Progress report. Cancer of the pancreas

Will Endoscopic-Ultrasound-Guided Choledocoduodenostomy with Electrocautery-Enhanced Lumen-Apposing Metal Stent Placement Replace Endoscopic Retrograde Cholangiopancreatography When Treating Distal Malignant Biliary Obstructions?

Malignant distal biliary obstructions are becoming increasingly common, especially in patients with cancers of the pancreatic head, despite progress in medical oncology research. ERCP is the current gold standard for management of such strictures, but the emergence of EC-LAMS has rendered EUS-CDS both safe and efficient. It is a "game changer"; originally intended for ERCP failure, two randomised clinical trials recently proposed EUS-CDS as a first-intent procedure in palliative settings. For resectable diseases, the absence of iatrogenic pancreatitis associated with a lower rate of postsurgical adverse events (compared with ERCP) leads us to believe that EUS-CDS might be used in first-intent as a pre-operative endoscopic biliary drainage.

Establishment and validation of a ubiquitination-related gene signature associated with prognosis in pancreatic duct adenocarcinoma

Background

Patients with pancreatic duct adenocarcinoma (PDAC) have varied prognoses that depend on numerous variables. However, additional research is required to uncover the latent impact of ubiquitination-related genes (URGs) on determining PDAC patients' prognoses.

Methods

The URGs clusters were discovered via consensus clustering, and the prognostic differentially expressed genes (DEGs) across clusters were utilized to develop a signature using a least absolute shrinkage and selection operator (LASSO) regression analysis of data from TCGA-PAAD. Verification analyses were conducted across TCGA-PAAD, GSE57495 and ICGC-PACA-AU to show the robustness of the signature. RT-qPCR was used to verify the expression of risk genes. Lastly, we formulated a nomogram to improve the clinical efficacy of our predictive tool.

Results

The URGs signature, comprised of three genes, was developed and was shown to be highly correlated with the prognoses of PAAD patients. The nomogram was established by combining the URGs signature with clinicopathological characteristics. We discovered that the URGs signature was remarkably superior than other individual predictors (age, grade, T stage, et al). Also, the immune microenvironment analysis indicated that ESTIMATEscore, ImmuneScores, and StromalScores were elevated in the low-risk group. The immune cells that infiltrated the tissues were different between the two groups, as did the expression of immune-related genes.

Conclusion

The URGs signature could act as the biomarker of prognosis and selecting appropriate therapeutic drugs for PDAC patients.

Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma

BACKGROUND

The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass.

METHODS

This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma.

RESULTS

We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05).

CONCLUSIONS

On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.

Genetic susceptibility in pancreatic ductal adenocarcinoma

BACKGROUND

The strongest risk factors for pancreatic adenocarcinoma are tobacco smoking and increasing age. However, only a few smokers or elderly individuals develop the disease and genetic factors are also likely to be important.

METHODS

The literature on genetic factors modifying susceptibility to cancer was reviewed, with particular regard to the interindividual variation that exists in the development of pancreatic adenocarcinoma.

RESULTS

Tobacco-derived carcinogen-metabolizing enzyme gene variants have been the main area of study in stratifying the risk of sporadic pancreatic cancer. Inconsistent results have emerged from the few molecular epidemiological studies performed.

CONCLUSION

There is great scope for further investigation of critical pathways and unidentified genetic influences may be revealed. This may eventually allow the identification of individuals at high risk who might be targeted for screening.

The inherited genetics of pancreatic cancer and prospects for secondary screening

It is estimated that pancreatic cancer has a familial component in approximately 5-10% of cases. Some of these cases are part of a defined cancer syndrome with a known gene mutation but in the remaining the causative gene remains unknown. In recent years, a better understanding of the molecular events that occur in the progression model of pancreatic cancer has lead to the development of secondary screening programmes with the aim of identifying early precursor lesions or pre-invasive cancer at a stage amenable to curative resection. High-risk groups who have an inherited predisposition for pancreatic cancer form the ideal group to study in developing a robust screening programme. Multimodality screening using computed tomography and endoluminal ultrasound in combination with molecular analysis of pancreatic juice are proving promising as diagnostics tools or at least serving as predictors of risk over a defined period.

Epidemiology of pancreatic cancer: an overview

INTRODUCTION

The incidence of pancreatic cancer worldwide appears to correlate with increasing age, and it is slightly more common among men and Jewish people. There is evidence that the incidence rate is higher among blacks than among whites.

METHODS

The published literature was reviewed for preparation of an overview on epidemiology of pancreatic cancer.

RESULTS

A possible role of diabetes in the etiology of pancreatic cancer has been suggested by different epidemiological studies. Several investigations indicate that a history of pancreatitis may increase the risk of pancreas cancer, and it appears that people with a history of pernicious anemia or partial gastrectomy for ulcer as well as cholecystectomy may be at higher risk. Individuals with familial adenomatous polyposis (FAP) also have a high risk of developing this cancer. Pancreatic cancer is seen in some breast cancer families with BRCA1 and BRCA2 mutations. Epidemiological studies have confirmed that relatives of individuals with pancreatic cancer have an increased risk of this malignancy. Affected family members of the familial atypical multiple-mole melanoma (FAMMM) as well as those with a positive family history of ataxia-telangiectasia (AT) have much higher risk of developing pancreatic cancer, compared with the general population. A positive association has been reported between pancreatic cancer risk and dietary intake such as fat and oil, meat, and dairy products, as well as with high intake of energy, fried foods, carbohydrates, cholesterol, and salt. The risk is found to decrease with increased consumption of fresh fruits and vegetables, fiber, natural foods, and Vitamin C. Cigarette smoking has shown the strongest positive association with risk of pancreatic cancer.

CONCLUSION

Some diseases and medical conditions such as diabetes, chronic pancreatitis, AP, family aggregation of pancreatic cancer, FAMMM, AT, as well as nutrition and lifestyle factors, like smoking may play important role in the etiology of pancreatic cancer.

Pancreatic cancer and diabetes: is there a relationship? A case-controlled study

BACKGROUND

There is controversy about whether diabetes mellitus is a risk factor for pancreatic cancer or an epiphenomenon of the cancer. The present study aims to determine if long-term diabetes is a risk factor for pancreatic cancer.

METHODS

The study undertook to determine the prevalence of diabetes among three matched (age/gender) patient groups (pancreatic cancer (PaC), colorectal cancer (CRC), and fracture neck of femur (NOF)) at the date of diagnosis of cancer or fracture as well as 1 and 5 years prior to this. A retrospective review of the medical records of the three groups of patients was undertaken. Patients identified with PaC in the period July 1994 to February 1998 were age (+/- 5 years)- and gender-matched to patients identified in the same time period with NOF and with CRC. The data were then analysed using McNemar's test for discordant pairs.

RESULTS

Over a 44-month period 116 patients with PaC were identified of which 24% had diabetes at the time of diagnosis of their malignancy (NOF, 8%; CRC, 9.5%). There was a statistically significant difference (PaC and NOF, P < 0.01; PaC and CRC, P < 0.01). For a duration of diabetes of > 5 years the prevalence of diabetes fell to 7.8% in the PaC group, to 6% in the NOF group and to 6.9% in the CRC group, with no significant difference between the groups.

CONCLUSION

There is no increase in the prevalence of long-standing diabetes mellitus in patients with PaC compared to age- and gender-matched controls with NOF and CRC. The relationship of PaC and diabetes may be an epiphenomenon, rather than diabetes being a risk factor for pancreatic malignancy.

A multispecialty approach to the diagnosis and management of pancreatic cancer

This article reviews recent developments in pancreatic cancer research and offers a multispecialty perspective on the diagnosis and management of this challenging disease. Current findings in the molecular biology of the disease and their implications for management are examined, as well as development in diagnostic techniques, including helical computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangio-pancreatography (MRCP), and, particularly, endoscopic ultrasound-guided fine-needle aspiration. Surgical management, the role of adjuvant/neoadjuvant chemoradiation therapy, and the critical importance of accurate preoperative imaging are also addressed in this review. Palliative techniques, including endoscopic stenting for malignant obstructive jaundice and chemotherapy for locally advanced and metastatic disease, are discussed, and results of recent clinical trials in pancreatic cancer are summarized. Finally, future directions for research are identified.

Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer

BACKGROUND

In a randomized double-blind study the efficacy of neurolytic coeliac plexus block (NCPB) was compared with pharmacological therapy in the treatment of pain from pancreatic cancer.

METHODS

Twenty-four patients were divided into two groups: 12 patients underwent NCPB (group 1) and 12 were treated with pharmacological therapy (group 2). Immediate and long-term efficacy, mean analgesic consumption, mortality and morbidity were evaluated at follow-up. Statistical analysis was performed with the unpaired t test, Mann-Whitney U test and Fisher's exact test.

RESULTS

Immediately after the block, patients in group 1 reported significant pain relief compared with those in group 2 (P < 0.05), but long-term results did not differ between the groups. Mean analgesic consumption was lower in group 1. There were no deaths. Complications related to NCPB were transient diarrhoea and hypotension (P not significant between groups). Drug-related adverse effects were constipation (five of 12 patients in group 1 versus 12 of 12 in group 2), nausea and/or vomiting (four of 12 patients in group 1 versus 12 of 12 in group 2) (P < 0.05), one gastric ulcer and one gluteal abscess in group 2.

CONCLUSION

NCPB was associated with a reduction in analgesic drug administration and drug-related adverse effects, representing an effective tool in the treatment of pancreatic cancer pain.

Pancreatic adenocarcinoma: epidemiology and genetics

Pancreatic adenocarcinoma is an important cause of death from cancer throughout the developed world. There are few established environmental risk factors, but a previous history of pancreatitis and exposure to tobacco and salted food appear to be the most important. A family history of pancreatic adenocarcinoma is not common in patients with this disease, but recent research has shown that pancreatic adenocarcinoma can be a feature of cancer susceptibility syndromes associated with germline mutations in p16, BRCA1, BRCA2, and APC. This highlights the need for a full family history in apparently sporadic cases. Somatic mutations in p16, BRCA2, and APC have also been reported in pancreatic cancer; however, K-RAS mutations appear to be the commonest oncogenic alteration. Recent advances in our understanding of the basis of hereditary cancer syndromes may be applicable to the diagnosis, treatment, and possibly prevention of pancreatic adenocarcinoma in the future.

Epidemiology of and risk factors for pancreatic cancer

In the United States, incidence of and mortality from pancreatic cancer increased for several decades earlier in this century but have tended to level off in recent years. Rates increase with age and are higher in blacks than in whites and higher in males than in females. No consistent differences by socioeconomic status or by geographic location in the United States have been identified, although international variation and differences in migrants have been observed. Thus, both genetic and environmental factors may be playing significant roles in the development of pancreatic cancer. Cigarette smoking increases the risk of pancreatic cancer, but the strength of this association is much less than for lung cancer or other smoking-related cancers. Epidemiologic studies of the effect of alcohol consumption on pancreatic cancer largely show no relationship, and the results for coffee consumption indicate little, if any, association. Human studies have suggested positive associations with meat consumption and carbohydrate intake and a protective effect of dietary fiber and consumption of fruits and vegetables. Results of a number of occupational studies are suggestive of increased risk associated with some exposures but are not fully consistent. Thus, much progress has been made in the last two decades in identifying risk factors, but much epidemiologic work is needed to identify and reduce putative exposures.

Cancer mortality in workers employed at a transformer manufacturing plant

This study examined mortality to December 31, 1989 in a cohort of 2,222 males employed between 1947 and 1975 at a transformer manufacturing plant in Canada, where there had been extensive use of transformer fluid, some containing polychlorinated biphenyls (PCBs). A combined cohort list of 2,222 names was independently obtained from plant management and union officials. Mortality of 1,939 workers with known birthdates was ascertained by record linkage with the Canadian Mortality Data-base. Standardized mortality ratios (SMRs) for different criteria for acceptance of the death certificate link and for cohort membership (based on work history) ranged from .71-1.05. There was no significant increase in overall cancer deaths. The only significant site-specific increased mortality was pancreatic cancer (11 deaths), with SMRs ranging from 2.92-7.64 and higher mortality risk in those who entered the cohort prior to 1960. All but one of these deaths had a latency period of at least 10 years, and greatest SMRs were found in departments with the greatest exposure to transformer fluid. Several previous studies have found excess pancreatic cancers in association with oil exposures and electrical equipment manufacturing. The need to further investigate pancreatic cancer in transformer manufacturing and related exposures is evident.

Pancreatic cancer and diabetes

Whether having diabetes predisposes an individual to developing pancreatic cancer continues to be studied. At present, the greater challenge for diabetes educators is to help those individuals who have had surgical resection for pancreatic cancer and now have resultant IGT or frank diabetes to manage their condition to the best of their ability and make their quality of life the best it can be, given the circumstances.

Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas

OBJECTIVE

This study was set up to identify patient-related factors favoring the application of either surgery or endoprostheses in the palliation of obstructive jaundice in subsets of patients with cancer of the head of the pancreas or periampullary region.

SUMMARY BACKGROUND DATA

In the palliation of obstructive jaundice, surgical biliodigestive anastomosis has traditionally been performed. Surgical biliary bypass is associated with high mortality (15% to 30%) and morbidity rates (20% to 60%) but little recurrent obstructive jaundice (0% to 15%). Biliary drainage with endoscopically placed endoprostheses has a lower complication rate, but recurrent obstructive jaundice is seen in up to 20% to 50% of patients.

METHODS

Patients with advanced cancer of the head of the pancreas or periampullary region treated at the University Hospital Dijkzigt, Rotterdam, The Netherlands, between 1980 and 1990 were reviewed. In 148 patients, data were compared concerning the morbidity and hospital stay after the palliation of obstructive jaundice with endoscopic endoprostheses or surgical biliary bypasses. These patients were stratified for long (> 6 months) and short (< 6 months) survival times.

RESULTS

In short-term survivors, the higher late morbidity rates after endoprostheses were offset by higher early morbidity rates and longer hospital stays after the surgical bypass. In long-term survivors, there was no difference in the hospital stay between the two groups, but the late morbidity rate was significantly higher in the endoprosthesis group.

CONCLUSIONS

These data suggest that endoscopic endoprosthesis is the optimal palliation for patients surviving less than 6 months and surgical biliary bypass for those surviving more than 6 months. This policy necessitates the development of prognostic criteria, which were obtained by Cox proportional-hazards survival analysis. Advanced age, male sex, liver metastases, and large diameters of tumors were unfavorable prognostic factors. With these factors, the risk of short- or long-term survival can be predicted. It is hoped that the application of these data may allow a rational approach toward optimal palliative treatment of this form of malignant obstructive jaundice.

Paraplegia following coeliac plexus block

Coeliac plexus block (CPB) is one of the few neurolytic procedures that is still considered very useful in managing chronic cancer pain. We describe what we believe to be the fifth case in the literature of paraplegia following coeliac plexus block with ethyl alcohol. Clinical and neurophysiological examination confirmed the hypothesis of an acute myelopathy probably caused by ischemia due to involvement of Adamkievicz's artery. The seriousness of this neurological complication led us to review the different pain-relieving strategies in pancreatic cancer. Several medical and surgical procedures are available for advanced pancreatic cancer, yet none of them alone can be considered the therapy of choice for all cases. Hence, only a multidisciplinary approach to pancreatic cancer pain can help in making the most appropriate choice for each patient.

Endoscopically inserted biliary endoprosthesis in malignant obstructive jaundice. A survey of the literature

Eighty-seven publications in English on endoscopic bile duct stenting for palliation of obstructive jaundice were electronically or manually retrieved. Only eight of these studies were found to represent series of more than 20 patients and to include only a single presentation of data from patients published more than once. These eight studies refer to data on 856 patients, of whom 702 are from four open series, whereas 154 are from four randomized trials comparing endoscopic insertion of endoprosthesis to percutaneous stents or surgical by-pass. Endoscopic insertion was successful in about 90% of the patients. Stent diameters were 7-12 French. Patient survival was not affected as it is governed by the natural history of the underlying malignant disease. Endoscopic endoprosthesis was superior to percutaneous stenting and equal to surgical by-pass, but probably less resource consuming. The most important unsolved problem is the tendency to cholangitis and clogging of endoprostheses. Some suggestions concerning questions to be addressed in a more uniform manner in future publications on this subject are presented.

Aetiology of pancreatic cancer

Curative surgery is possible in only a small minority of patients with pancreatic cancer and, to date, responses to chemotherapy and radiotherapy have been disappointing. To make any impact on the incidence of the disease a clearer understanding of its aetiology is required. This review explores present knowledge of the aetiology and epidemiology of pancreatic cancer.

Epidemiology of pancreas cancer (1988)

This article reviews the epidemiology of cancer of the pancreas, both descriptive and analytical, at all times cognizant of the problems of misdiagnosis, particularly underdiagnosis, of this lethal disease that continue to hinder epidemiological studies. Pancreas cancer is consistently reported to occur more frequently in men than in women, in blacks than in whites, and in urban rather than rural population groups. In some countries, the mortality rates continue to rise, whereas in others, declining levels of disease can be seen among members of younger birth cohorts. Although some of these patterns can be explained by variation in pancreas cancer risk factors, many cannot. Analytical studies consistently demonstrate that cigarette smoking increases the risk of cancer of the pancreas, and this appears, at the present time, to be the only clearly demonstrated risk factor for pancreatic cancer. Although the association with disease risk and coffee consumption, alcohol consumption, occupational exposures, diabetes, pancreatitis, and other factors requires clarification, it appears likely that the most fruitful research area in the coming years may involve exploration of pancreatic cancer risk and nutritional practices.

Tumours of the pancreas as a sequel to abdominal irradiation

Two cases of tumours arising in or near the pancreatic head are reported in patients previously treated with abdominal irradiation for testicular tumours. These are only the third and fourth such cases to be reported and they suggest that second cancers may develop as a result of abdominal irradiation for malignant disease.

Influence of cholecystokinin antagonist on the effects of cholecystokinin and bombesin on azaserine-induced lesions in rat pancreas

Both cholecystokinin and bombesin have been shown to promote pancreatic carcinogenesis in the azaserine-rat model. The present study was undertaken to discriminate between the effects of cholecystokinin and bombesin and to establish the modulating properties of the specific cholecystokinin receptor antagonist CR-1409 on pancreatic carcinogenesis. After initiation with 30 mg/kg of azaserine, six groups of 15 Wistar rats were treated for 16 wk with cholecystokinin, bombesin, or gelatin (control), some in combination with CR-1409. Doses of cholecystokinin (2.5 micrograms/kg) and bombesin (10 micrograms/kg) were chosen that rendered approximately equal plasma cholecystokinin levels. Both cholecystokinin and bombesin were found to stimulate pancreatic growth, whereas CR-1409 only inhibited the growth-promoting effect of cholecystokinin significantly. Furthermore, both peptides stimulated the development of putative preneoplastic lesions, whereas CR-1409 only inhibited the effect of cholecystokinin significantly. It is concluded that (a) CR-1409 inhibits the promoting effect of cholecystokinin on pancreatic growth and azaserine-induced early pancreatic lesions and (b) the effects of bombesin cannot be fully ascribed to stimulation of the secretion of endogenous cholecystokinin.

Atypical and neoplastic acinar cell lesions of the pancreas in an autopsy study of Japanese patients

A histopathologic examination of the pancreas was performed on a series of adult Japanese autopsies. In ten of 162 pancreases (6%) with adequate tissue available, two types of focal atypical acinar cell lesions, composed of acidophilic or basophilic cells, were found. Acidophilic atypical acinar cell lesions were more frequent than basophilic ones, although the one case of acinar cell adenoma and two cases of acinar cell carcinomas showed high incidences of basophilic atypical acinar cell lesions. The findings are concluded to support the possibility that atypical acinar cell lesions are precursors for acinar cell carcinomas.

Fistula from the superior mesenteric artery to duodenum: a rare cause of death from pancreatic carcinoma

A fistula from the superior mesenteric artery to the duodenum is an extremely rare complication of pancreatic carcinoma. It presents with overwhelming upper gastrointestinal hemorrhage and can lead to death from blood loss.

Familial pancreatic adenocarcinoma in three generations. A case report and a review of the literature

Although scattered case reports of familial clustering of pancreatic cancer have appeared in the literature, hereditary factors have not been clearly associated with increased risk for this malignancy. The current report documents the familial occurrence of pancreatic adenocarcinoma in three women of consecutive generations who died of their disease at progressively younger ages. The diagnoses are histologically confirmed in all three cases. Although two of the women carried a single known risk factor for pancreatic carcinoma (cigarette smoking), a familial predisposition to this disease is strongly implicated. The case suggests that the role of inheritance in pancreatic carcinoma may merit further exploration.

Endoscopic palliative treatment in pancreatic cancer

Patients with carcinoma of the head of the pancreas will develop obstructive jaundice at some point in their course in 80% to 90% of the cases. Surgical biliary digestive anastomosis carries a high 30-day mortality (20%), and hospitalization may be prolonged for several weeks owing to postoperative morbidity. We attempted endoscopic endoprosthesis placement in 221 patients with pancreatic carcinoma for palliation of obstructive jaundice. The procedure was successful in 200 of 221 (90%) with a procedure-related mortality of only 2% and a 30-day mortality of 10%. The serum bilirubin level normalized in 92% of those who survived, and the mean survival of 6 months is comparable to that achieved with biliodigestive anastomosis. Early cholangitis (8%) and late clogging of the endoprosthesis (21% at a mean of 5 months) are problem areas that need to be improved. We believe these results justify considering endoscopic biliary prosthesis as the treatment of choice in nonresectable jaundiced patients with carcinoma of the head of the pancreas.

The use of epidemiology, scientific data, and regulatory authority to determine risk factors in cancers of some organs of the digestive system. 6. Pancreatic cancer

The etiology of pancreatic cancer remains elusive. It predominates in males and in certain ethnic populations (i.e., Polynesians and blacks). Primarily a disease of aging, it is rare in individuals under 40. Genetics is believed to play a very small part if any. While diabetics have higher than expected incidence and mortality rates, several recent studies have indicated that in most cases the diabetes is an early sign of pancreatic cancer rather than a predisposing condition. Other conditions have been infrequently reported in association with pancreatic cancer. None of them have shown a definitive associative pattern and are believed to represent coincidental occurrences. Migrant studies of Japanese immigrants implicate some type of environmental etiology, since pancreatic cancer rates increase dramatically within one to two generations. Studies on atom bomb survivors have demonstrated no link between a single intense dose of radiation and subsequent development of this disease. Workers exposed to low-level radiation have shown an increase in pancreatic cancer, but this result may reflect methodologic problems. Many chemicals have been shown to cause pancreatic cancer in animals, and chemists exhibit higher pancreatic cancer rates than expected. However, the human cases have not been traced to any specific chemical. Many other occupations besides chemistry have shown increased pancreatic cancer rates, but the common factor in these occupations is not obvious. Studies analyzing the relationship of alcohol consumption to pancreatic cancer yield conflicting results. This may be explained if the observed effects are due to a confounder, such as cigarette smoking; to an ingredient other than alcohol contained in alcoholic beverages, such as nitrosamines; or to the immunosuppressive effects of chronic excessive alcohol consumption. Smoking is the risk factor showing the most definitive and consistent results. There is little doubt that it plays an etiologic role, and it probably accounts for the higher incidence of the disease in males. Most other research does not support MacMahon's reported association between coffee drinking and pancreatic cancer. Recent studies have indicated a generally increased fluid intake in pancreatic cancer patients due to a disease-induced disturbance in glucose tolerance function. Such increased fluid intake would tend to manifest itself in the most popular beverage of the country (i.e., coffee in the United States and tea in the United Kingdom). Animal studies have indicated a link between pancreatic cancer and high fat and/or high protein diets as well as raw soybean consumption.(ABSTRACT TRUNCATED AT 400 WORDS)

Hypertrophic foci of pancreatic acinar cells in rats

A morphologically distinctive type of pancreatic acinar cell foci, different from hyperplastic nodules and adenomas, in rats has been recognized for two decades. The lesions have been observed to occur spontaneously and to be induced experimentally. They consist of enlarged acinar cells with abundant cytoplasm of altered staining characteristics and prominent nuclei. There is, however, a wide divergence of opinion among investigators regarding the nature of the lesions. As a result of different interpretations and classifications, many terms have been given to them. Based on morphologic characteristics, the author has designated the lesions as hypertrophic foci, a descriptive morphological term. The biologic significance with particular reference to age and the relationship with acinar cell neoplasia is discussed. Also included in the review are similar lesions in other rodent species.

Effects of soybean flour on the pancreas of rats

We have reviewed the growth-promoting and carcinogenic effects of feeding raw soya flour to rats. If the raw soya flour-containing diets are fed for more than a year, about 10% of the animals develop pancreatic cancer. In addition, feeding raw soya flour markedly potentiates the action of even subthreshold amounts of pancreatic carcinogens. The raw soya flour therefore acts as a potent promoter, as well as a weak carcinogen. In view of this promotion, the rat fed raw soya flour is a sensitive model for screening pancreatic carcinogens. It is not known whether the human pancreas responds to dietary trypsin inhibitors in a manner similar to the rat. However, in view of the use of soya-based products in human nutrition--especially in infant foods--we urge that the effect of all soya-based products intended for human use be tested on the rat pancreas in long-term feeding studies, combined with subthreshold doses of azaserine to highlight any promoting activity of the product. It seems probable that if a product exerts no effect on the rat pancreas, the human pancreas will also be spared from noxious effects.

Combined modality treatment of pancreatic cancer: implications for the surgeon

Since pancreatic cancer is still increasing and has a poor prognosis, there is great interest in improving treatment results by combined modality approaches. This paper considers the most appropriate studies to analyze the status of treatment and future implications for surgeons. With new radiation sources and more sophisticated treatment plans, intra- and post-operative radiotherapy now has an established role in local tumor control. Combination chemotherapy has yielded response rates of 40-45% and improved chemotherapy will play a role in the treatment and perhaps in the prevention of disseminated disease. Although it seems likely that chemotherapy combined with newer radiotherapeutic technique could improve treatment results in advanced pancreatic cancer, treatment-related and limiting toxicity still must be defined. There are suggestions that more surgeons become involved in the combined modality approach, as both radiotherapy and chemotherapy may be more valuable in primary management. The unsatisfactory results of surgical treatment imply the need for adjuvant treatment, which must be tested in randomized multicenter trials. Future efforts will require an interdisciplinary approach to this disease.

The use and mechanism of urinary clearance of cathodic trypsin-like immunoreactivity to creatinine clearance ratio in the diagnosis of pancreatic cancer

The ratio between urinary clearance of cathodic trypsin-like immunoreactivity and creatinine clearance (CTr/CCr ratio) was evaluated as a test for pancreatic cancer in patients with chronic pancreatic diseases and gastrointestinal diseases clinically mistakable for pancreatic cancer. The efficiency of the CTr/CCr ratio in the diagnosis of pancreatic cancer was no better than the urinary clearances of albumin and beta2-microglobulin to creatinine clearance (CA1b/CCr ratio and C beta 2m/CCr ratio). An overall positive association was found between the three ratios. Furthermore, there was a positive relationship between proteinuria and elevation of any of the ratios--as well as between proteinuria and the degree of cancer dissemination. The latter was positively associated with elevation of any of the three ratios. The results point to a changed renal handling of proteins due to cancer disease per se as the mechanism causing elevated CTr/CCr ratios in pancreatic cancer.

Diet, alcohol, tobacco and risk of cancer of the pancreas: a case-control study

In view of the increased incidence of pancreatic cancer and the possible aetiological role of certain dietary factors, a retrospective epidemiological study was undertaken to investigate the roles of tobacco, alcohol, fat, protein and carbohydrate intakes. Sixty-nine patients with pancreatic adenocarcinoma, and 199 normal subjects were interviewed. Data were obtained on life time drinking, smoking and dietary habits. Conditional logistic regression models were used to analyse the relative risk variations. It was shown that the relative risk of cancer of the pancreas increases with fat and alcohol intakes, does not vary with protein intake, and decreases with carbohydrate intake and duration of alcohol consumption. Alcohol may be not directly involved in the aetiology of cancer of the pancreas: its effect could be due to the contents of some alcoholic beverages.

Postoperative irradiation of carcinoma of the head of the pancreas area: short-time tolerance and results to precision high-dose technique in 18 patients

During the period from January 1977-August 1979, 18 patients with biopsy-proven pancreas duct or ampullary adenocarcinoma with no distant or liver metastases underwent external beam radiation therapy following laparotomy. With the use of a 25 MEV photon beam and a four field "box" technique, the dose delivered to the target volume identified with radio-opaque clips at laparotomy was 6000 rad in six weeks, while largely sparing the spinal cord, kidney, liver and gut. All patients subjected to low fat, gluten free diet completed treatment as planned without any acute reaction. Three patients developed delayed pancreatic insufficiency. According to actuarial survival analysis and low morbidity such an approach may lead to increase survival in patients with pancreatic cancer.

Obstructive biliary tract disease

The techniques that have come into general use for diagnosing problems of obstructive jaundice, particularly in the past ten years, have been ultrasonography, computerized tomography, radionuclide imaging, transhepatic percutaneous cholangiography using a long thin needle, transhepatic percutaneous drainage for obstructive jaundice due to malignancy, endoscopic retrograde cannulation of the papilla (ERCP), endoscopic sphincterotomy and choledochoscopy. It is helpful to review obstructive jaundice due to gallstones from a clinical point of view and the use of the directable stone basket for the retrieval of retained stones, choledochoscopy for the same purpose using the rigid versus flexible choledochoscopes and dissolution of stones using various fluids through a T tube. The use of dilation of the sphincter for the treatment of stenosis or stricture of the bile duct is now frowned on; rather, treatment choices are between the use of sphincteroplasty versus choledochoduodenostomy and choledochojejunostomy. Any patient with obstructive jaundice or anyone undergoing manipulation of the bile ducts should have prophylactic antibiotic therapy. The current literature regarding treatment of cancer of the bile ducts is principally devoted to the new ideas relative to treatment of tumors of the upper third, especially the bifurcation tumors that are now being resected rather than bypassed. Tumors of the distal bile duct are still being resected by focal operations. Finally, it is now felt that early operation for congenital biliary atresia and choledochal cysts gives the best prognosis, with preoperative diagnosis now possible with the use of ultrasonography and ERCP.

Coffee consumption and pancreatic cancer: temporal and spatial correlation

An examination of available data on per caput consumption of coffee and pancreatic cancer mortality in the United States since 1950 shows a temporal association. A rise and fall in coffee consumption was followed by a rise and fall in the incidence of pancreatic cancer with roughly a 10-year lag. Nevertheless, there were inconsistencies in this relationship was also found between the consumption of coffee and pancreatic cancer mortality in 13 countries. While this relationship suggests an association, major inconsistencies case doubt on the possibility that it is one of cause and effect. This may be due to confounding, particularly by cigarette smoking and cancer of the pancreas is much more consistent with a causal relationship.

Partial characterisation of an oncofetal pancreatic antigen. Its role in the differential diagnosis and therapy of patients with pancreatic cancer

An oncofetal pancreatic antigen (OPA) has been identified and purified from the blood of patients with pancreatic cancer. Characterisation studies on OPA have shown that it is a protein of molecular weight 40 000 with alpha2 electrophoretic mobility. OPA is clearly different from alpha-fetoprotein, carcinoembryonic antigen, ferritin, acute phase reactants, and normal serum proteins. A rocket immunoassay has been developed allowing the quantitation of OPA in serum; it has been applied to samples from over 700 individuals with a variety of conditions. Elevated levels of OPA have been found in 42 of 48 (88%) patients with biopsy-proven pancreatic cancer and in a much smaller percentage of patients with other cancers or with other conditions considered in the differential diagnosis of pancreatic cancer. The studies indicate that serum OPA measurements may be useful as a preliminary screening test for pancreatic cancer and for monitoring the course of the disease.

The results of surgery for carcinoma of the pancreas

A retrospective analysis was performed on 104 consecutive patients with carcinoma of the pancreas treated between 1970 and 1974 inclusive. Fifty-three per cent underwent palliative bypass, 13% laparotomy only, 6% had a Whipple operation, 7% various miscellaneous operations, and 21% did not undergo operation. The operative mortality of palliative bypass and diagnostic laparotomy was 13% and 71% respectively. The mean survival of patients after biliary bypass was 6.7 months. Seven patients undergoing bypass had tumours of the pancreatic head, five centimetres or less in diameter, and apparently localized disease, and their means survival was 15.9 months. The mean survival of the four patients surviving radical surgery was 15.5 months. There were no cures. It was concluded that cholecystojejunostomy without enteroenterostomy was an appropriate biliary bypass operation and that diagnostic laparotomy should be avoided in patients without obstructive jaundice and with disseminated disease.

The diagnosis of exocrine pancreatic disease: the present position reviewed

In this paper, recent advances in the diagnosis of pancreatic disease are reviewed, together with older methods currently in use. The clinical role of these techniques in the diagnosis of pancreatic disease is discussed with particular reference to symptomatology and prognosis of the various pancreatic disorders. Likely future developments in this field are considered.

Pancreatic carcinoma

Carcinoma of pancreas is not uncommon in Africa where the prognosis seems to be worse than in cases seen in Europe and North America. The reason for this poor prognosis is because patients with this disease are seen in medical institutions at late stages.There seems to be a rise also in the incidence of this disease in our environment. This increased incidence may be real or apparent, and may be related to the rise in hospital consciousness in the population.As seen in Ibadan, the pattern of the disease is not much different from that reported from other parts of Africa.