pancreatic resections for pancreatic and periampullary diseases

CONTEXT

The use of interventional radiology has increased as the first-line management of complications after pancreatic resections.

METHODS

Patients in whom interventional radiology was performed were compared with those in whom interventional radiology was not performed as regards type of pancreatic resection, diagnosis, postoperative mortality and morbidity, postoperative pancreatic fistula postpancreatectomy haemorrhage, bile leakage, reoperation rate and length of hospital stay. Our aim was to evaluate the usefulness of interventional radiology in the treatment of complications after pancreatic resection.

RESULTS

One hundred and eighty-two (62.8%) out of 290 patients experienced postoperative complications. Interventional radiology procedures were performed in 37 cases (20.3%): percutaneous drainage in 28, transhepatic biliary drainage in 8 and arterial embolisation in 3 cases. Technical success was obtained in all cases and clinical success in 75.7%. Reoperation was avoided in 86.5%. In patients with major complications, clinically relevant postoperative pancreatic fistula and bile leaks as well as those with late postpancreatectomy haemorrhage (P=0.030) and patients with postpancreatectomy haemorrhage grade C (P=0.029), interventional radiology was used (P<0.001, P<0.001 and P=0.009, respectively) significantly more frequently than in the remaining patients. The reoperation and mortality rates were similar in the two groups (P=0.885 and P=0.100, respectively) while patients treated with interventional radiology procedures had a significant longer length of hospital stay than those in the non-interventional radiology group (37.5 ± 23.4 vs. 18.7 ± 11.7 days; P<0.001).

CONCLUSIONS

Interventional radiology procedures were useful, especially for patients with postoperative pancreatic fistulas and bile leaks in whom reoperation was very often avoided.

The role of lymph node ratio in recurrence after curative surgery for pancreatic endocrine tumours

BACKGROUND

The prognostic role of lymph nodes metastasis in pancreatic neuroendocrine tumours is unclear.

METHODS

Retrospective study of 53 patients who underwent a curative standard resection for pancreatic neuroendocrine tumours. The endpoint was to define the role of the lymph nodes ratio in recurrence after curative surgery. The following data were considered as possible factors for predicting the risk of recurrence: gender, age, presence of symptoms, hormonal status, site of tumours, type of resection, size of the tumours, radical resection, pathological T, N and M stage, the Ki67 index, the number of lymph nodes harvested, the number of metastatic lymph nodes and the lymph node ratio. Recurrence rate and time of recurrence were evaluated.

RESULTS

Twelve (26.4%) patients developed a recurrence with a median time of 42.8 (1-305) months. At multivariate analysis, the only factors related to recurrence were: size of lesions (HR 1.1, C.I. 95% 1.0-1.1, P = 0.011), Ki67 ≥ 5% (HR 3.6, C.I. 95% 1.3-10, P = 0.014) and LNR > 0.07 (HR 5.2, C.I. 95% 1.1-25, P = 0.045).

CONCLUSIONS

Our study confirmed that the lymph nodes ratio played an important role in the recurrence rate and suggested that a low number of metastatic lymph nodes reduced the disease free survival.

A bizarre foreign body in the appendix: A case report

Foreign bodies are rare causes of appendicitis and, in most cases, ingested foreign bodies pass through the alimentary tract asymptomatically. However, ingested foreign bodies may sometimes remain silent within the appendix for many years without an inflammatory response. Despite the fact that cases of foreign-body-induced appendicitis have been documented, sharp and pointed objects are more likely to cause perforations and abscesses, and present more rapidly after ingestion. Various materials, such as needles and drill bits, as well as organic matter, such as seeds, have been implicated as causes of acute appendicitis. Clinical presentation can vary from hours to years. Blunt foreign bodies are more likely to remain dormant for longer periods and cause appendicitis through obstruction of the appendiceal lumen. We herein describe a patient presenting with a foreign body in his appendix which had been swallowed 15 years previously. The contrast between the large size of the foreign body, the long clinical history without symptoms and the total absence of any histological inflammation was notable. We suggest that an elective laparoscopic appendectomy should be offered to such patients as a possible management option.

Whole-transcriptome paired-end sequencing and the pancreatic cancer genetic landscape

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Background: A deeper knowledge of the pancreatic cancer (PDAC) biology is needed to improve the prognosis of the disease. Methods: 17 PDAC samples were collected by ultrasound-guided biopsy used for DNA and RNA extraction. 14 samples were analyzed by high resolution copy number analysis (CNA) on Affymetrix SNP array 6.0 and with segmentation algorithm against a reference of 270 Ceu HapMap individuals (Partek Genomic Suite). 17 samples were analyzed by whole transcriptome massively parallel sequencing, performed at 75x2 bp on a HiScanSQ Illumina platform. An average of 7, 3x107 reads per sample were generated, with a mean read depth of 50X. Single nucleotide variants (SNVs) were detected with SNVMix2 and compared with genetic variation databases (dbSNP, 1000genomes, Cosmic). Non-synonimous SNVs were analyzed with the predictors SNPs and GO and PROVEAN. Results: CNA results in 9/14 samples exhibited both macroscopic and cryptic cytogenetic alterations, with a mean of 10 CNA per patient. Most frequent gains were observed in 18q11.2 involving GATA6 (3/14) and 19q13 targeting AKT2 (3/14) while hotspot deletions were found on 18q21 (7/14), 17p13 (6/14), 9p21.3 (6/14), 15q (5/14) and 1q35 (4/14). RNAseq showed that samples exhibited a mean of 145 (range: 61-240) non-synonimous SNVs, of which 16 on average are potentially disease-related. Merging copy number and RNAseq data we highlighted the major oncogenic hits of PDAC, confirming the prevalence (14/17) of KRAS mutations, in one case also NRAS (G13D), and the three oncosuppressor CDKN2A (mutated in 3 cases and deleted in 6 cases, in hetero- or homozygosity), SMAD4 (altered by point mutation or gene deletion in 7/14), and TP53 (lost in 6/14 and mutated in 5/17). The signaling pathways affected were: KRAS/MAPK, TGFbeta and integrin signaling, proliferation and apoptosis, DNA damage response, and epithelial to mesenchymal transition. Moreover we found new oncogenic alterations, such as HMGCR, that displayed mutations in 17% of the analyzed patients (3/17). Conclusions: NGS combined with high resolution cytogenetic analysis can improve the understanding of pancreatic carcinogenesis.

Abstract 812: Whole genome discovery of genetic alterations carried by pancreatic adenocarcinoma

Background: Pancreatic ductal adenocarcinoma (PDAC) is characterized by a 5-year survival rate of 4%. Even if some genetic hits leading to PDAC development are known, a deeper knowledge of the genetic landscape of tumor is necessary to identify druggable targets.

Methods: PDAC samples from 14 localized and advanced cases of pancreatic adenocarcinomas were collected by ultrasound-guided biopsy used for DNA and RNA extraction. High resolution copy number analysis was performed on Affymetrix SNP array 6.0 and analyzed with segmentation algorithm against a reference of 270 Ceu HapMap individuals (Partek Genomic Suite). Whole transcriptome massively parallel sequencing was performed at 75x2 bp on a HiScanSQ Illumina platform. An average of 7,3x107 reads per sample were generated, with a mean read depth of 50X. Single nucleotide variants (SNVs) were detected with SNVMix2 and compared with genetic variation databases (dbSNP, 1000genomes, Cosmic). Non-synonimous SNVs were analyzed with SNPs&GO and SIFT to predict disease association.

Results: Whole transcriptome sequencing showed that PDAC samples exhibited a mean of 145 (range: 61-240) non-synonimous SNVs, of which 16 on average are potentially disease-related. 9/14 patients exhibited both macroscopic and cryptic cytogenetic alterations, with a mean of 10 copy number alterations per patient, while 5 patients did not show any copy number gain or loss. Most frequent gains were observed in 18q11.2 involving GATA6 (3/14) and 19q13 targeting AKT2 (3/14) while hotspot deleted regions were found on 18q21 (7/14), 17p13 (6/14), 9p21.3 (6/14), 15q (5/14) and 1q35 (4/14). Merging copy number and RNAseq data we highlighted the major oncogenic hits of PDAC, confirming the prevalence (9/14) of KRAS mutations, in one case also NRAS (G13D), and the central role of the three oncosuppressor CDKN2A (mutated in 3 cases and deleted in 6 cases, either in hetero- or homozygosity), SMAD4 (altered by either point mutation or gene deletion in 8/14 cases), and TP53 (lost in 7/14 samples). We identified novel pathogenic single nucleotide variants and frameshift mutations, and inter- and intra-chromosomal translocation events that give rise to chimeric fusion transcripts. Even if the mutation profile was heterogeneous in different patients the signaling pathways affected were shared, and included KRAS/MAPK, TGFbeta and integrin signaling, proliferation and apoptosis, DNA damage response, and epithelial to mesenchymal transition. New oncogenic alterations emerged, as ARID1A that was inactivated by somatic mutation (G91R and P1425fs) or copy number loss in 6 patients, NOTCH2 and HMGCR, that displayed pathogenic mutations in 15-20% of the analyzed patients.

Conclusions: Next generation sequencing combined with high resolution cytogenetic analysis can improve the understanding of carcinogenesis and highlight new biomarkers for early diagnosis and potential therapeutic targets in PDAC.

Citation Format: Marina Macchini, Annalisa Astolfi, Riccardo Casadei, Valentina Indio, Carla Serra, Silvia Vecchiarelli, Elisa Grassi, Claudio Ricci, Marielda D'Ambra, Giovanni Taffurelli, Donatella Santini, Raffaele Pezzilli, Francesco Minni, Guido Biasco, Mariacristina Di Marco. Whole genome discovery of genetic alterations carried by pancreatic adenocarcinoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 812. doi:10.1158/1538-7445.AM2013-812

Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy. An Italian, prospective, dual-institution study

OBJECTIVE

To evaluate Peng's binding pancreaticojejunostomy as a safe technique which avoids anastomotic leakage after a pancreaticoduodenectomy.

METHODS

Prospective, observational, dual-institutional study, of patients who underwent a Peng's binding pancreaticojejunostomy was conducted. It was compared with an historical control group of patients who underwent duct to mucosa pancreaticojejunostomy. Overall postoperative mortality, morbidity, postoperative pancreatic fistulas, postpancreatectomy hemorrhage, reoperation, length and costs of hospital stay were collected. Factors related with pancreatic fistula were: sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, type of resection, extension of resection, characteristics of the pancreatic remnant, pathological diagnosis and surgeons. Univariate and multivariate analyzes were carried out.

RESULTS

Sixty-nine patients who underwent binding pancreaticojejunostomy were reported. The control group consisted of 52 patients. The mean length of hospital stay was significantly shorter in the control group than in binding group (p = 0.003). Multivariate analyzes showed that soft pancreatic remnant was significantly related to an increasing rate of postoperative pancreatic fistula (OR 3.7-CI 1.1-12.8-P = 0.034) while the type of pancreatic anastomosis was not significantly related with the occurrence of postoperative pancreatic fistula.

CONCLUSIONS

In the European population, the binding pancreaticojejunostomy according to Peng did not preclude or reduce the postoperative pancreatic fistula rate.

Open versus endoscopic adrenalectomy in the treatment of localized (stage I/II) adrenocortical carcinoma: results of a multiinstitutional Italian survey

BACKGROUND

We compared the oncologic effectiveness of open adrenalectomy and endoscopic adrenalectomy in the treatment of patients with localized adrenocortical carcinoma.

METHODS

One hundred fifty-six patients with localized adrenocortical carcinoma (stage I/II) who underwent R0 resection were included in an Italian multiinstitutional surgical survey. They were divided into 2 groups based on the operative approach (either conventional or endoscopic).

RESULTS

One hundred twenty-six patients underwent open adrenalectomy and 30 patients underwent endoscopic adrenalectomy. The 2 groups were well matched for age, sex, lesion size, and stage (P = NS). The mean follow-up time was similar for the 2 groups (P = NS). The local recurrence rate was 19% for open adrenalectomy and 21% for endoscopic adrenalectomy, whereas distant metastases were recorded in 31% of patients in the conventional adrenalectomy group and 17% in the endoscopic adrenalectomy group (P = NS). The mean time to recurrence was 27 ± 27 months in the conventional open adrenalectomy group and 29 ± 33 months in the endoscopic adrenalectomy group (P = NS). No significant differences were found between the 2 groups in terms of 5-year disease-free survival (38.3% vs 58.2%) and 5-year overall survival rates (48% vs 67%; P = NS).

CONCLUSION

The operative approach does not affect the oncologic outcome of patients with localized adrenocortical carcinoma, if the principles of surgical oncology are respected.

Preoperative gemcitabine and oxaliplatin in a patient with ovarian metastasis from pancreatic cystadenocarcinoma

We describe a case of clinical benefit and partial response with gemcitabine and oxaliplatin (GEMOX) in a young patient with ovarian metastasis from cystadenocarcinoma of the pancreas. A young woman complained of abdominal pain and constipation. Computed tomography (CT) and magnetic resonance imaging scans disclosed two bilateral ovarian masses with pancreatic extension. She underwent bilateral ovarian and womb resection. During surgery peritoneal carcinosis, a pancreatic mass and multiple abdominal lesions were found. The final diagnosis was mucinous pancreatic cystadenocarcinoma with ovarian and peritoneal metastases. She started chemotherapy with GEMOX (gemcitabine 1,000 mg/m(2)/d1 and oxaliplatin 100 mg/m(2)/d2 every 2 weeks). After 12 cycles of chemotherapy a CT scan showed reduction of the pancreatic mass. She underwent distal pancreatic resection, regional lymphadenectomy and splenectomy. Pathologic examination documented prominent fibrous tissue and few neoplastic cells with mucin-filled cytoplasm. Chemotherapy was continued with gemcitabine as adjuvant treatment for another 3 cycles. There is currently no evidence of disease. As reported in the literature, GEMOX is associated with an improvement in progression-free survival and clinical benefit in patients with advanced pancreatic cancer. This is an interesting case in whom GEMOX transformed inoperable pancreatic cancer into a resectable tumor.

Factors related to long-term survival in patients affected by well-differentiated endocrine tumors of the pancreas

Aim. To identify factors related to survival in patients affected by well-differentiated PETs (benign, uncertain behavior, and carcinoma) who underwent R0 pancreatic resection. Methods. Retrospective study of 74 consecutive patients followed up from January 1980 to December 2011. Prognostic factors were sex, age, type of tumor, presence of symptoms, type of surgical procedure, size of tumor, lymph nodes status, WHO classification, and TNM stage. Overall survival was evaluated using the Kaplan-Meier method. Cox regression analyses were used to identify the factors associated with prognosis in univariate and multivariate analysis. Results. The mean follow-up of all the patients was 106 ± 89 months. The 5-10-year long-term survival was 90.9% and 79.1%, respectively. At univariate analysis, patient age <55 years was significantly related to a better long-term survival compared to patients age ≥55 years (307 ± 15 months versus 192 ± 25 months; P = 0.010). Multivariate analysis showed that female gender (P = 0.006), patients without comorbidities (P = 0.033), and patients affected by well-differentiated benign pancreatic endocrine tumors (P = 0.008 and P = 0.002 in relation to tumors with uncertain behavior and carcinomas, resp.) were factors significantly related to a better long-term survival. Conclusions. Patients factors were strongly related to a better long-term survival in patients observed. WHO classification is a very useful prognostic tool for well-differentiated PETs.

New WHO classification for pancreatic endocrine tumors: Is time to leave the previous one?

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Background: In 2010 WHO released a new classification (NWHO) system for endocrine pancreatic tumours (NETs). The aims of this study was to compare the NWHO and previous one (OWHO) in patients affected by NETs. Methods: From January 1980 to December 2010, 89 consecutives patients underwent surgical intervention for PNETs Data regarding sex, age, presence of symptoms, hormonal status, presence of MEN1, surgical procedure, R status, TNM stage, older and new WHO classification and disease specific survival (DSS) were prospectively collected. Multivariate analysis, including OWHO and NWHO, was carried out to evaluate the independent factors related to DSS. A sensitivity analysis was performed to include patients in which NWHO was impossible to be calculated. Results: Mean age of patients was 54.7 ± 14.2 years. There were 46 (51.7%) female and 43 (48.3%) male. Symptoms were present in 68 (76.4%) patients. Fifty-two (58.4%) patients had non-functioning NETs. Left pancreatectomy was performed in 48 (53.9%) cases, atypical resection in 22 (24.7%), pancreaticoduodenectomy in 12 (13.5%), total pancreatectomy in 2 (2.2%) and palliative surgery in 5 (5.6%). R0/1 resection was carried out in 79(88.7%) cases. According TNM stage there were: I, 27 (30.3%); II 29 (32.6%); III, 22 (24.7%); IV, 11 (12.4%). According OWHO 46 (51.7%) patients had a well differentiated tumours (WDT), 32 (36%) well differentiated carcinoma (WDCa), 11(12.4%) poorly differentiated carcinoma (PDCa). The NWHO was available only in 49 (55.1 %) patients: 20 (22.5%) NET G1, 25 (28.1%) NET G2, 4 (4.5%) neuroendocrine carcinomas (NEC) G3. At multivariate analysis OWHO and R2 status were the only independent factors related to DSS (RR=6.7, p<0.001 and RR 2.0, p=0.018 respectively). OWHO stratifies DSS better than NWHO: RR 0.12 (C.I. 95% 0.01-0.99; p=0.049) and RR 0.16 (C.I 95% 0.16-0.05; p=0.002) comparing WDT vs WDCa and WDCa vs PDCa, respectively. The sensitivity analysis confirmed in two model the superiority of OWHO while in others two we did not find any difference. Conclusions: In our experience OWHO still remains the best prognostic factor to predict DSS in patients with NETs .

Late postpancreatectomy hemorrhage after pancreaticoduodenectomy: is it possible to recognize risk factors?

CONTEXT

Post-pancreatectomy hemorrhage is one of the most common complications after pancreaticoduodenectomy.

OBJECTIVE

To evaluate the late post-pancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery criteria and to recognize factors related to its onset.

METHODS

A prospective study of 113 patients who underwent pancreaticoduodenectomy was conducted. Late post-pancreatectomy hemorrhage was defined according to the criteria of the International Study Group of Pancreatic Surgery. Demographic, clinical, surgical and pathological data were considered and related to late post-pancreatectomy hemorrhage.

RESULTS

Thirty-one (27.4%) patients had a post-pancreatectomy hemorrhage. Twenty-five (22.1%) patients developed late post-pancreatectomy hemorrhage: 19 (16.8%) grade B, 6 (5.3%) grade C. Surgical re-operation was performed in 2 out of the 25 cases with late post-pancreatectomy hemorrhage (8.0%) grade C associated with postoperative pancreatic fistula. At univariate analysis, the only factor significantly related to late post-pancreatectomy hemorrhage was postoperative pancreatic fistula (P<0.001). Multivariate analysis underlined that the severity of postoperative pancreatic fistula (P<0.001) and pancreatic anastomosis (P=0.049) independently increased the risk of late hemorrhage.

CONCLUSION

In patients undergoing pancreaticoduodenectomy, the criteria introduced by International Study Group of Pancreatic Surgery to define late postpancreatectomy hemorrhage are related to a higher incidence of hemorrhage than previously detected because they considered also mild hemorrhage.

Combined aldosterone and cortisol secretion by adrenal incidentaloma

A 70-year-old woman was referred to the authors' unit following hospitalization for cardiac failure, high urinary free cortisol concentrations and severe hypokaliemia. A computed tomography scan of the abdomen showed an adrenal adenoma. The 24-hour urinary free cortisol values were high and plasma cortisol levels failed to suppress following 1 mg dexamethasone test. Aldosterone to plasma renin activity ratio was also pathologic, confirmed by saline load. She showed no symptoms of glucocorticoid excess. She was diagnosed with combined primary hyperaldosteronism and Cushing's syndrome. Cases of adrenal incidentalomas co-secreting cortisol and aldosterone are rare; they should be addressed in patients undergoing adrenal surgery for Conn's syndrome to avoid adrenal insufficiency after removal of the tumor.

Total pancreatectomy: indications, operative technique, and results: a single centre experience and review of literature

The aims of this study were to identify the indications to perform a total pancreatectomy and to evaluate the outcome and quality of life of the patient who underwent this operation. A retrospective analysis of a prospective database, regarding all the patients who underwent total pancreatectomy from January 2006 to June 2009, was carried out. Perioperative and outcome data were analyzed in two different groups: ductal adenocarcinoma (group 1) and non-ductal adenocarcinoma (group 2). Twenty (16.9%) total pancreatectomies out of 118 pancreatic resections were performed. Seven (35.0%) patients were affected by ductal adenocarcinoma (group 1) and the remaining 13 (65.0%) by pancreatic diseases different from ductal adenocarcinoma (group 2) [8 (61.5%) intraductal pancreatic mucinous neoplasms, 2 (15.4%) well-differentiated neuroendocrine carcinomas, 2 (15.4%) pancreatic metastases from renal cell cancer and, finally, 1 (7.7%) chronic pancreatitis]. Eleven patients (55%) underwent primary elective total pancreatectomy; nine (45%) had a completion pancreatectomy previous pancreaticoduodenectomy. Primary elective total pancreatectomy was significantly more frequent in group 2 than in group 1. Early and long-term postoperative results were good without significant difference between the two groups except for the disease-free survival that was significantly better in group 2. The follow-up examinations showed a good control of the apancreatic diabetes and of the exocrine insufficiency without differences between the two groups. In conclusion, currently, total pancreatectomy is a standardized and safe procedure that allows good early and late results. Its indications are increasing because of the more frequent diagnose of pancreatic disease that involved the whole gland as well as intraductal pancreatic mucinous neoplasm, neuroendocrine tumors and pancreatic metastases from renal cell cancer.

Assessment of complications according to the Clavien-Dindo classification after distal pancreatectomy

CONTEXT

The absence of a definition and a widely accepted ranking system to classify surgical complications has hampered proper interpretation of the surgical outcome.

PATIENTS

Sixty-one patients undergoing distal pancreatectomy.

MAIN OUTCOME MEASURES

The complications were classified according to the Clavien-Dindo classification; each grade was evaluated regarding the length of the postoperative stay and was compared to the most important complications.

RESULTS

Thirty (49.2%) patients had no complications; out of the thirty-one (50.8%) patients with complications, 9 (14.5%) had grade I, 15 (24.6%) had grade II, 6 (9.8%) had grade III, and 1 (1.6%) had grade IV. There were no postoperative deaths (grade V). A progressive increase in the length of hospitalization from patients with no complications to those having grade IV (P < 0.001) was noted. Postoperative pancreatic fistula and postpancreatectomy hemorrhage rates did not significantly increase from Clavien-Dindo grade I to grade IV (P = 0.118 and P = 0.226, respectively). The severity of a postpancreatectomy hemorrhage, instead, was positively related to the grade of the Clavien-Dindo classification (P = 0.049) while postoperative pancreatic fistula resulted near the significant value (P = 0.058).

CONCLUSIONS

The Clavien-Dindo classification is a simple way of reporting all complications following distal pancreatectomy. It allows us to distinguish a normal postoperative course from any deviation and the severity of complications and it may be useful for comparing postoperative morbidity between different pancreatic centers.