International Association of Pancreatology (IAP)/European Pancreatic Club (EPC) consensus review of guidelines for the treatment of pancreatic cancer

Recurrent disease detection after resection of pancreatic ductal adenocarcinoma using a recurrence-focused surveillance strategy (RADAR-PANC): protocol of an international randomized controlled trial according to the Trials within Cohorts design

BACKGROUND

Disease recurrence remains one of the biggest concerns in patients after resection of pancreatic ductal adenocarcinoma (PDAC). Despite (neo)adjuvant systemic therapy, most patients experience local and/or distant PDAC recurrence within 2 years. High-level evidence regarding the benefits of recurrence-focused surveillance after PDAC resection is missing, and the impact of early detection and treatment of recurrence on survival and quality of life is unknown. In most European countries, recurrence-focused follow-up after surgery for PDAC is currently lacking. Consequently, guidelines regarding postoperative surveillance are based on expert opinion and other low-level evidence. The recent emergence of more potent local and systemic treatment options for PDAC recurrence has increased interest in early diagnosis. To determine whether early detection and treatment of recurrence can lead to improved survival and quality of life, we designed an international randomized trial.

METHODS

This randomized controlled trial is nested within an existing prospective cohort in pancreatic cancer centers in the Netherlands (Dutch Pancreatic Cancer Project; PACAP) and the United Kingdom (UK) (Pancreas Cancer: Observations of Practice and survival; PACOPS) according to the "Trials within Cohorts" (TwiCs) design. All PACAP/PACOPS participants with a macroscopically radical resection (R0-R1) of histologically confirmed PDAC, who provided informed consent for TwiCs and participation in quality of life questionnaires, are included. Participants randomized to the intervention arm are offered recurrence-focused surveillance, existing of clinical evaluation, serum cancer antigen (CA) 19-9 testing, and contrast-enhanced computed tomography (CT) of chest and abdomen every three months during the first 2 years after surgery. Participants in the control arm of the study will undergo non-standardized clinical follow-up, generally consisting of clinical follow-up with imaging and serum tumor marker testing only in case of onset of symptoms, according to local practice in the participating hospital. The primary endpoint is overall survival. Secondary endpoints include quality of life, patterns of recurrence, compliance to and costs of recurrence-focused follow-up, and the impact on recurrence-focused treatment.

DISCUSSION

The RADAR-PANC trial will be the first randomized controlled trial to generate high level evidence for the current clinical equipoise regarding the value of recurrence-focused postoperative surveillance with serial tumor marker testing and routine imaging in patients after PDAC resection. The Trials within Cohort design allows us to study the acceptability of recurrence-focused surveillance among cohort participants and increases the generalizability of findings to the general population. While it is strongly encouraged to offer all trial participants treatment at time of recurrence diagnosis, type and timing of treatment will be determined through shared decision-making. This might reduce the potential survival benefits of recurrence-focused surveillance, although insights into the impact on patients' quality of life will be obtained.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04875325 . Registered on May 6, 2021.

Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service

OBJECTIVE

Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center.

BACKGROUND

The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable.

MATERIALS AND METHODS

Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds.

RESULTS

Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099).

CONCLUSIONS

There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.

Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm

Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?

Clinical development of a blood biomarker using apolipoprotein-A2 isoforms for early detection of pancreatic cancer

BACKGROUND

We have previously reported apolipoprotein A2-isoforms (apoA2-is) as candidate plasma biomarkers for early-stage pancreatic cancer. The aim of this study was the clinical development of apoA2-is.

METHODS

We established a new enzyme-linked immunosorbent sandwich assay for apoA2-is under the Japanese medical device Quality Management System requirements and performed in vitro diagnostic tests with prespecified end points using 2732 plasma samples. The clinical equivalence and significance of apoA2-is were compared with CA19-9.

RESULTS

The point estimate of the area under the curve to distinguish between pancreatic cancer (n = 106) and healthy controls (n = 106) was higher for apoA2-ATQ/AT [0.879, 95% confidence interval (CI): 0.832-0.925] than for CA19-9 (0.849, 95% CI 0.793-0.905) and achieved the primary end point. The cutoff apoA2-ATQ/AT of 59.5 μg/mL was defined based on a specificity of 95% in 2000 healthy samples, and the reliability of specificities was confirmed in two independent healthy cohorts as 95.3% (n = 106, 95% CI 89.4-98.0%) and 95.8% (n = 400, 95% CI 93.3-97.3%). The sensitivities of apoA2-ATQ/AT for detecting both stage I (47.4%) and I/II (50%) pancreatic cancers were higher than those of CA19-9 (36.8% and 46.7%, respectively). The combination of apoA2-ATQ/AT (cutoff, 59.5 μg/mL) and CA19-9 (37 U/mL) increased the sensitivity for pancreatic cancer to 87.7% compared with 69.8% for CA19-9 alone. The clinical performance of apoA2-is was blindly confirmed by the National Cancer Institute Early Detection Research Network.

CONCLUSIONS

The clinical performance of ApoA2-ATQ/AT as a blood biomarker is equivalent to or better than that of CA19-9.

Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer

Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.

Combined analytical approach empowers precise spectroscopic interpretation of subcellular components of pancreatic cancer cells

The lack of specific and sensitive early diagnostic options for pancreatic cancer (PC) results in patients being largely diagnosed with late-stage disease, thus inoperable and burdened with high mortality. Molecular spectroscopic methodologies, such as Raman or infrared spectroscopies, show promise in becoming a leader in screening for early-stage cancer diseases, including PC. However, should such technology be introduced, the identification of differentiating spectral features between various cancer types is required. This would not be possible without the precise extraction of spectra without the contamination by necrosis, inflammation, desmoplasia, or extracellular fluids such as mucous that surround tumor cells. Moreover, an efficient methodology for their interpretation has not been well defined. In this study, we compared different methods of spectral analysis to find the best for investigating the biomolecular composition of PC cells cytoplasm and nuclei separately. Sixteen PC tissue samples of main PC subtypes (ductal adenocarcinoma, intraductal papillary mucinous carcinoma, and ampulla of Vater carcinoma) were collected with Raman hyperspectral mapping, resulting in 191,355 Raman spectra and analyzed with comparative methodologies, specifically, hierarchical cluster analysis, non-negative matrix factorization, T-distributed stochastic neighbor embedding, principal components analysis (PCA), and convolutional neural networks (CNN). As a result, we propose an innovative approach to spectra classification by CNN, combined with PCA for molecular characterization. The CNN-based spectra classification achieved over 98% successful validation rate. Subsequent analyses of spectral features revealed differences among PC subtypes and between the cytoplasm and nuclei of their cells. Our study establishes an optimal methodology for cancer tissue spectral data classification and interpretation that allows precise and cognitive studies of cancer cells and their subcellular components, without mixing the results with cancer-surrounding tissue. As a proof of concept, we describe findings that add to the spectroscopic understanding of PC.

Evaluation of post-operative surveillance strategies and surgeon perceptions and beliefs of surveillance for pancreatic ductal adenocarcinoma in the UK

BACKGROUND

Despite high rates of recurrence after surgery for pancreatic ductal adenocarcinoma (PDAC) there is lack of standardised surveillance practices. We aimed to identify UK surveillance practice and interrogate surgeon beliefs around surveillance.

METHODS

A web-based survey was sent to all UK pancreatic units to assess surveillance practice for resected PDAC, factors influencing surveillance protocols, and perceptions and beliefs surrounding on current postoperative surveillance.

RESULTS

There was wide variation in reported practice between 40 consultant surgeons from 28 pancreatic units (100% unit response rate). 26% had standardised surveillance compared to 18% with no standardised practice. 16% individualised surveillance to the patient, and 40% reported differing practices between surgeons within units despite local surveillance protocols. 66% felt surveillance should be tailored to patient factors, and 58% to patient preference. There was a broad belief regarding a lack of robust evidence supporting surveillance making a trial necessary. Thematic analysis identified surveillance barriers, considerations for trial design, necessity for patient engagement and potential benefits of surveillance.

DISCUSSION

Wide variation in surveillance practice exists within and between units. A surveillance trial was deemed beneficial, however identified barriers potentially preclude a trial. Future work should assess acceptability for patients including impact on anxiety and quality-of-life.

Can the molecules carried by extracellular vesicles help to diagnose pancreatic cancer early?

BACKGROUND

Pancreatic cancer is a deadly malignancy mainly because of its asymptomatic onset which prevents the implementation of the primary tumour's resection surgery, leading to metastatic spread resistant to chemotherapy. Early-detection of this cancer in its initial stage would represent a game changer in the fight against this disease. The few currently available biomarkers detectable in patients' body fluids lack sensitivity and specificity.

SCOPE OF REVIEW

The recent discovery of extracellular vesicles and their role in promoting cancer's advancement, has boosted interest in researching their cargo, to find reliable early detection biological markers. This review examines the most recent discoveries in the analysis of potential extra vesicle-carried biological markers for the early detection of pancreatic cancer.

MAJOR CONCLUSIONS

Despite the advantages of using extracellular vesicles for early diagnosis, and the promising findings of extracellular vesicle-carried molecules possibly functional as biomarkers, until now there are no validated markers derived from extracellular vesicles available to be used in the clinic.

GENERAL SIGNIFICANCE

Further studies in this direction are urgently required to provide what would be a major asset for defeating pancreatic cancer.

Can combined use of tumor markers in pancreatic cancer be a solution to short- and long-term consequences?: A retrospective study

As in other types of cancer, tumor markers are used in pancreatic ductal adenocarcinoma (PDAC) for disease follow-up, especially after surgery. There has been shown to be a significant correlation between the tumor marker levels and poor prognosis in locally or systemic advanced stage PDAC patients. However, there is no significant correlation between prognosis and marker levels in patients with early stage PDAC patients. This study aimed to examine the effect of the carbohydrate antigen 19-9 (Ca19-9)/carcinoembryogenic antigen (CEA) ratio in ductal adenocarcinoma of the pancreatic head on disease prognosis and mean survival. This retrospective study was conducted with 129 pancreatic head adenocarcinoma patients who were treated with whipple procedure at the Ankara University Surgical Oncology Clinic between 2010 and 2020. All patients' demographics, stage of the disease, CEA, CA 19-9 levels, and CEA/Ca 19-9 ratio were enrolled and compared statistically. A new cutoff value was calculated for the Ca19-9/CEA ratio. A Ca19-9/CEA ratio >29.77 showed 69.9% sensitivity and 70.9% specificity for the probability of the T3 and T4 stages. The cutoff value for the Ca19-9/CEA ratio was 27.18. This cutoff value had a sensitivity of 79.4% and a specificity of 80.3% for lymph node metastasis. Patients with a Ca19-9/CEA ratio below the cutoff value of 28.475 had a mean survival of 93.161 months and those with a value higher than the cutoff value had a mean survival of 28.541 months (P < .001). A simple combination of tumor markers was determined to have higher accuracy rates in predicting tumor prognosis and in determining mean survival, which are particularly needed in early stage cancers.

Vibrational spectroscopy – are we close to finding a solution for early pancreatic cancer diagnosis?

Pancreatic cancer (PC) is an aggressive and lethal neoplasm, ranking seventh in the world for cancer deaths, with an overall 5-year survival rate of below 10%. The knowledge about PC pathogenesis is rapidly expanding. New aspects of tumor biology, including its molecular and morphological heterogeneity, have been reported to explain the complicated “cross-talk” that occurs between the cancer cells and the tumor stroma or the nature of pancreatic ductal adenocarcinoma-associated neural remodeling. Nevertheless, currently, there are no specific and sensitive diagnosis options for PC. Vibrational spectroscopy (VS) shows a promising role in the development of early diagnosis technology. In this review, we summarize recent reports about improvements in spectroscopic methodologies, briefly explain and highlight the drawbacks of each of them, and discuss available solutions. The important aspects of spectroscopic data evaluation with multivariate analysis and a convolutional neural network methodology are depicted. We conclude by presenting a study design for systemic verification of the VS-based methods in the diagnosis of PC.

Role of Neoplastic Markers in Pancreatic Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is considered one of the "Big Five" lethal cancers, which include lung, bowel, breast and prostate cancer [...].

An Exosomal miRNA Biomarker for the Detection of Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) remains a difficult tumor to diagnose and treat. To date, PDAC lacks routine screening with no markers available for early detection. Exosomes are 40-150 nm-sized extracellular vesicles that contain DNA, RNA, and proteins. These exosomes are released by all cell types into circulation and thus can be harvested from patient body fluids, thereby facilitating a non-invasive method for PDAC detection. A bioinformatics analysis was conducted utilizing publicly available miRNA pancreatic cancer expression and genome databases. Through this analysis, we identified 18 miRNA with strong potential for PDAC detection. From this analysis, 10 (MIR31, MIR93, MIR133A1, MIR210, MIR330, MIR339, MIR425, MIR429, MIR1208, and MIR3620) were chosen due to high copy number variation as well as their potential to differentiate patients with chronic pancreatitis, neoplasms, and PDAC. These 10 were examined for their mature miRNA expression patterns, giving rise to 18 mature miRs for further analysis. Exosomal RNA from cell culture media was analyzed via RTqPCR and seven mature miRs exhibited statistical significance (miR-31-5p, miR-31-3p, miR-210-3p, miR-339-5p, miR-425-5p, miR-425-3p, and miR-429). These identified biomarkers can potentially be used for early detection of PDAC.

[Indications for the surgical management of pancreatic neoplasms]

Due to its rising incidence, pancreatic neoplasia, which mainly include adenocarcinomas, neuroendocrine and cystic neoplasia of the pancreas, is becoming increasingly relevant in everyday clinical practice.Based on a systematic literature search, a working group of pancreatic experts developed evidence-based recommendations for surgical indications in pancreatic neoplasia to improve the quality.There is a clear surgical indication for primary or secondary resectable pancreatic carcinomas without metastasis, for functionally active, symptomatic and functionally inactive neuroendocrine neoplasia of more than 2 cm in size and for cystic neoplasm with symptoms or signs of malignancy including all intraductal papillary-mucinous neoplasia (IPMN) of the main duct and mixed type, all mucinous-cystic neoplasia (MCN) > 4 cm and all solid pseudopapillary neoplasia (SPN). Surgery can be indicated for pancreatic carcinomas with isolated arterial vascular infiltration or for long periods of stable oligometastasis, regarding neuroendocrine neoplasias for metastasis or debulking surgery as well as for branch-duct IPMN with risk criteria and MCN <4 cm. There is no primary indication for surgery in locally advanced and metastatic pancreatic cancer or asymptomatic serous-cystic neoplasia (SCN).The indication for surgery should always be individualized taking into account age, comorbidities and patient wishes.

The effect of minimally invasive or open radical antegrade modular pancreatosplenectomy on pancreatic cancer: A multicenter randomized clinical trial protocol

Background

Radical antegrade modular pancreatosplenectomy (RAMPS) has been proven to improve R0 resection and lymph harvest in treating patients with distal pancreatic cancer. The development of minimally invasive surgery has advantages in postoperative recovery. Therefore, minimally invasive (MI-) RAMPS may combine the advantages of both benefits to improve survival. Nevertheless, evidence to validate the safety and efficacy of MI-RAMPS is limited.

Method/Design

The MIRROR trial will be the first multicenter prospective randomized clinical trial to investigate the outcome of MI-RAMPS. The hypothesis is that MI-RAMPS is superior in postoperative recovery. The primary outcome is the length of postoperative stay. Based on the hypothesis and primary outcome, the sample size is 250 patients (125 participants in each group). The trial will investigate factors related to surgical safety, short-term outcome, pathological assessment, and survival as secondary outcomes.

Conclusion

This study will offer a relatively higher level of evidence to further illustrate the accessibility and benefits of MI-RAMPS for the treatment of distal pancreatic cancer.

Clinical Trial Registration

Clinicaltrials.gov, NCT03770559.

Optimal lymph-node dissection for pancreatic tail cancer

PURPOSE

The optimal range of lymph-node dissection for pancreatic tail cancer remains unclear. We investigated the location and frequency of lymph-node metastases to identify the correct range of lymph-node dissection for pancreatic tail cancer.

METHODS

We analyzed clinical data retrospectively, on patients who underwent distal pancreatectomy for resectable left-sided pancreatic cancer, between February, 2006 and March, 2021. Eligible patients were divided into two groups according to the tumor location: those with pancreatic tail cancer (Pt group) and those with pancreatic body or body and tail cancer (non-Pt group).

RESULTS

Of the 96 patients analyzed, 61 (64%) were assigned to the Pt group and 35 (36%) were assigned to the non-Pt group. Metastases to stations 7, 8, 9, 10, 11, 14, and 18 were found in 0 (0%), 0 (0%), 0 (0%), 4 (7%), 18 (30%), 2 (4%), and 10 (17%) patients in the Pt group, and in 1 (3%), 4 (12%), 2 (6%), 1 (3%), 18 (51%), 3 (9%), and 6 (17%) patients in the non-Pt group, respectively.

CONCLUSION

Lymph-node dissection at stations 7, 8, and 9 might not be necessary in patients with resectable pancreatic cancer confined to the pancreatic tail.

Levels of Evidence Supporting United States Guidelines in Pancreatic Adenocarcinoma Treatment

Simple Summary

The aim of our work is to describe the level of evidence supporting therapeutic recommendations in United States pancreatic adenocarcinoma guidelines, and its evolution over time. We recorded the level of evidence for each therapeutic recommendation extracted from the American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines. In both United States guidelines, less than 9% of therapeutic recommendations are supported by a high level of evidence. In the National Comprehensive Cancer Network guidelines, there was no significant increase in high level of evidence recommendations over time. However, guidelines authors can only deal with the available evidence to develop recommendations while highlighting the strengths and weaknesses of included studies. There is a need for a more collaborative effort in pancreatic adenocarcinoma treatment to tackle important therapeutic questions and challenge the current framework of evidence.

Abstract

Cancer guidelines are ideally based on high levels of evidence (LOE). We aim to evaluate the LOE supporting recommendations in United States (US) guidelines on pancreatic adenocarcinoma (PDAC) treatment and its evolution over time. We searched for current guidelines from the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) and their prior publicly available versions on societies’ websites and/or MEDLINE. We recorded the LOE and class of recommendation (opinion of the writing panel) for each recommendation. We defined high LOE as: a “high” quality of evidence from the GRADE methodology (ASCO) and “Category 1” (NCCN). Our main outcome was the proportion of PDAC recommendations supported by high LOE. Proportions of high LOE recommendations were 5% (2/40) and 8% (12/153) in current ASCO and NCCN guidelines, respectively. Less than 10% of class I recommendations were based on high LOE. For NCCN guidelines, the proportion of high LOE recommendations did not improve over time and only three recommendations increased their LOE. We identified a small percentage of high LOE recommendations for PDAC treatment in US guidelines. However, guidelines authors can only deal with the available evidence. The current framework of evidence should be challenged with consideration of observational evidence.

US-Guided Percutaneous Radiofrequency Ablation of Locally Advanced Pancreatic Adenocarcinoma: A 5-Year High-Volume Center Experience

PURPOSE

 The aim of this study was to investigate the safety and effectiveness of percutaneous radiofrequency ablation (RFA) in locally advanced pancreatic cancer (LAPC) of the pancreatic body by assessing the overall survival of patients and evaluating the effects of the procedure in the clinical and radiological follow-up.

MATERIALS AND METHODS

 Patients with unresectable LAPC after failed chemoradiotherapy for at least six months were retrospectively included. Percutaneous RFA was performed after a preliminary ultrasound (US) feasibility evaluation. Contrast-enhanced computed tomography (CT) and CA 19.9 sampling were performed before and 24 hours and 30 days after the procedure to evaluate the effects of the ablation. Patients were followed-up after discharge considering the two main endpoints: procedure-related complications and death.

RESULTS

 35 patients were included, 5 were excluded. All patients underwent RFA with no procedure-related complications reported. The mean size of tumors was 49 mm before treatment. The mean dimension of the ablated necrotic zone was 32 mm, with a mean extension of 65 % compared to the whole tumor size. Tumor density was statistically reduced one day after the procedure (p < 0.001). The mean CA 19.9 levels before and 24 hours and 30 days after the procedure were 285.8 U/mL, 635.2 U/mL, and 336.0 U/mL, respectively, with a decrease or stability at the 30-day evaluation in 80 % of cases. The mean survival was 310 (65-718) days.

CONCLUSION

 Percutaneous RFA of LAPC is a feasible technique in patients who cannot undergo surgery, with great debulking effects and a very low complication rate.

The Diagnostic Performance of 18F-FDG PET/CT in Recurrent Pancreatic Cancer: A Systematic Review and Meta-analysis

Purpose

The CT scan is the best common screening test for pancreatic cancer recurrence after surgery. The goal of our meta-analysis was to assess the diagnostic accuracy of 18F-FDG PET/CT for pancreatic cancer recurrence.

Methods

We examined PubMed and Embase for suitable papers between 2009 and 2022. The researchers considered studies that looked at the diagnostic usefulness of 18F-FDG PET/CT in identifying local and/or distant disease recurrence throughout the follow-up following pancreatic cancer resection. The Quality Assessment of Diagnostic Performance Studies-2 (QUADAS-2) method was used to evaluate the quality of each study. For each of the publications included, two researchers extracted data independently. The extracted data included general data (authors, year of publication), literature characteristics (country, type of literature, and design of study), characteristics of the patient (patients' number, mean or median age, and treatment regimen), and technical aspects (scanner, injection activity, and image analysis).

Results

The analysis includes 7 trials with a total of 263 patients. The sensitivity and specificity of 18F-FDG PET/CT in detecting recurrent pancreatic cancer following definitive treatment were 0.89 (95 percent CI: 0.83-0.93) and 0.88 (95 percent CI: 0.72-0.96), respectively, according to the pooled estimates. PET/CT performed well in the diagnosis of recurrent pancreatic cancer, with an AUC of 0.94. (0.91-0.95).

Conclusions

18F-FDG PET-CT was found to be a reliable detection method in recurrent pancreatic tumor.

Pancreatic surgery during the COVID-19 pandemic 2020-2021: an observational cohort study from a third level referral center

Background

During the COVID pandemic there has been limited access to elective surgery including oncologic surgery in several countries world-wide. The aim of this study was to investigate if there was any lockdown effect on pancreatic surgery with special focus on malignant pancreatic and periampullary tumours.

Methods

Patients who underwent pancreatic surgery during the two Danish lockdown periods from 11. March 2020 and the following 12 months were compared with patients who were operated the preceding 3 years. Data on patients’ characteristics, waiting time, operations, and clinical outcomes were evaluated.

Results

During lockdown and the previous three years the annual number of resections were 242, 232, 253, and 254, respectively (p = 0.851). Although the numbers were not significantly different, there were fluctuations in operations and waiting time during the lockdown. During the second outbreak of COVID October 2020 to March 2021 the overall median waiting time increased to 33 days (quartiles 26;39) compared to 23 (17;33) days during the first outbreak from March to May 2020 (p = 0.019). The same difference was seen for patients with malignant tumours, 30 (23;36) vs. 22 (18;30) months (p = 0.001). However, the fluctuations and waiting time during lockdown was like the preceding three years. Neither 30- nor 90-days mortality, length of stay, number of extended operations, and complications and tumour stage were significantly different from previous years.

Conclusions

There were significant fluctuations in waiting time for operations during the lockdown, but these variations were not different from the preceding three years, wherefore other explanations than an impact from COVID are conceivable.

Current Pathology Model of Pancreatic Cancer

Pancreatic cancer (PC) is one of the most aggressive and lethal malignant neoplasms, ranking in seventh place in the world in terms of the incidence of death, with overall 5-year survival rates still below 10%. The knowledge about PC pathomechanisms is rapidly expanding. Daily reports reveal new aspects of tumor biology, including its molecular and morphological heterogeneity, explain complicated "cross-talk" that happens between the cancer cells and tumor stroma, or the nature of the PC-associated neural remodeling (PANR). Staying up-to-date is hard and crucial at the same time. In this review, we are focusing on a comprehensive summary of PC aspects that are important in pathologic reporting, impact patients' outcomes, and bring meaningful information for clinicians. Finally, we show promising new trends in diagnostic technologies that might bring a difference in PC early diagnosis.

[Surgical treatment of pancreatic cancer-What is new?]

The incidence of pancreatic ductal adenocarcinoma is continuously increasing and will become the second leading cause of cancer-related death in Europe and the USA by 2030. With a 5-year overall survival rate of less than 10% the prognosis remains poor. So far surgical tumor resection remains the only curative treatment option, which is now partially supported by multimodal neoadjuvant and adjuvant therapy concepts. Due to the aggressive tumor biology patients with advanced pancreatic cancer in particular can profit from these multimodal therapy concepts. Additionally, in recent years surgical treatment was optimized, the criteria for tumor resectablity were defined and minimally invasive surgery was widely introduced. This review article summarizes the newest developments and the new German S3 guidelines concerning surgery of pancreatic cancer.

[Pathological processing in pancreatic ductal adenocarcinoma-What is new?]

The macroscopic and microscopic assessments of pancreatic cancer resection specimens belong to the standard repertoire of any department of pathology. In recent years standards have been developed regarding both macroscopic and microscopic assessments, which are laid down in international and national guidelines and classifications and are regularly updated. In this way the reporting of results and interdisciplinary communication are facilitated. These classifications and guidelines are influenced by current studies and the data from them provide information on which histopathological factors are particularly relevant for the prognosis and treatment. Due to the increasing use of neoadjuvant therapy the assessment of tumor regression in histopathological specimens is also gaining in importance. Finally, individual targeted treatments are also now available for pancreatic cancer, which require extended molecular pathological diagnostics.

N, LNR or LODDS: Which Is the Most Appropriate Lymph Node Classification Scheme for Patients with Radically Resected Pancreatic Cancer?

Simple Summary

To date, no data are available regarding the most appropriate alternative LN classification system with respect to prognostic power and discriminative ability in cases with resectable pancreatic ductal adenocarcinoma (PDAC). We compared different lymph node classification systems with regard to accurate evaluation of overall survival in 319 patients with resected PDAC. One LNR and one LODDS classification scheme were found to out-perform the N category in distinct patient subgroups. Only the LODDS classification exhibited statistically significant, gradually increasing HRs of their subcategories and, at the same time, significantly better discriminative potential in the subgroups of patients with PDAC of the head or corpus and in patients with tumor-free resection margins or M0 status, respectively.

Abstract

Background: Even though numerous novel lymph node (LN) classification schemes exist, an extensive comparison of their performance in patients with resected pancreatic ductal adenocarcinoma (PDAC) has not yet been performed. Method: We investigated the prognostic performance and discriminative ability of 25 different LN ratio (LNR) and 27 log odds of metastatic LN (LODDS) classifications by means of Cox regression and C-statistic in 319 patients with resected PDAC. Regression models were adjusted for age, sex, T category, grading, localization, presence of metastatic disease, positivity of resection margins, and neoadjuvant therapy. Results: Both LNR or LODDS as continuous variables were associated with advanced tumor stage, distant metastasis, positive resection margins, and PDAC of the head or corpus. Two distinct LN classifications, one LODDS and one LNR, were found to be superior to the N category in the complete patient collective. However, only the LODDS classification exhibited statistically significant, gradually increasing HRs of their subcategories and at the same time significantly higher discriminative potential in the subgroups of patients with PDAC of the head or corpus and in patients with tumor free resection margins or M0 status, respectively. On this basis, we built a clinically helpful nomogram to estimate the prognosis of patients after radically resected PDAC. Conclusion: One LNR and one LODDS classification scheme were found to out-perform the N category in terms of both prognostic performance and discriminative ability, in distinct patient subgroups, with reference to OS in patients with resected PDAC.

Detection, Treatment, and Survival of Pancreatic Cancer Recurrence in the Netherlands: A Nationwide Analysis

OBJECTIVE

To evaluate whether detection of recurrent pancreatic ductal adenocarcinoma (PDAC) in an early, asymptomatic stage increases the number of patients receiving additional treatment, subsequently improving survival.

SUMMARY OF BACKGROUND DATA

International guidelines disagree on the value of standardized postoperative surveillance for early detection and treatment of PDAC recurrence.

METHODS

A nationwide, observational cohort study was performed including all patients who underwent PDAC resection (2014-2016). Prospective baseline and perioperative data were retrieved from the Dutch Pancreatic Cancer Audit. Data on follow-up, treatment, and survival were collected retrospectively. Overall survival (OS) was evaluated using multivariable Cox regression analysis, before and after propensity-score matching, stratified for patients with symptomatic and asymptomatic recurrence.

RESULTS

Eight hundred thirty-six patients with a median follow-up of 37 months (interquartile range 30-48) were analyzed. Of those, 670 patients (80%) developed PDAC recurrence after a median follow-up of 10 months (interquartile range 5-17). Additional treatment was performed in 159/511 patients (31%) with symptomatic recurrence versus 77/159 (48%) asymptomatic patients (P < 0.001). After propensity-score matching on lymph node ratio, adjuvant therapy, disease-free survival, and recurrence site, additional treatment was independently associated with improved OS for both symptomatic patients [hazard ratio 0.53 (95% confidence interval 0.42-0.67); P < 0.001] and asymptomatic patients [hazard ratio 0.45 (95% confidence interval 0.29-0.70); P < 0.001].

CONCLUSIONS

Additional treatment of PDAC recurrence was independently associated with improved OS, with asymptomatic patients having a higher probability to receive recurrence treatment. Therefore, standardized postoperative surveillance aiming to detect PDAC recurrence before the onset of symptoms has the potential to improve survival. This provides a rationale for prospective studies on standardized surveillance after PDAC resection.

Validation of IL-7R as an Immunological Biomarker for Human Pancreatic Ductal Adenocarcinoma

Simple Summary

Despite being the fourth-leading cause of cancer-related deaths worldwide, pancreatic ductal adenocarcinoma (PDAC) lacks early diagnostic methods. We performed mRNA sequencing on peripheral blood mononuclear cells isolated from PDAC patients and identified IL-7R as a potential early diagnostic biomarker for PDAC. Furthermore, we found that IL-7R had improved diagnostic performance when combined with CA19-9. Our previous study’s results with 23 individuals were validated in a cohort of 522 patients. Our findings suggested that IL-7R in combination with CA19-9 could have important clinical implications that contribute to an earlier PDAC diagnosis and improved patient survival.

Abstract

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer for which no early diagnostic method is available. The immune surveillance hypothesis suggests that the immune system plays crucial roles in tumor development and progression. We validated a PDAC-specific biomarker derived from peripheral blood mononuclear cells (PBMCs) to facilitate early PDAC diagnosis. mRNA levels of interleukin-7R (IL-7R), reportedly a potential immunological marker for PDAC, were measured in PBMCs isolated prospectively from healthy controls (n = 100) and patients with PDAC (n = 135), pancreatic cysts (n = 82), chronic pancreatitis (n = 42), acute pancreatitis (n = 47), and other malignancies (n = 116). The IL-7R level was significantly higher in patients with PDAC than in healthy controls, patients with benign pancreatic disease, and patients with other malignancies. As diagnostic parameters, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for IL-7R were 58.5%, 92%, 90.8%, 62.2%, and 72.8%, respectively. The area under the receiver operating characteristic curve (AUROC) was 0.766. IL-7R levels did not differ between resectable and unresectable PDAC cases. The combined measurement of IL-7R and carbohydrate antigen 19-9 (CA19-9) significantly improved the diagnostic parameters and AUROC compared with the use of IL-7R or CA19-9 alone. IL-7R is significantly upregulated in PBMCs in patients with PDAC, and it may be a novel diagnostic marker for PDAC. The combined use of IL-7R and CA19-9 enhanced the diagnostic performance.

[Pylorus-Preserving Pancreaticoduodenectomy (PPPD) with Segmental Portal Vein Resection]

INTRODUCTION

Pylorus-preserving partial pancreatoduodenectomy is a complex visceral operation, especially when simultaneous resection and reconstruction of the portal venous axis is necessary. Pancreatic anastomosis plays a decisive role in this procedure, since postoperative pancreatic fistula (POPF) is a frequent complication, with serious consequences (morbidity and mortality) for the affected patient. Various techniques are available for anastomosing the residual pancreas: the duct-to-mucosa pancreaticojejunostomy, invaginating pancreatojejunostomy, Blumgart anastomosis and pancreatogastrostomy.

INDICATION

Adenocarcinoma of the pancreatic head with portal vein infiltration.

PROCEDURE

Pylorus-preserving pancreaticoduodenectomy (PPPD) with portal vein resection.

CONCLUSION

A standardised and structured approach to pylorus-preserving partial pancreatoduodenectomy helps the surgeon to perform this procedure safely. Performing a simultaneous portal vein resection increases the complexity of the procedure, but nonetheless, if infiltration of the portal venous axis is suspected, the indication for en-bloc resection should be given generously, as intraoperatively it is not possible to differentiate reliably between inflammatory adherence and tumour infiltration and portal vein/V.-mesenterica-superior-resection does not increase morbidity and mortality. The choice of the surgical technique for anastomosing the residual pancreas should be made by the surgeon on the basis of his expertise and, if necessary, adapted to the patient's situs, since the most important pancreatic anastomosis techniques appear to be equivalent according to the current evidence.

Computed Tomographic Sarcopenia in Pancreatic Cancer: Further Utilization to Plan Patient Management

Purpose

The presence of a sarcopenia adversely affects the prognosis of patients with pancreatic cancer. There is an emerging role for using computed tomography (CT) to calculate skeletal muscle index (SMI) and the presence of sarcopenia. The aim of this study was to assess if detecting ‘computed tomographic sarcopenia’ is feasible and can contribute to the management of patients with locally advanced pancreatic cancer (LAPC).

Methods

Patients diagnosed with LAPC referred for endoscopic ultrasound-guided biopsy (EUS-B) by our regional cancer network were identified. Age, body mass index (BMI), and Eastern Cooperative Oncology Group performance status (ECOG-PS) were noted. CT images were analysed for SMI and the presence of sarcopenia. Decision outcomes on receiving chemotherapy or not were collected from the regional oncology database.

Results

In total, 51/204 (25%) patients with LAPC who underwent EUS-B were not given chemotherapy and received best supportive care (BSC) only. The prevalence of sarcopenia (p = 0.0003), age ≥ 75 years old (p = 0.03), and ECOG-PS 2–3 (p = 0.01) were significantly higher in the patients receiving BSC only. Logistic regression analysis demonstrated that SMI was the only independent associated factor identifying patients with LAPC who were treated with BSC only and not chemotherapy after adjusting for age and ECOG-PS.

Conclusion

Our study has shown that computed tomographic skeletal muscle analysis at the time of a diagnostic CT for patients with pancreatic cancer is feasible and can detect sarcopenia and malnourished patients who are much less likely to take up chemotherapy. These patients could be triaged to oncology assessment prior to EUS-B to avoid unnecessary investigations.

Biomarkers in the diagnosis of pancreatic cancer: Are we closer to finding the golden ticket?

Pancreatic cancer (PC) is a leading cause of cancer related mortality on a global scale. The disease itself is associated with a dismal prognosis, partly due to its silent nature resulting in patients presenting with advanced disease at the time of diagnosis. To combat this, there has been an explosion in the last decade of potential candidate biomarkers in the research setting in the hope that a diagnostic biomarker may provide a glimmer of hope in what is otherwise quite a substantial clinical dilemma. Currently, serum carbohydrate antigen 19-9 is utilized in the diagnostic work-up of patients diagnosed with PC however this biomarker lacks the sensitivity and specificity associated with a gold-standard marker. In the search for a biomarker that is both sensitive and specific for the diagnosis of PC, there has been a paradigm shift towards a focus on liquid biopsy and the use of diagnostic panels which has subsequently proved to have efficacy in the diagnosis of PC. Currently, promising developments in the field of early detection on PC using diagnostic biomarkers include the detection of microRNA (miRNA) in serum and circulating tumour cells. Both these modalities, although in their infancy and yet to be widely accepted into routine clinical practice, possess merit in the early detection of PC. We reviewed over 300 biomarkers with the aim to provide an in-depth summary of the current state-of-play regarding diagnostic biomarkers in PC (serum, urinary, salivary, faecal, pancreatic juice and biliary fluid).

Clinical benefit of surveillance after resection of pancreatic ductal adenocarcinoma: A systematic review and meta-analysis

BACKGROUND

The value of routine surveillance after resection of pancreatic ductal adenocarcinoma (PDAC) is unclear, and expert guidelines offer conflicting recommendations. This study is a systematic review of evidence for surveillance programs.

METHODS

A systematic review of studies evaluating different surveillance methods was undertaken. A meta-analysis was performed for those studies reporting rates of asymptomatic recurrence, treatment of recurrence and overall survival, according to different surveillance methods.

RESULTS

Ten studies were included in the literature review, with five studies appropriate for meta-analysis (1596 patients). Patients within active surveillance programs were more likely to have recurrence detected at an asymptomatic stage (Pooled Rate: 49.3% vs. 19.1%, p = 0.043). Within studies reporting these outcomes, patients with asymptomatic recurrence were more likely to receive treatment for recurrence (Odds Ratio 3.49; 95% CI: 1.73-7.07; p < 0.001) and had longer overall survival (Mean Difference: 9.5 months; 95% CI: 4.1-14.8; p < 0.001) than those with symptoms at time of recurrence.

DISCUSSION

Routine surveillance after surgery for PDAC appears to detect more patients at an asymptomatic stage. Data from these non-randomised trials also suggest that treatment rates and survival may be superior in patients were recurrence is detected when asymptomatic. As such, these data suggest that routine surveillance may improve patient outcomes, although an appropriately conducted trial would be required to address concerns that various sources of bias may be affecting these results.

Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer

Simple Summary

Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life.

Abstract

Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.

Silencing of FTX suppresses pancreatic cancer cell proliferation and invasion by upregulating miR-513b-5p

BACKGROUND

Abnormal expression of long non-coding RNA (lncRNA) FTX (five prime to Xist), which is involved in X chromosome inactivation, has been reported in various tumors. However, the effect of FTX on the development of pancreatic cancer (PC) has not been elucidated. The purpose of this study was to explore the possible molecular mechanism of FTX in PC.

METHODS

Quantitative real-time PCR (qRT-PCR) was used to measure the expression levels of FTX and miR-513b-5p in PC cell lines. Proliferation and apoptosis of PC cells were determined by CCK-8, Edu assay, and flow cytometry. Invasion and migration ability of PC cells were detected by Transwell assay and scratch test. Bioinformatics analysis, luciferase reporter gene assay, and RNA immunoprecipitation (RIP) assay were used to verify the direct binding between FTX and miR-513b-5p. The xenotransplantation mouse model was established to explore the effect of FTX and miR-513b-5p on the PC tumor growth in vivo.

RESULTS

The expression levels of FTX were increased in PC cell lines, and silencing of FTX remarkably suppressed the invasion ability and cell viability. Besides, FTX could bind to miR-513b-5p as a competitive endogenous RNA, thus promoting the invasion and proliferation ability of PC cells. Moreover, knockdown of FTX inhibited the tumor growth and increased the expression levels of miR-513b-5p and apoptosis-related proteins in vivo.

CONCLUSIONS

FTX could directly combine with miR-513b-5p as a competitive endogenous RNA, thus promoting the occurrence and development of PC in vitro and in vivo.

Essential updates 2019/2020: Multimodal treatment of localized pancreatic adenocarcinoma: Current topics and updates in survival outcomes and prognostic factors

Overall survival of patients with localized pancreatic ductal adenocarcinoma (PDAC) is extremely poor. Therefore, the establishment of multimodal treatment strategies is indispensable for PDAC patients because surgical treatment alone could not contribute to the improvement of survival. In this review article, we focus on the current topics and advancement of the treatments for localized PDAC including resectable, borderline resectable, and locally advanced PDAC in accordance with the articles mainly published from 2019 to 2020. Reviewing the articles, the recent progress of multimodal treatments notably improves the prognosis of patients with localized PDAC. For resectable PDAC, neoadjuvant chemo or chemoradiation therapy, rather than upfront surgery, plays a key role, especially in patients with a large tumor, poor performance status, high tumor marker levels, peripancreatic lymph nodes metastasis, or neural invasion suspected on preoperative imaging. For borderline resectable PDAC, neoadjuvant treatments followed by surgery is a desirable approach, and maintenance of immunonutritional status during the treatments are also important. For locally advanced disease, conversion surgery has a central role in improving a survival outcome; however, its indication should be standardized.

Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis

BACKGROUND

The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC.

METHODS

A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC).

RESULTS

Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery.

CONCLUSION

Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.

A nomogram of preoperative predictors for occult metastasis in patients with PDAC during laparoscopic exploration

Background

Surgical resection is the only potentially curative treatment for pancreatic ductal adenocarcinoma (PDAC). However, most of patients lose the chance of surgery due to the unresectable disease at the time of diagnosis. Despite the improvement of radiological imaging, a portion of patients intended for radical resection were proven to be unresectable at surgical exploration due to occult metastasis.

Methods

Patients who were aimed to undergo radical pancreatectomy for PDAC from 2010 to 2019 were reviewed retrospectively. All patients included underwent diagnostic laparoscopic exploration. Patients were divided into two groups depending on whether distant metastasis were encountered during exploration. Univariate and multivariate logistic regression analyses were used to identify risk factors for occult metastasis. A nomogram to predict occult metastasis of PDAC on exploration was developed and evaluated.

Results

A total of 273 patients who underwent diagnostic laparoscopic exploration were included in this study. Nineteen (7.0%) patients were found with distant metastasis during exploration. Multivariate logistic regression analysis showed that ALT>40U/L, CA19-9, CA125 and regional nodes enlargement were independent predictors for occult metastasis. Incorporating these four factors, the nomogram achieved concordance index of 0.799, with a well-fitted calibration curve.

Conclusions

Occult metastasis is not unusual during surgical exploration in patients with resectable or borderline resectable PDAC. The nomogram could achieve a personal prediction of unexpected distant metastasis on exploration. It may help to sift through patients with PDAC who would benefit from laparoscopic exploration.

Para-aortic lymph node metastasis detected intraoperatively by systematic frozen section examination in pancreatic head adenocarcinoma: is resection improving the prognosis?

BACKGROUND

This study aimed to evaluate the controversial benefit of a pancreaticoduodenectomy (PD) in patients with PALN metastasis intraoperatively detected by systematic frozen section examination in pancreatic adenocarcinoma.

METHODS

PALN intraoperative examination by frozen section was systematically performed from January 2006 to February 2018 prior to performing PD for pancreatic adenocarcinoma. Until June 2012, PALN + patients still underwent PD (PALN+/PD group) in the framework of a prospective study. Since July 2012, PALN+ was considered as contraindicating the planned PD (PALN+/No-PD group). Post-operative morbidity and survival were compared between these two groups.

RESULTS

Of the 32 PALN + patients intraoperatively detected, the first 13 underwent a PD, while the last 19 did not undergo resection. Seven patients (54%) among 13 PALN+/PD patients developed a post-operative complication against 3 (16%) among 19 PALN+/No-PD patients (p = 0.049). The median length of stay was 5 days longer for PALN+/PD patients (p = 0.001). The median survival did not differ between PALN+/No-PD and PALN+/PD groups (respectively 13.4 months (95%CI:7.6-19.3) and 11.5 months (95%CI:5.9-17.1), p = 0.471). No patient was alive 4 years after surgery in both the PALN+/No-PD or PALN+/PD groups.

CONCLUSION

In case of PALN detected intraoperatively in pancreatic adenocarcinoma, PD does not improve survival compared to current palliative treatment.

Amperometric galectin-3 immunosensor-based gold nanoparticle-functionalized graphitic carbon nitride nanosheets and core-shell Ti-MOF@COFs composites

Antigen galectin-3 (GL-3), a member of β-galactoside proteins indicates cardiac fibrosis and is a significant biomarker for monitoring heart failure risk and death risk. In this study, a novel sensitive amperometric method for antigen GL-3 detection is developed based on gold nanoparticle-functionalized graphitic carbon nitride nanosheets (g-C₃N₄@Au NPs) as the sensor platform and Ti-based metal organic framework (Ti-MOF, NH₂-MIL-125)@covalent organic frameworks (COFs) composite for the signal amplification. The Ti-MOF@COF composite not only facilitates the penetration of antibody proteins into pore channels, but also the highly stable antigen-antibody interactions. The prepared sensor platform and signal amplification material are characterized by transmission electron microscopy (TEM), scanning electron microscopy (SEM), X-ray diffraction (XRD) method, X-ray photoelectron spectroscopy (XPS), UV-vis spectroscopy, Fourier transform infrared spectroscopy (FTIR), cyclic voltammetry (CV) and electrochemical impedance spectroscopy (EIS). The amperometric technique is utilized to achieve antigen GL-3 detection in plasma samples. The immunosensor demonstrates a wide linearity range (0.0001-20.0 ng mL^-1) and a low detection limit (0.025 pg mL^-1). Finally, the prepared immunosensor shows high stability and selectivity under optimum conditions.

Italian registry of families at risk of pancreatic cancer: AISP Familial Pancreatic Cancer Study Group

Pancreatic cancer is one of the main causes of cancer-related death worldwide, with a survival rate around 9%. In Italy 13,500 new cases of pancreatic cancer occurred in 2019. It is estimated that at least 5% have a hereditary background. Surveillance is advisable for healthy individuals with specific genetic syndromes with or without family history of pancreatic cancer or members of families with multiple cases of pancreatic cancer, irrespective of genetic syndromes. In 2010 the Italian Association for the Study of the Pancreas (AISP) defined criteria to include individuals in such surveillance programs with the first-round results published in 2019. In order to include other categories at high-risk and increase the diagnostic yield of surveillance, these criteria have recently been modified. The present position paper presents the updated criteria of the Italian Registry of Families at Risk of Pancreatic Cancer (IRFARPC) with their diagnostic yield calculation. Also, AISP priority projects concerning: (a) increasing awareness of citizens and primary care physicians through a dedicated App; (b) increasing access to germline testing to personalize surveillance; (c) measuring psychological impact of surveillance; (d) investigating the role of risk-modifiers and (e) evaluating the cost-effectiveness and ability to save lives of the program are briefly presented.

Estimating Recurrence after Upfront Surgery in Patients with Resectable Pancreatic Ductal Adenocarcinoma by Using Pancreatic CT: Development and Validation of a Risk Score

Background No preoperative model is available for predicting postsurgical prognosis of patients with resectable pancreatic ductal adenocarcinoma (PDAC). Purpose To develop and validate a preoperative risk scoring system using clinical and CT variables to predict recurrence-free survival (RFS) after upfront surgery in patients with resectable PDAC. Materials and Methods In this retrospective study, consecutive patients with resectable PDAC underwent upfront surgery from January 2014 to December 2015 (development set) and from January 2016 to January 2017 (test set). In the development set, multivariable Cox proportional hazard modeling with bootstrapping was used to select clinical and CT variables associated with RFS and to construct a risk scoring system. The discrimination capability of the risk score was assessed by using the Harrell C-index and compared with that of pathologic American Joint Committee on Cancer tumor stage. The risk score was validated in the test set. Results A total of 395 patients were evaluated, including 262 patients (mean age ± standard deviation, 64 years ± 10; 155 men) in the development set and 133 (mean age, 64 years ± 9; 79 men) in the test set. Five independent variables predicted risk of recurrence or death: tumor size (hazard ratio [HR], 1.23; 95% confidence interval [CI]: 1.05, 1.44; P = .009), hypodense tumor in the portal venous phase (HR, 1.66; 95% CI: 1.01, 2.73; P = .04), tumor necrosis (HR, 2.04; 95% CI: 1.38, 3.03; P < .001), peripancreatic tumor infiltration (HR, 1.50; 95% CI: 1.07, 2.11; P = .02), and suspicious metastatic lymph nodes (HR, 1.94; 95% CI: 1.38, 2.72; P < .001). In the test set, the risk score showed good discrimination capability (C-index of 0.68; 95% CI: 0.63, 0.74) and outperformed the pathologic tumor stage (C-index of 0.60; 95% CI: 0.55, 0.66; P = .03). Patients were categorized into favorable, intermediate, and poor prognosis groups with 1-year RFS of 0.87, 0.58, and 0.26, respectively. Conclusion The presented preoperative risk score can predict recurrence-free survival after upfront surgery in patients with resectable pancreatic ductal adenocarcinoma. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Pandharipande and Anderson in this issue.

Von der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie konsentierte Operationsindikationen beim duktalen Pankreasadenokarzinom

Hintergrund Die Zahl der Operationen für Pankreaskarzinome in Deutschland nimmt kontinuierlich zu. Das entspricht der steigenden Inzidenz dieser Erkrankung in der Bevölkerung. Diese Übersichtsarbeit fasst die evidenzbasierten aktuellen Operationsindikationen bei Patienten mit Pankreaskarzinom zusammen.

Methode Als DGAV-Initiative wurde eine Arbeitsgruppe von Pankreasexperten eingerichtet. Diese formulierte konkrete Schlüsselfragen nach dem PICO-Schema, führte eine systematische Literatursuche in Medline und Cochrane Library (1989 – 2019) zu Studien und Leitlinien mit Aussagen zu Operationsindikationen bei Pankreaskarzinom durch und erstellte daraus resultierende evidenzbasierte Empfehlungen. Diese wurden innerhalb der CALGP im Rahmen eines Delphi-Verfahrens abgestimmt.

Ergebnisse Die Operationsindikation bei Pankreaskarzinom soll im Tumorboard von erfahrenen Pankreaschirurgen leitliniengerecht und unter Berücksichtigung der individuellen Besonderheiten der Patienten gestellt werden. Fortgeschrittene Infiltration der großen Viszeralgefäße, multiple Fernmetastasen und schwere Komorbiditäten, die einen Eingriff in Vollnarkose verbieten, stellen die häufigsten Kontraindikationen zur Operation dar. Die Therapie von Borderline-resektablen und primär resektablen oligometastatischen Patienten sowie solchen mit sekundärer Resektabilität nach neoadjuvanter Behandlung soll bevorzugt an Zentren und im Rahmen von Studien erfolgen. Die Behandlung an Pankreaszentren reduziert die Mortalität und verbessert das Überleben. Die palliative Bypasschirurgie kann bei endoskopisch nicht therapierbaren Gallenwegs- und Duodenalobstruktionen indiziert sein. Bei diagnostischen Schwierigkeiten kann die Staging-Laparoskopie mit histologischer Sicherung eingesetzt werden.

Schlussfolgerung Unabhängig von der Entwicklung erfolgversprechender multimodaler Behandlungskonzepte bleibt die chirurgische Resektion weiterhin der einzig kurative Therapieeinsatz. Wegen des hohen Anteils von primär fortgeschrittenen und metastasierten Pankreaskarzinomen spielt auch die palliative Chirurgie weiterhin eine wichtige Rolle in der komplexen Versorgung dieses Patientenkollektivs.

Routine Chest Computed Tomography for Staging of Pancreatic Head Carcinoma

OBJECTIVES

The diagnostic value of routine chest computed tomography (CT) in addition to abdominal CT in workup for pancreatic head carcinoma is unclear. The aim of this study was to determine if routine chest CT revealed significant lesions that altered the management of patients with suspected pancreatic head carcinoma.

METHODS

All Dutch pancreatic cancer centers were surveyed on the use of chest CT in preoperative staging. In addition, a single-center retrospective cohort study was performed including all patients referred with suspected pancreatic head malignancy without chest CT between 2005 and 2016. The primary end point was the proportion of patients in which chest CT revealed clinically significant lesions, leading to a change in management.

RESULTS

In 7 of 18 Dutch pancreatic cancer centers (39%), a preoperative chest CT is not routinely performed. In the study cohort, 170 of 848 patients (20%) were referred without chest CT and underwent one by local protocol. Chest CT revealed new suspicious lesions in 17 patients (10%), of whom 6 had metastatic disease (3.5%).

CONCLUSIONS

Routine use of chest CT in diagnostic workup for pancreatic head carcinoma reveals clinically significant lesions in 10% of patients, being metastases in up to 4%.

Pancreatic Cancer: A Review of Risk Factors, Diagnosis, and Treatment

This review aims to summarize the latest knowledge on factors, diagnosis, and treatment of pancreatic cancer, and aims to promote further research on this under-studied malignant tumor. At present, we urgently need to identify high-risk patients with precancerous diseases through screening approaches, so that medical professionals and the general public may better understand prevention strategies or early detection measures. Pancreatic cancer is a highly invasive malignant tumor with a fatal risk, mainly seen in men and older adults (60-85 years old). Pancreatic cancer is now increasingly observed in young patients. Because the disease has no early symptoms and can quickly invade surrounding tissues and organs, it is one of the deadliest cancers. With a view to identify the important factors for the development of pancreatic cancer, previous studies have found that smoking, alcohol, and chronic pancreatitis are considered high-risk factors. Recent studies have shown that abnormal metabolism of human microorganisms, blood type, and glucose and lipid levels are also important factors in the development of pancreatic cancer. Identifying early diagnosis options is an important way to improve detection and survival rates of pancreatic cancer. None of the many tumor markers associated with pancreatic cancer are highly specific, which also indicates further research is required to improve the early detection rate. Future directions in terms of treatment evaluating the relationship between the microbiology-free system and immunotherapy will bring a major breakthrough and is expected to bring exciting clinical applications in improving the life-cycle of pancreatic cancer patients.

Whipple Grossing in the Era of New Staging: Should We Standardize?

Whipple procedure, also known as pancreatoduodenectomy, is the most common surgery for the removal of tumors of the head of the pancreas, ampulla, distal common bile duct, or periampullary duodenum. It is also one of the most challenging resection specimens grossed by surgical pathologists. A thorough and consistent evaluation of the gross surgical specimen is the most critical first step for accurate diagnosis, determination of tumor origin, staging, and evaluation of margin status. However, there has been no standard grossing protocol for Whipple specimens, which has led to inaccurate diagnoses, staging, and inconsistent reporting. This issue has become even more challenging in the era of the size-based tumor staging systems recommended by the new 8th Edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual. Moreover, new concerns have been raised regarding how to best evaluate margin status and lymph nodes. Studies have shown that different Whipple grossing methods can significantly impact margin assessment and lymph node yield and thus affect R0/R1 status and clinical stage. Other important issues under debate include nomenclature, definitions of margin (versus surface), and R1 status. Consistent Whipple grossing and standardization of reporting will provide better communication and more accurate diagnosis and staging, as well as prognostic prediction.

Population-based observational study of acute pancreatitis in southern England

INTRODUCTION

Acute pancreatitis is a common surgical emergency. Identifying variations in presentation, incidence and management may assist standardisation and optimisation of care. The objective of the study was to document the current incidence management and outcomes of acute pancreatitis against international guidelines, and to assess temporal trends over the past 20 years.

METHODS

A prospective four-month audit of patients with acute pancreatitis was performed across the Wessex region. The Atlanta 2012 classifications were used to define cases, severity and complications. Outcomes were recorded using validated systems and correlated against guideline standards. Case ascertainment was validated with clinical coding and hospital episode statistics data.

RESULTS

A total of 283 patient admissions with acute pancreatitis were identified. Aetiology included 153 gallstones (54%), 65 idiopathic (23%), 29 alcohol (10%), 9 endoscopic retrograde cholangiopancreatography (3%), 6 drug related (2%), 5 tumour (2%) and 16 other (6%). Compliance with guidelines had improved compared with our previous regional audit. Results were 6.5% mortality, 74% severity stratification, 23% idiopathic cases, 65% definitive treatment of gallstones within 2 weeks, 39% computed tomography within 6-10 days of severe pancreatitis presentation and 82% severe pancreatitis critical care admission. The Atlanta 2012 severity criteria significantly correlated with critical care stay, length of stay, development of complications and mortality (2% vs 6% vs 36%, P < 0.0001).

CONCLUSIONS

The incidence of acute pancreatitis in southern England has risen substantially. The Atlanta 2012 classification identifies patients with severe pancreatitis who have a high risk of fatal outcome. Acute pancreatitis management is seen to have evolved in keeping with new evidence and updated clinical guidelines.

Protein Induced by Vitamin K Absence II (PIVKA-II) as a potential serological biomarker in pancreatic cancer: a pilot study

Introduction

Protein induced by vitamin K absence II (PIVKA-II) is an abnormal prothrombin increased in gastrointestinal malignancy. We aimed to evaluate PIVKA-II in comparison to established pancreatic cancer (PC) biomarkers (CA 19-9, carcinoembryonic antigen (CEA) and CA 242) measured in PC patients and in patients with benign pancreatic diseases.

Materials and methods

We studied 26 PC patients (Group 1) and 20 patients with benign pancreatic diseases (Group 2). PIVKA-II and CEA were measured by chemiluminescent enzyme immunoassay method (CLEIA) on LUMIPULSE G1200 (Fujirebio-Europe, Gent, Belgium), CA 19-9 and CA 242 were measured by ELSA (CisBio Bioassays, Codolet, France) and EIA (Fujirebio Diagnostics AB, Göteborg, Sweden), respectively. Receiver operating characteristic (ROC) analysis was performed to assess biomarkers’ diagnostic characteristics in both groups.

Results

Median and interquartile range (IQR) in Group 1 and Group 2 were: 1749.0 (320.2 – 3921.0) vs. 31.0 (23.0 – 43.0) mAU/mL (P < 0.001) for PIVKA-II, 260.0 (158.7 – 272.0) vs. 45.2 (9.0 – 58.0) U/mL (P = 0.034) for CA 19-9, 104.0 (30.2 – 150.0) vs. 7.2 (4.8 – 26.0) U/mL (P < 0.050) for CA 242, 9.4 (5.3 – 37.5) vs. 4.5 (1.8 – 7.0) ng/mL (P = 0.021) for CEA. Areas under the ROC curve of PIVKA-II, CA 19-9, CA 242, CEA were 0.86 (95% CI: 0.71 – 1.00), 0.58 (95% CI: 0.38 – 0.78), 0.73 (95% CI: 0.54 – 0.92), 0.64 (95% CI: 0.44 – 0.85), respectively.

Conclusions

PIVKA-II is significantly higher in PC than in benign pancreatic diseases. PIVKA-II shows a rather good diagnostic performance compared to CA 19-9, CEA and CA242, thus its determination could help PC management.

Meta-analysis of recurrence pattern after resection for pancreatic cancer

Background

Initial recurrence mapping of resected pancreatic ductal adenocarcinoma (PDAC) could help in stratifying patient subpopulations for optimal postoperative follow-up. The aim of this systematic review and meta-analysis was to investigate the initial recurrence patterns of PDAC and to correlate them with clinicopathological factors.

Methods

MEDLINE and Web of Science databases were searched systematically for studies reporting first recurrence patterns after PDAC resection. Data were extracted from the studies selected for inclusion. Pooled odds ratios (ORs) and 95 per cent confidence intervals were calculated to determine the clinicopathological factors related to the recurrence sites. The weighted average of median overall survival was calculated.

Results

Eighty-nine studies with 17 313 patients undergoing PDAC resection were included. The weighted median rates of initial recurrence were 20·8 per cent for locoregional sites, 26·5 per cent for liver, 11·4 per cent for lung and 13·5 per cent for peritoneal dissemination. The weighted median overall survival times were 19·8 months for locoregional recurrence, 15·0 months for liver recurrence, 30·4 months for lung recurrence and 14·1 months for peritoneal dissemination. Meta-analysis revealed that R1 (direct) resection (OR 2·21, 95 per cent c.i. 1·12 to 4·35), perineural invasion (OR 5·19, 2·79 to 9·64) and positive peritoneal lavage cytology (OR 5·29, 3·03 to 9·25) were significantly associated with peritoneal dissemination as initial recurrence site. Low grade of tumour differentiation was significantly associated with liver recurrence (OR 4·15, 1·71 to 10·07).

Conclusion

Risk factors for recurrence patterns after surgery could be considered for specific surveillance and treatments for patients with pancreatic cancer.

Bridging clinic: The initial medical management of patients with newly diagnosed pancreatic cancer

Pancreatic cancer is the 11th most common cancer in the UK and has the worst prognosis of any tumour with minimal improvements in survival over recent decades. As most patients are either ineligible for surgery or may decline chemotherapy, the emphasis is on control of symptoms and management of complications such as poor nutritional status. The time period between informing the patient of their diagnosis and commencing cancer treatments presents a valuable opportunity to proactively identify and treat symptoms to optimise patients' overall well-being. The 'bridging clinic', delivered by a range of healthcare professionals from gastroenterologists to nurse practitioners, can provide this interface where patients are first informed of their diagnosis and second supportive therapies offered. In this article, we provide a structure for instituting such supportive therapies at the bridging clinic. The components of the clinic are summarised using the mnemonic INDASH (Information/Nutrition/Diabetes and Depression/Analgesia/Stenting/Hereditary) and each is discussed in detail below.

Postoperative surveillance of pancreatic cancer patients

BACKGROUND

The aim of this study is to collect the best available evidence for diagnostic modalities, frequency, and duration of surveillance after resection for pancreatic ductal adenocarcinoma (PDAC).

METHODS

PDAC guidelines published after 2015 were collected. Furthermore, a systematic search of the literature on postoperative surveillance was performed in PubMed and Embase from 2000 to 2019. Articles comparing different diagnostic modalities and frequencies of postoperative surveillance in PDAC patients with regard to survival, quality of life, morbidity and cost-effectiveness were selected.

RESULTS

The literature search resulted in 570 articles. A total of seven guidelines and twelve original clinical studies were eventually evaluated. PDAC guidelines increasingly recommend a combination of tumor marker testing and computed tomography (CT) imaging every three to six months during the first two years after resection. These guidelines are, however, based on expert opinion and other low-level evidence. Prospective studies comparing different surveillance strategies are lacking. According to recent studies, surveillance with tumor markers and imaging at regular intervals results in the detection of PDAC recurrence before the onset of symptoms and more frequent administration of further therapy, such as chemotherapy or radiotherapy.

CONCLUSION

Current evidence for recurrence-focused surveillance after PDAC resection is limited and contradictory. Consequently, recommendations on surveillance are conflicting. To define the clinical merit of recurrence-focused surveillance, patients who are most likely to benefit from early detection and treatment of PDAC recurrence need to be identified. To this purpose, well-designed prospective studies are needed, accounting for both economical and psychosocial implications of surveillance.