Early diagnosis of chronic pancreatitis and pancreatic cancer

Pancreatic cancer after surgery for chronic pancreatitis

BACKGROUND

Chronic pancreatitis is known to be a risk factor for pancreatic cancer.

AIMS

To identify patients who were diagnosed with pancreatic cancer after undergoing surgery for histologically documented chronic pancreatitis.

PATIENTS/METHODS

Records of 484 consecutive patients who underwent surgery for chronic pancreatitis from 1976 to 1997 were reviewed.

RESULTS

Pancreatic cancer was diagnosed after a mean of 3.4 years (range: 2 months-1 years) in 14 patients (2.9%). In four patients, pancreatic cancer became evident within 12 months of surgery for chronic pancreatitis, suggesting cancer was present at the original surgery. Cancer presented with recurrent or persistent pain, jaundice, and/or weight loss. Pancreatic resection was possible in eight patients, but in the others, the cancer was inoperable. There was one long-term survivor (alive 14 years postoperatively), but for theothers mean survival was 10 months (16 months after resection vs. 4 months for inoperable cancer).

CONCLUSION

Pancreatic malignancy should be suspected in patients who have had surgery for chronic pancreatitis when symptoms (such as recurrent pain, jaundice, weight loss, or anorexia) recur. Attempts at curative pancreatic resection are indicated and can offer palliation and the potential for a cure.

Co-existent chronic pancreatitis and pancreatic neuroendocrine tumor. Case report and review of the literature

BACKGROUND

Few reports exist in the literature regarding neuroendocrine tumors either presenting as, or associated with, chronic pancreatitis. We report a case of chronic pancreatitis with a coexisting neuroendocrine tumor (gastrinoma) of the body of the pancreas. The available literature is reviewed.

METHODS

Patient data including history, surgical procedure, histology and radiology investigations were collected and summarized. A Medline search using the key words 'pancreatitis' and 'neuroendocrine tumors' was performed for the years 1966-1999. Cited references in the relevant papers not listed in Medline databases were also evaluated.

RESULTS

A 64-year-old female patient was operated on for unclear cystic lesions in the head and tail of the pancreas. Intraoperatively, a gastrinoma was incidentally discovered in the body of the pancreas. It did not appear to be obstructing the main pancreatic duct. The patient underwent a distal pancreatectomy with pancreatico-jejunostomy. Four months postoperatively, she is doing well with no signs of tumor recurrence. The Medline search revealed 125 publications, of which only 17 dealt with either acute or chronic pancreatitis associated with neuroendocrine tumors. When all available data were included, there were 26 cases of neuroendocrine tumors associated with acute pancreatitis. Additionally, 11 cases were associated with chronic pancreatitis, of which only 3 appear to be merely coexistent with chronic pancreatitis without an apparent cause-and-effect relationship between these two entities.

CONCLUSION

We report the rare co-existence of chronic pancreatitis and a neuroendocrine tumor (gastrinoma) of the pancreas. The cause-and-effect relationship between neuroendocrine tumors of the pancreas and chronic pancreatitis continues to be uncertain. However, when the etiology of chronic pancreatitis is unclear, rare neuroendocrine tumors of the pancreas might be considered. Questions remain with regard to the potential role of chronic pancreatitis in the pathogenesis of pancreatic neuroendocrine tumors.

Ductal lesions in patients with chronic pancreatitis show K-ras mutations in a frequency similar to that in the normal pancreas and lack nuclear immunoreactivity for p53

BACKGROUND

Chronic pancreatitis (CP) is considered to be a risk factor for the development of pancreatic carcinoma. The detection of K-ras mutations in the duodenal or pancreatic juice has been held to be a reliable tool for its early diagnosis. However, K-ras mutations also occur in hyperplastic ductal epithelium, making it difficult to interpret their role in pancreatic carcinogenesis.

METHODS

The study included 30 resection specimens, 15 from patients with alcoholic CP, and 15 from patients with idiopathic CP. The mean duration of disease was 6.8 years. A total of 429 ductal lesions were classified according to the World Health Organization classification (1996) and microdissected. K-ras analysis was performed by means of polymerase chain reaction (45 cycles), constant denaturing gel electrophoresis, and sequencing. Immunostaining was performed with antibodies against p53, Ki-S5, carcinoembryonic antigen, and two types of mucins.

RESULTS

The 30 specimens demonstrated all types of ductal lesions. Severe cellular atypia was not observed. A total of 429 ductal lesions were analyzed. Approximately 4.4% of the lesions (19 of 429) from 27% of the patients (8 of 30) showed K-ras mutations, but they were unrelated to the duration or type of CP. Immunostaining for mutated p53 protein always was negative. Increased proliferative activity was noted only in patients with papillary hyperplasia. No patient developed pancreatic carcinoma within a follow-up period of at least 3 years.

CONCLUSIONS

Ductal lesions in patients with CP exhibit K-ras mutations without additional indications of neoplastic transformation such as severe dysplasia or mutated p53 protein. Therefore, for diagnostic and therapeutic purposes, the detection of K-ras mutations should be supplemented by the demonstration of additional genetic alterations or clinical signs of malignancy.

Long-term results after surgery for chronic pancreatitis

AIM

To determine the early and late morbidity and mortality after surgical treatment of chronic pancreatitis.

METHODS

We determined long-term outcome and early and late morbidity and mortality, respectively, in 484 consecutive patients undergoing surgery for chronic pancreatitis from 1976 through 1997. Sixty-five percent of the patients had small duct disease (main pancreatic duct <7 mm), whereas 35% had large duct disease. Indications for operation were pain (95%), suspicion of malignancy (28%), and complications involving adjacent organs (35%). Pseudocysts were present in 27% of patients. Hospital morbidity (8 vs 23%, p = 0.0002) and mortality (0 vs 1.9%, p = 0.12) were less after drainage procedures (n = 162) than after pancreatic resections (n = 286). Among resectional procedures, total pancreatectomy had the highest 30-d operative mortality (5%) and morbidity rates (47%), followed by pancreatoduodenectomy (3 and 32%, respectively). The best results with pain relief occurred after proximal pancreatic resection (89% after mean follow-up of 6.5 yr). The number of patients able to function normally after surgical treatment increased from 39 to 79% (p < 0.001). Long-term survival of our patients was lower than expected rates based on Minnesota life tables analysis (p < 0.0001) especially in alcoholics. Patients undergoing a ductal drainage procedure had the longest survival, whereas those after total pancreatectomy had the shortest survival (p = 0.06). Pancreatic insufficiency, peptic ulcer, and/or anastomotic ulcers caused significant morbidity after total pancreatectomy and pancreatoduodenectomy. A small percentage (3%) developed pancreatic cancer.

CONCLUSIONS

Operative treatment of chronic pancreatitis, when indicated, can be performed safely with good results in terms of pain relief and quality of life. Resectional procedures (especially total pancreatectomy) are associated with higher early and late morbidity, greater perioperative mortality, and lower survival rates compared with drainage procedures. Abstinence from alcohol is associated with longer survival rates, which, however, still remain lower than expected rates.

Pancreatic cancer in patients with chronic pancreatitis: a challenge from a surgical perspective

Chronic pancreatitis (CP) is generally considered as a risk factor for pancreatic adenocarcinoma (PAC). However, the cumulative risk differs among the epidemiological studies. In the individual patient, the differential diagnosis between PAC and CP cannot be always resolved preoperatively and even intraoperatively. In those cases, the uncertainty can only be answered with histological studies of the resected specimen after a radical resection, provided that this type of surgery can be performed with a reasonable risk in a surgically fit patient. The type of resection depends on the location of the suspicious mass. For masses in the tail of the pancreas, a distal pancreatectomy is the procedure of choice. For suspicious lesions in the head of the pancreas, a pancreatoduodenectomy (PD) should be performed. The surgeon and the patient should also acknowledge that a radical resection will occasionally be performed for a suspected malignancy only to find that another etiology (i.e. CP) accounts for the suspicious pancreatic mass. In the presence of a strong suspicion for an underlying malignancy in a patient with head dominant CP, PD should probably be preferred over the newer organ-preserving Beger and Frey procedures, since it is an adequate procedure for both CP and PAC.

Intraductal carcinoma (carcinoma in situ) of the pancreas with microinvasion

We report a case of predominantly intraductal carcinoma of the pancreas with microscopic foci of invasive carcinoma in a patient with chronic pancreatitis. In this article, we discuss the pathologic and prognostic features of pancreatic carcinoma in situ. This entity is probably overlooked due to a number of reasons, including the fact that, in most cases, pancreatic ductal carcinomas are extensively infiltrative at the time of surgical removal; the atypical epithelial changes in the intraductal carcinoma had been overlooked in the presence or absence of an invasive component; epithelial changes may be missed due to insufficient sampling; and last, the differentiation with atypical epithelial hyperplasia is a subjective matter. Intraductal carcinoma of the pancreas is a distinct pathological entity with characteristic morphologic changes restricted to the ductal epithelium, bearing important prognostic implications.

Thyroid autoantibodies and thyroid function in patients with pancreatic adenocarcinoma

Pancreatic adenocarcinoma (PA) patients often present high serum titres of several autoantibodies including autoantibodies against beta-islet cells and insulin. In the present study we examined with an hemagglutination method the sera of 33 patients with PA for the presence of both anti-mitochondrial and anti-thyroglobulin antithyroid autoantibodies (ATA). Twenty-six surgical patients with other non-malignant gastrointestinal tract (GI) disease (chronic pancreatitis or hernia) and 40 healthy volunteers were used as controls. Eight of the 33 PA patients were found to have ATA autoantibodies, whereas only one patient with chronic pancreatitis and 2 normal individuals had high serum ATA titres. The difference between the PA patients and either of the control groups was statistically significant (p < 0.05). The production of autoantibodies could be attributed to impaired immunoregulation caused by the malignant cells.

Pancreatitis associated with neuroendocrine (islet cell) tumors of the pancreas

BACKGROUND

The association of pancreatitis with neuroendocrine tumors of the pancreas is uncommon, whereas its association with exocrine pancreatic cancer is well recognized. Since the latter, but not the islet cell tumor, is thought to originate within the ductal system, it is not surprising that pancreatitis is less likely to result from the islet cell tumor. The senior author has recently noted that the first recognizable indication of an islet cell carcinoma may be one or more discrete attacks of acute pancreatitis.

METHODS AND RESULTS

Acute pancreatitis, resulting from an islet cell tumor, has been observed in five patients, in one of whom it had become chronic. In four of the patients, the tumor was malignant. A review of the English language literature reveals 14 such patients with pancreatitis, and 2 others have been noted in other languages (a total of 21 patients). The tumor was malignant in 15 of the 21 patients (71%). Although the development of pancreatitis was found to result from the obstruction of the duct in most patients, at least three seemed unrelated. In 12 of 21 cases (57%), an acute attack of pancreatitis, usually recurrent, was the initial syndrome, in contradistinction to pancreatitis resulting from exocrine tumors, which has usually been chronic in nature.

CONCLUSION

Pancreatitis, particularly acute pancreatitis, may result from an islet cell tumor. Although unusual, its occurrence may be the first signal of the presence of the tumor. In our experience, obstruction of the pancreatic duct by the islet cell carcinoma appears to be the important etiologic factor.

Autoantibodies against insulin and beta-islet cells in pancreatic adenocarcinoma: a possible explanation for diabetes mellitus

To evaluate the prevalence of autoantibodies against the b-islet cells (ICA) and the molecule of insulin (IAA) in the serum of patients with pancreatic adenocarcinoma (PA), we examined the sera of 36 newly diagnosed pancreatic adenocarcinoma patients for the presence of these antibodies, using an enzyme-linked immuno-assay method. These results were correlated with survival. Ten patients with insulin-dependent diabetes mellitus (IDDM) and 21 healthy volunteers were evaluated as age-matched controls. Twenty out of 36 (57%) PA patients were found to have detectable ICA autoantibodies and 17 (48%) PA patients had detectable IAA antibodies. Five out of 10 (50%) and 3 out of 10 (30%) IDDM patients had ICA and IAA antibodies, respectively. None of the healthy volunteers was positive for either of the autoantibodies examined. The difference was statistically very significant and the presence of high serum titers of both autoantibodies was associated with a worse outcome for these patients than for those without such autoantibodies. Our data suggest that the high incidence of diabetes mellitus in patients with PA may be attributed to the presence of these autoantibodies. Further clinical studies are needed to establish the above autoantibodies as prognostic markers of pancreatic cancer.

Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group

BACKGROUND

The results of case-control studies and anecdotal reports suggest that pancreatitis may be a risk factor for pancreatic cancer, but there have been no studies of sufficient size and power to assess the magnitude of the relation between these two diseases.

METHODS AND RESULTS

We undertook a multicenter historical cohort study of 2015 subjects with chronic pancreatitis who were recruited from clinical centers in six countries. A total of 56 cancers were identified among these patients during a mean (+/-SD) follow-up of 7.4 +/- 6.2 years. The expected number of cases of cancer calculated from country-specific incidence data and adjusted for age and sex was 2.13, yielding a standardized incidence ratio (the ratio of observed to expected cases) of 26.3 (95 percent confidence interval, 19.9 to 34.2). For subjects with a minimum of two or five years of follow-up, the respective standardized incidence ratios were 16.5 (95 percent confidence interval, 11.1 to 23.7) and 14.4 (95 percent confidence interval, 8.5 to 22.8). The cumulative risk of pancreatic cancer in subjects who were followed for at least 2 years increased steadily, and 10 and 20 years after the diagnosis of pancreatitis, it was 1.8 percent (95 percent confidence interval, 1.0 to 2.6 percent) and 4.0 percent (95 percent confidence interval, 2.0 to 5.9 percent), respectively.

CONCLUSIONS

The risk of pancreatic cancer is significantly elevated in subjects with chronic pancreatitis and appears to be independent of sex, country, and type of pancreatitis.