Inherited pancreatic cancer: surveillance and treatment strategies for affected families

A Review of the Indications, Outcomes, and Postoperative Management After Total and Completion Pancreatectomy for Pancreatic Cancer: More Is Not Necessarily Better

With improvements in surgical technique and advances in pancreatic endocrine and exocrine replacement therapy, the indications for, and threshold to perform, total or completion pancreatectomy in the modern surgical era are ever evolving. The following review will evaluate such indications for pancreatic cancer including pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasms. The authors also review the literature on oncologic outcomes of total and completion pancreatectomy for pancreatic cancer. Finally, they discuss the quality of life and postoperative management of the a-pancreatic state.

The role of endoscopic ultrasound in the detection of pancreatic lesions in high-risk individuals

Individuals at high risk of developing pancreatic ductal adenocarcinoma are eligible for surveillance within research programs. These programs employ periodic imaging in the form of magnetic resonance imaging/magnetic resonance cholangiopancreatography or endoscopic ultrasound for the detection of early cancer or high-grade precursor lesions. This narrative review discusses the role of endoscopic ultrasound within these surveillance programs. It details its overall strengths and limitations, yield, burden on patients, and how it compares to magnetic resonance imaging. Finally, recommendations are given when and how to incorporate endoscopic ultrasound in the surveillance of high-risk individuals.

Are All Cysts Created Equal?: Pancreatic Cystic Neoplasms in Patients with Familial or Genetic Risk Factors for Pancreatic Cancer

Pancreatic cystic lesions (PCLs) have become more prevalent over time, particularly in asymptomatic individuals. Current screening guidelines for incidental PCLs offer a unified approach to surveillance and management, predicated on "worrisome features." Although PCLs are common in the general population, their prevalence may be higher in high-risk individuals (HRI, unaffected patients with specific familial and/or genetic risk factors). As more PCLs are diagnosed and more HRI identified, it is important to promote research that bridges data gaps and introduces nuance to risk assessment tools, ensuring tailoring of guidelines to the needs of HRI with varying pancreatic cancer risk factors.

Threshold Analysis of the Cost-effectiveness of Endoscopic Ultrasound in Patients at High Risk for Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Data from the International Cancer of the Pancreas Screening Consortium studies have demonstrated that screening for pancreatic ductal adenocarcinoma can be effective and that surveillance improves survival in high-risk individuals. Endoscopic ultrasound (EUS) and cross-sectional imaging are both used, although there is some suggestion that EUS is superior. Demonstration of the cost-effectiveness of screening is important to implement screening in high-risk groups.

METHODS

Results from centers with EUS-predominant screening were pooled to evaluate efficacy of index EUS in screening. A decision analysis model simulated the outcome of high-risk patients who undergo screening and evaluated the parameters that would make screening cost-effective at a US $100,000 per quality-adjusted life-year willingness to pay.

RESULTS

One-time index EUS has a sensitivity of 71.25% and specificity of 99.82% to detection to detect high-risk lesions. Screening with index EUS was cost-effective, particularly at lifetime pancreatic cancer probabilities of greater than 10.8%, or at lower probabilities if life expectancy after resection of a lesion that was at least 16 years, and if missed, lesion rates on index EUS are 5% or less.

CONCLUSIONS

Pancreatic cancer screening can be cost-effective through index EUS, particularly for those individuals at high-lifetime risk of cancer.

The Management of Peutz-Jeghers Syndrome: European Hereditary Tumour Group (EHTG) Guideline

The scientific data to guide the management of Peutz–Jeghers syndrome (PJS) are sparse. The available evidence has been reviewed and discussed by diverse medical specialists in the field of PJS to update the previous guideline from 2010 and formulate a revised practical guideline for colleagues managing PJS patients. Methods: Literature searches were performed using MEDLINE, Embase, and Cochrane. Evidence levels and recommendation strengths were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). A Delphi process was followed, with consensus being reached when ≥80% of the voting guideline committee members agreed. Recommendations and statements: The only recent guidelines available were for gastrointestinal and pancreatic management. These were reviewed and endorsed after confirming that no more recent relevant papers had been published. Literature searches were performed for additional questions and yielded a variable number of relevant papers depending on the subject addressed. Additional recommendations and statements were formulated. Conclusions: A decade on, the evidence base for recommendations remains poor, and collaborative studies are required to provide better data about this rare condition. Within these restrictions, multisystem, clinical management recommendations for PJS have been formulated.

Cost-effectiveness of Pancreatic Cancer Surveillance in High-Risk Individuals: An Economic Analysis

OBJECTIVE

The aim of the study was to perform an economic analysis to identify the clinical and cost determinants of pancreatic cancer (PC) surveillance in high-risk individuals (HRIs).

METHODS

A Markov model was created to compare the following 3 strategies: no screening, endoscopic ultrasound (EUS), and magnetic resonance imaging (MRI) screening. Patients were considered HRIs according to the Cancer of the Pancreas Screening consortium recommendations. Risk for developing PC, survival, and costs data were obtained from the Surveillance, Epidemiology, and End Results and Medicare databases. Surveillance effectiveness was obtained from a recent meta-analysis.

RESULTS

Analysis of a cohort with fivefold relative risk of PC higher than the US population showed that MRI is the most cost-effective strategy. For those with the highest risk (>×20 relative risk), EUS became the dominant strategy. Our model was impacted by cost and imaging performance, but still cost-effective within the range reported in literature. Threshold analysis showed that if MRI increases greater than US $1600, EUS becomes more cost-effective. Once patients reached the age of 76 years, "no screening" was favored. Both surveillance strategies were cost-effective over a wide range of willingness to pay.

CONCLUSIONS

Abdominal imaging followed by pancreatectomy is cost-effective to prevent PC in HRIs, favoring MRI in moderate risk cases but EUS in those with highest risk.

Current Approaches to Pancreatic Cancer Screening

Pancreatic ductal adenocarcinoma (PDAC) has a 5-year survival rate of only 8% and is estimated to be the second leading cause of cancer-related deaths by 2021. Prior convention held that screening for PDAC would not be beneficial; however, a deeper understanding of the carcinogenesis pathway supports a potential window of opportunity among the target population. Screening for PDAC is not a standard practice among the general population because of its low incidence. However, screening may be beneficial for individuals with familial history, chronic diseases with genetic predispositions, or inherited cancer syndromes, such as hereditary breast ovarian cancer syndrome, hereditary pancreatitis, Peutz-Jeghers syndrome, familial atypical multiple mole melanoma, Lynch syndrome (hereditary nonpolyposis colorectal cancer), ataxia telangiectasia, and Li-Fraumeni syndrome, all of which have been associated with an increased risk of developing PDAC. The screening strategies among these high-risk individuals are targeted to identify precursor lesions and PDAC at an early resectable stage. This review describes the risk factors for pancreatic cancer, especially the genetic risk factors in high-risk individuals and current screening strategies available for PDAC.

Diagnostic Yield From Screening Asymptomatic Individuals at High Risk for Pancreatic Cancer: A Meta-analysis of Cohort Studies

BACKGROUND & AIMS

There have been few studies of abdominal imaging screening of individuals at high risk for pancreatic cancer (based on family history or genetic variants). We performed a meta-analysis of prospective cohort studies to determine the diagnostic yield and outcomes of abdominal imaging screening for asymptomatic individuals at high risk.

METHODS

Through a systematic review of multiple electronic databases and conference proceedings through July 2017, we identified prospective cohort studies (>20 patients) of asymptomatic adults determined to be at high-risk of pancreatic cancer (lifetime risk >5%, including specific genetic-associated conditions) who were screened by endoscopic ultrasound (EUS) and/or magnetic resonance imaging (MRI) to detect pancreatic lesions. Our primary outcome was identification of high-risk pancreatic lesions (high-grade pancreatic intraepithelial neoplasia, high-grade dysplasia, or adenocarcinoma) at initial screening, and overall incidence during follow up. Summary estimates were reported as incidence rates per 100 patient-years.

RESULTS

We identified 19 studies comprising 7085 individuals at high risk for pancreatic cancer; of these, 1660 patients were evaluated by EUS and/or MRI. Fifty-nine high-risk lesions were identified (43 adenocarcinomas: 28 during the initial exam and 15 during follow-up surveillance) and 257 patients underwent pancreatic surgery. Based on our meta-analysis, the overall diagnostic yield screening for high-risk pancreatic lesions was 0.74 (95% CI, 0.33-1.14), with moderate heterogeneity among studies. The number needed to screen to identify 1 patient with a high-risk lesion was 135 (95% CI, 88-303). The diagnostic yield was similar for patients with different genetic features that increased risk, and whether patients were screened by EUS or MRI.

CONCLUSIONS

Based on meta-analysis, 135 patients at high-risk for pancreatic cancer must be screened to identify 1 patient with a high-risk pancreatic lesion. Further studies are needed to determine whether screening reduces mortality and is cost effectiveness for individuals at high-risk of pancreatic cancer.

German National Case Collection for familial pancreatic Cancer (FaPaCa) - acceptance and psychological aspects of a pancreatic cancer screening program

Background

Pancreatic cancer screening is recommended to individuals at risk (IAR) of familial pancreatic cancer (FPC) families, but little is known about the acceptance of such screening programs. Thus, the acceptance and psychological aspects of a controlled FPC screening program was evaluated.

Methods

IAR of FPC families underwent comprehensive counseling by a geneticist and pancreatologist prior to the proposed screening. Participating IAR, IAR who discontinued screening and IAR who never participated in the screening program were invited to complete questionnaires to assess the motivation for participating in surveillance, cancer worries, structural distress and experiences with participation. Questionnaires were completed anonymously to receive most accurate answers.

Results

Of 286 IAR to whom pancreatic ductal adenocarcinoma (PDAC) screening was recommended, 139 (48.6%) IAR regularly participated (group 1), 49 (17.1%) IAR (group 2) discontinued screening after median 1 (1–10) screening visits and 98 (34.2%) IAR (group 3) never underwent screening. The overall response rate of questionnaires was 67% (189/286) with rates of 100% (139 of 139 IAR), 49% (29 of 49 IAR) and 23.4% (23 of 98 IAR) for groups 1, 2 and 3, respectively. At least 93% of IAR felt adequately informed about the screening program after initial counseling. However, only 38.8% received knowledge of or the recommendation for PDAC screening by physicians. The reported cancer-related distress and the fear of investigations were highest in group 1, but acceptably low in all three groups. The main reasons to discontinue or not to participate in screening were the time efforts and travel costs (groups 2 and 3 48,7%).

Conclusion

Less than 50% of IAR regularly participate in a proposed PDAC screening program, although the associated psychological burden is quite low. Physicians should be educated about high risk PDAC groups and screening recommendations. Time and travel efforts must be reduced to encourage more IAR to participate in a recommended screening.

Surveillance for neoplasia in the pancreas

Despite its low incidence in the general population, pancreatic cancer is one of the leading causes of cancer-related mortality. Survival greatly depends on operability, but most patients present with unresectable disease. Therefore, there is great interest in the early detection of pancreatic cancer and its precursor lesions by surveillance. Worldwide, several programs have been initiated for individuals at high risk for pancreatic cancer. Their first results suggest that surveillance in high-risk individuals is feasible, but their effectiveness in decreasing mortality remains to be proven. This review will discuss which individuals are eligible for surveillance, which lesions are aimed to be detected, and which surveillance modalities are being used in current clinical practice. Furthermore, it addresses the management of abnormalities found during surveillance and topics for future research.

[Total pancreatectomy for pancreatic cancer]

AIM

to determine the indications and to evaluate early and long-term outcomes of total pancreatectomy for pancreatic cancer.

MATERIAL AND METHODS

Treatment of 29 patients who underwent one- and two-stage pancreatectomy for different malignancies was analyzed.

RESULTS

Median of surgery duration and intraoperative blood loss was 280 min and 2200 ml respectively. Postoperative complications were observed in 9 (31%) patients. There were 2 (6.9%) deaths. 1- and 3-year overall actual survival was 61% and 16% respectively in case of ductal adenocarcinoma. Median was 18 months. Patients after surgery for primary multiple lesion (cancer of pancreatic body-tail and major duodenal papilla), pancreatic metastases of renal cancer, mucinous cystadenoma and neuroendocrine cancer are still alive. Follow-up periods are 4, 49, 49 and 65 months respectively.

CONCLUSION

Total pancreatectomy is difficult intervention followed by severe metabolic disorders. However it can improve long-term survival with acceptable incidence of postoperative complications and quality of life if clear indications for surgery are present.

Is screening for pancreatic cancer in high-risk groups cost-effective? - Experience from a Danish national screening program

OBJECTIVE

Pancreatic cancer (PC) is the fourth leading cause of cancer death worldwide, symptoms are few and diffuse, and when the diagnosis has been made only 10-15% would benefit from resection. Surgery is the only potentially curable treatment for pancreatic cancer, and the prognosis seems to improve with early detection. A hereditary component has been identified in 1-10% of the PC cases. To comply with this, screening for PC in high-risk groups with a genetic disposition for PC has been recommended in research settings.

DESIGN

Between January 2006 and February 2014 31 patients with Hereditary pancreatitis or with a disposition of HP and 40 first-degree relatives of patients with Familial Pancreatic Cancer (FPC) were screened for development of Pancreatic Ductal Adenocarcinoma (PDAC) with yearly endoscopic ultrasound. The cost-effectiveness of screening in comparison with no-screening was assessed by the incremental cost-utility ratio (ICER).

RESULTS

By screening the FPC group we identified 2 patients with PDAC who were treated by total pancreatectomy. One patient is still alive, while the other died after 7 months due to cardiac surgery complications. Stratified analysis of patients with HP and FPC provided ICERs of 47,156 US$ vs. 35,493 US$ per life-year and 58,647 US$ vs. 47,867 US$ per QALY. Including only PDAC related death changed the ICER to 31,722 US$ per life-year and 42,128 US$ per QALY. The ICER for patients with FPC was estimated at 28,834 US$ per life-year and 38,785 US$ per QALY.

CONCLUSIONS

With a threshold value of 50,000 US$ per QALY this screening program appears to constitute a cost-effective intervention although screening of HP patients appears to be less cost-effective than FPC patients.

Clinical importance of Familial Pancreatic Cancer Registry in Japan: a report from kick-off meeting at International Symposium on Pancreas Cancer 2012

Pancreatic cancer is still a highly lethal disease with a 5-year survival rate of approximately 5 %. Early detection offers one of the best hopes for improving survival. Previous cohort studies and case-control studies showed that 4-10 % of pancreatic cancers have a hereditary basis, and individuals with a family history have an increased risk of developing pancreatic and extra-pancreatic malignancies. Since individuals with a family history of pancreatic cancer and those with a known genetic syndrome that predisposes to pancreatic cancer will be the first to benefit from early detection tests as they become available, familial pancreatic cancer (FPC) registries have been established in the US and Europe, but not yet in Japan. Such registries form the basis for epidemiological studies, clinical trials, and basic research on familial pancreatic cancer. There is a need for FPC registries in Japan as cancer risk varies among different populations and discoveries made in Western populations may not translate to the Japanese population. These registries in Japan will align with ongoing international efforts and add to a better understanding of the natural history, risk factors, screening strategies, and responsible genes, for improving survival of this dismal disease.

The role of endoscopic ultrasound in pancreatic cancer screening

Pancreatic cancer (PC) is a highly lethal cancer. Despite a significant advancement in cancer treatment, the mortality rate of PC is nearly identical to the incidence rates. Early detection of tumor or its precursor lesions with dysplasia may be the most effective approach to improve survival. Screening strategies should include identification of the population at high risk of developing PC, and an intense application of screening tools with adequate sensitivity to detect PC at an early curable stage. Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) seem to be the most promising modalities for PC screening based on the data so far. EUS had an additional advantage over MRI by being able to obtain tissue sample during the same examination. Several questions remain unanswered at this time regarding the age to begin screening, frequency of screening, management of asymptomatic pancreatic lesions detected on screening, timing of resection, and extent of surgery and impact of screening on survival. Novel techniques such as needle-based confocal laser endomicroscopy (nCLE), along with biomarkers, may be helpful to identify pancreatic lesions with more aggressive malignant potential. Further studies will hopefully lead to the development of strategies combining EUS with other technological/biological advancements that will be cost-effective and have an impact on survival.

Hereditary Pancreatic Cancer Syndromes

Despite decades of scientific and clinical research, pancreatic ductal adenocarcinoma (PDAC) remains a lethal malignancy. The clinical and pathologic features of PDAC, specifically the known environmental and genetic risk factors, are reviewed here with special emphasis on the hereditary pancreatic cancer (HPC) syndromes. For these latter conditions, strategies are described for their identification, for primary and secondary prevention in unaffected carriers, and for disease management in affected carriers. Nascent steps have been made toward personalized medicine based on the rational use of screening, tumor subtyping, and targeted therapies; these have been guided by growing knowledge of HPC syndromes in PDAC.

Screening for pancreatic cancer in familial high-risk individuals: A systematic review

AIM: To analyze the benefits and harms of pancreatic cancer screening in familial high-risk individuals (HRIs).

METHODS: Studies were identified by searching PubMed, EBSCO, ClinicalTrials.gov and the Cochrane database from database inception to June 2014. We also obtained papers from the reference lists of pertinent studies and systematic reviews. English-language trials and observational studies were searched. The key words used as search terms were “screening” and “surveillance”. Cost-effectiveness, diagnostic rate, survival rate, mortality and adverse events were the outcomes of interest. Age, sex, lifestyle and other confounding factors were also considered. However, anticipating only a few of these studies, we also included observational studies with or without control groups. We also included studies concerning the anxiety associated with pancreatic cancer risk and other psychological changes in familial HRIs. We extracted details on study design, objectives, population characteristics, inclusion criteria, year of enrollment, method of screening, adjusted and unadjusted mortality, cost-effectiveness and adverse events from the included studies. Studies were assessed using the Reporting of Observational studies in Epidemiology (STROBE) checklist.

RESULTS: Sixteen studies on pancreatic cancer screening were included. Five studies included control groups, nine were observational studies without control groups, and the other two studies investigated the worry associated with pancreatic cancer risk. We found that pancreatic cancer screening resulted in a high curative resection rate (60% vs 25%, P = 0.011), longer median survival time (14.5 mo vs 4 mo, P < 0.001), and higher 3-year survival rate (20% vs 15.0%, P = 0.624). We also found that familial HRIs had a higher diagnostic rate of pancreatic tumors than controls (34% vs 7.2%, P < 0.001). In patients who underwent regular physical examinations, more stage I pancreatic cancers were observed (19% vs 2.6%, P = 0.001). In addition, endoscopic ultrasonography, which was the main means of detection, diagnosed 64.3% of pancreatic cancers. In comparison, endoscopic retrograde cannulation of the pancreas, magnetic resonance imaging, and computed tomography diagnosed 28.6%, 42.9%, and 21.4%, respectively. For mass lesions, instant surgery was recommended because of the beneficial effects of post-operative chemotherapy. However, in patients with intraductal papillary mucinous neoplasms, we did not find a significant difference in outcome between surgery and follow-up without treatment. Moreover, pancreatic cancer screening in familial HRIs had a greater perceived risk of pancreatic cancer (P < 0.0001), higher levels of anxiety regarding pancreatic cancer (P < 0.0001), and increased economic burden.

CONCLUSION: Pancreatic cancer screening in familial HRIs is associated with a higher detection rate and longer survival, although screening may influence psychological function and increase the economic burden.

Pancreatic ductal adenocarcinoma: Risk factors, screening, and early detection

Pancreatic cancer is the fourth most common cause of cancer-related deaths in the United States, with over 38000 deaths in 2013. The opportunity to detect pancreatic cancer while it is still curable is dependent on our ability to identify and screen high-risk populations before their symptoms arise. Risk factors for developing pancreatic cancer include multiple genetic syndromes as well as modifiable risk factors. Genetic conditions include hereditary breast and ovarian cancer syndrome, Lynch Syndrome, familial adenomatous polyposis, Peutz-Jeghers Syndrome, familial atypical multiple mole melanoma syndrome, hereditary pancreatitis, cystic fibrosis, and ataxia-telangiectasia; having a genetic predisposition can raise the risk of developing pancreatic cancer up to 132-fold over the general population. Modifiable risk factors, which include tobacco exposure, alcohol use, chronic pancreatitis, diet, obesity, diabetes mellitus, as well as certain abdominal surgeries and infections, have also been shown to increase the risk of pancreatic cancer development. Several large-volume centers have initiated such screening protocols, and consensus-based guidelines for screening high-risk groups have recently been published. The focus of this review will be both the genetic and modifiable risk factors implicated in pancreatic cancer, as well as a review of screening strategies and their diagnostic yields.

Screening and early detection of pancreatic cancer in high risk population

Pancreatic cancer is a serious growing health issue in developed countries. For patients diagnosed with pancreatic cancer, the five year survival rate is below 5%. One major important reason leads to the poor survival rate is lack of early detection of pancreatic cancer. Over 80% of the patients are diagnosed in advanced disease stages. Screening for pancreatic cancer is a desirable option for high risk individuals to allow early detection and treatment of curable pancreatic neoplasms at a pre-invasive stage. This article highlights the need, endpoint, population, method, diagnostic yield, and the problems of current screening programs.

Familial pancreatic cancer--status quo

INTRODUCTION

Familial pancreatic cancer (FPC) is defined by families with at least two first-degree relatives with confirmed pancreatic ductal adenocarcinoma (PDAC) that do not fulfill the criteria of other inherited tumor syndromes with an increased risk for the development of PDAC, such as hereditary pancreatitis or hereditary breast and ovarian cancer. FPC is mostly autosomal dominant inherited and presents with a heterogeneous phenotype. Although the major gene defect has not yet been identified, some important germline mutations in the BRCA2-, PALB2-, and ATM-genes are causative in some FPC families.

FPC SCREENING

It is suggested by experts to include high-risk individuals in a screening program with a multidisciplinary approach under research protocol conditions. However, neither biomarkers nor reliable imaging modalities for the detection of high-grade precursor lesions are yet available. Most screening programs are currently based on endoscopic ultrasound and magnetic resonance imaging, and first data demonstrated that precursor lesions (pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasm) of PDAC can be identified. Timing and extent of surgery are still a matter of debate.

SCOPE OF THE REVIEW

The present review focuses on the clinical phenotype of FPC, its histopathological characteristics, known underlying genetic changes, genetic counseling, and screening.

Familial pancreatic cancer: current status

The term 'familial pancreatic cancer (FPC) defines families with at least two first-degree relatives with confirmed pancreatic cancer that do not fulfill the criteria of other inherited cancer syndromes with an increased risk for the development of PC, such as Peutz-Jeghers syndrome, hereditary pancreatitis and hereditary breast and ovarian cancer. FPC is a mostly autosomal dominant inherited tumor syndrome with a heterogeneous phenotype. The major genetic defect has not been identified yet, although mutations, for example in the BRCA2 gene, could be identified in some FPC families. Nevertheless, most experts recommend participation in screening and surveillance programs to high-risk individuals. Most board-approved screening programs are based on endoscopic ultrasound. The first data on the prospective screening of high-risk individuals have demonstrated that precursor lesions of PC can be identified, but false-positive findings do occur.

Pancreatic ductal adenocarcinoma screening: New perspectives

Pancreatic ductal adenocarcinoma accounts for more than 90% of all pancreatic cancers and its incidence has increased significantly worldwide. Patients with pancreatic ductal adenocarcinoma have a poor outcome and more than 95% of the people affected die from the disease within 12 mo after diagnosis. Surgery is the first-line treatment in the case of resectable neoplasm, but only 20% of patients are candidates for this approach. One of the reasons there are few candidates for surgery is that, during the early phases of the disease, the symptoms are poor or non-specific. Early diagnosis is of crucial importance to improve patient outcome; therefore, we are looking for a good screening test. The screening test must identify the disease in an early stage in order to be effective; having said this, a need exists to introduce the concept of “early” ductal adenocarcinoma. It has been reported that at least five additional years after the occurrence of the initiating mutation are required for the acquisition of metastatic ability of pancreatic adenocarcinoma and patients die an average of two years thereafter. We have reviewed the most recent literature in order to evaluate the present and future perspectives of screening programs of this deadly disease.

Familial pancreatic cancer--current knowledge

Familial pancreatic cancer (FPC) describes families with at least two first-degree relatives with confirmed exocrine pancreatic cancer that do not fulfil the criteria of other inherited tumour syndromes with increased risks of pancreatic cancer, such as Peutz-Jeghers syndrome, hereditary pancreatitis, and hereditary breast and ovarian cancer. The inheritance of FPC is mostly autosomal dominant and with a heterogeneous phenotype. The major gene defect is yet to be identified, although germline mutations in BRCA2, PALB2 and ATM are causative in some FPC families. Expert consensus conferences considered it appropriate to screen for pancreatic cancer in high-risk individuals using a multidisciplinary approach under research protocol conditions. However, neither biomarkers nor reliable imaging modalities for the detection of high-grade precursor lesions are yet available. Most screening programmes are currently based on findings from endoscopic ultrasonography and MRI, and data has demonstrated that precursor lesions of pancreatic cancer can be identified. No consensus exists regarding the age to initiate or stop screening and the optimal intervals for follow-up. Timing and extent of surgery as a treatment for FPC are debated. This Review focuses on the clinical phenotype of FPC, its histopathological characteristics, known underlying genetic changes and associated genetic counselling and screening.

Individuals at high-risk for pancreatic cancer development: management options and the role of surgery

Pancreatic cancer (PC) is a highly lethal disease. Despite advances regarding the safety and long-term results of pancreatectomies, early diagnosis remains the only hope for cure. This necessitates the implementation of an intensive screening program (based mainly on modern imaging), which - given the incidence of PC - is not cost effective for the general population. However, this screening program is recommended for individuals at high-risk for PC development. Indications for screening include the following three clinical settings: hereditary cancer predisposition syndromes associated with PC, hereditary pancreatitis and familial pancreatic cancer syndrome. The aim of this strategy is to identify pre-invasive (precursor) lesions, which are curable. Surgery is recommended in the presence of recognizable lesion on imaging lesions. Partial (anatomic) pancreatectomy - depending on the location of the suspicious lesion - is the most widely accepted type of surgical intervention in this setting; occasionally, however, total pancreatectomy may be required, in carefully selected patients. Despite that experience still remains limited, there is evidence that this aggressive strategy allows early detection of neoplastic lesions, thereby improving the effectiveness of surgery and prognosis.

Pancreatic cancer risk counselling and screening: impact on perceived risk and psychological functioning

Individuals at increased risk for pancreatic cancer who undergo screening can experience psychological and emotional distress. The objective of this study is to determine whether individuals participating in a pancreatic cancer screening program experience disruptions in risk perception, cancer-related anxiety or emotional distress. A pretestposttest design was used to examine perceived risk and psychological functioning of individuals participating in a pancreatic cancer screening protocol. The screening protocol includes genetic counselling, transcutaneous abdominal ultrasound, magnetic resonance imaging, and blood collection and eligible participants included individuals with a family history of pancreatic cancer or BRCA2 mutation carriers. At baseline, participants (n = 198) showed low to moderate levels of risk perception, pancreatic cancer-related anxiety, and general distress. Participants with familial pancreatic cancer (FPC) (n = 131) endorsed higher risk perception of pancreatic cancer than the BRCA2 carriers (n = 67) (perceived lifetime risk 42 vs. 15%), but did not differ on cancer worry or general distress prior to the first study appointment. From baseline to 3 months follow-up, no significant time or time by group interactions emerged on risk perception or general distress, but cancer worry decreased over time for the FPC group regardless of the number of affected relatives. Our findings indicate that participation in a pancreatic cancer screening program does not lead to a significant increase in risk perception, cancer worry, or general distress and that participants with high baseline levels of risk perception and distress may benefit from a more comprehensive risk assessment and psychological support.

Familial pancreatic cancer in Italy. Risk assessment, screening programs and clinical approach: a position paper from the Italian Registry

In Italy, pancreatic cancer is the fifth leading cause of tumor related death with about 7000 new cases per year and a mortality rate of 95%. In a recent prospective epidemiological study on the Italian population, a family history was found in about 10% of patients suffering from a ductal adenocarcinoma of the pancreas (PDAC). A position paper from the Italian Registry for Familial Pancreatic Cancer was made to manage these high-risk individuals. Even though in the majority of high-risk individuals a genetic test to identify familial predisposition is not available, a screening protocol seems to be reasonable for subjects who have a >10-fold greater risk for the development of PDAC. However this kind of screening should be included in clinical trials, performed in centers with high expertise in pancreatic disease, using the least aggressive diagnostic modalities.

Pathology analysis reveals that dysplastic pancreatic ductal lesions are frequent in patients with hereditary pancreatitis

BACKGROUND & AIMS

Hereditary pancreatitis (HP) is a risk factor for pancreatic adenocarcinoma. We performed a retrospective, multicenter study to characterize and evaluate the frequency of pancreatic intraepithelial neoplasia (PanIN) and to describe the characteristics of fibrosis in pancreatic surgical specimens from patients with HP.

METHODS

Samples from partial pancreatectomies (n = 13) of patients with HP complications (n = 12; 7 males; mean age, 24 y; 1 patient underwent 2 surgeries over 16 years) were analyzed by histologic and immunohistologic analyses; patients with suspected or proven pancreatic adenocarcinoma were excluded. HP diagnosis was confirmed by analysis of PRSS1 mutations. Dysplastic lesions were described according to the PanIN classification.

RESULTS

Eleven patients were found to have the R122H mutation in PRSS1 and 1 patient was found to have the N29I mutation in PRSS1. Fifty-one PanIN lesions were observed in 10 specimens (77%): PanIN lesions 1a, 1b, 2, and 3 were observed in 8, 5, 8, and 5 specimens, respectively. The median number of PanIN lesions was 3.5 for each specimen. The density of the lesions was 2.6 per 10 cm(2). The size of lesions was greater than 0.5 mm in 55% of the samples. Two patients with PanIN-3 developed pancreatic cancer, 18 months and 44 years after surgery.

CONCLUSIONS

PanIN lesions are frequent, severe, and occur early in the course of HP. Among patients with PanINs, 50% had PanIN-3 lesions. Pancreatectomy could be considered as a prophylactic against pancreatic cancer in patients with high-grade dysplasia.

Risk of pancreatic cancer in families with Lynch syndrome

CONTEXT

Lynch syndrome is an inherited cause of colorectal cancer caused by mutations of DNA mismatch repair (MMR) genes. A number of extracolonic tumors have been associated with the disorder, including pancreatic cancer; however, the risk of pancreatic cancer in Lynch syndrome is uncertain and not quantified.

OBJECTIVE

To estimate pancreatic cancer risk in families with germline MMR gene mutations.

DESIGN, SETTING, AND PATIENTS

Cancer histories of probands and their relatives were evaluated in MMR gene mutation carriers in the familial cancer registries of the Dana-Farber Cancer Institute (n = 80), Boston, Massachusetts, and University of Michigan Comprehensive Cancer Center (n = 67), Ann Arbor, Michigan. Families enrolled before the study start date (June 2008) were eligible. Age-specific cumulative risks and hazard ratio estimates of pancreatic cancer risk were calculated and compared with the general population using modified segregation analysis, with correction for ascertainment.

MAIN OUTCOME MEASURES

Age-specific cumulative risks and hazard ratio estimates of pancreatic cancer risk.

RESULTS

Data on 6342 individuals from 147 families with MMR gene mutations were analyzed. Thirty-one families (21.1%) reported at least 1 case of pancreatic cancer. Forty-seven pancreatic cancers were reported (21 men and 26 women), with no sex-related difference in age of diagnosis (51.5 vs 56.5 years for men and women, respectively). The cumulative risk of pancreatic cancer in these families with gene mutations was 1.31% (95% confidence interval [CI], 0.31%-2.32%) up to age 50 years and 3.68% (95% CI, 1.45%-5.88%) up to age 70 years, which represents an 8.6-fold increase (95% CI, 4.7-15.7) compared with the general population.

CONCLUSIONS

Among 147 families with germline MMR gene mutations, the risk of pancreatic cancer was increased compared with the US population. Individuals with MMR gene mutations and a family history of pancreatic cancer are appropriate to include in studies to further define the risk of premalignant and malignant pancreatic neoplasms and potential benefits and limitations of surveillance.

Novel presentation of a familial pancreatic cancer syndrome

INTRODUCTION

Earlier detection of pancreatic cancer may help identify patients for whom surgical intervention could provide cure or prolong life. In this article, we report the occurrence of breast cancer, melanoma, squamous cell carcinoma of the alveolar ridge, colon cancer, a desmoid tumor of the abdominal wall, and pancreatic adenocarcinoma in a 65-year-old woman. She was identified as having the familial atypical multiple mole melanoma-pancreatic cancer syndrome (FAMMM-PC) with a germline p16 mutation at amino acid position 15.

DISCUSSION

Patients with this syndrome traditionally present with multiple nevi and melanoma, and a subset also present with other cancers, including pancreatic cancer; however, no FAMMM-PC patient has yet been described with this constellation of cancers, including squamous cell carcinoma of the alveolar ridge and a desmoid tumor. Recognition of the tumors this population of patients is susceptible to developing and their genetic associations can help guide the surgeon in screening, surveillance, and eventually prevention of many of these cancers.

Screening of high-risk families for pancreatic cancer

PURPOSE OF REVIEW

To discuss how to recognise and manage high-risk individuals.

RECENT FINDINGS

Publication of initial results of screening for pancreatic cancer from US centres. Several masses and premalignant lesions have been detected, but the detection of the first pancreatic cancer through an organised study of screening has yet to be published. There has been progress in risk stratification; the role of diabetes in predisposing for cancer has been characterised and molecular modalities have been published which could be used in conjunction with imaging in a screening programme. A mutation in the palladin gene was found to segregate with the disease in a family with a clear predisposition for pancreatic cancer, though this has yet to be found in other such kindreds.

SUMMARY

Significant challenges remain to be solved in screening for early pancreatic cancer. Risk stratification needs to be improved and high-risk patients included in research-based screening programmes. It will be impossible to confirm that screening can detect cancers early enough for curative treatment until the results of these prospective studies become available.

[Hereditary pancreatic cancer]

An inherited predisposition to pancreatic cancer (PC) is prevalent in about 3% of PC cases and is currently believed to occur in three distinct clinical settings, (1) hereditary tumour predisposition syndromes with an increased risk of PC such as Peutz-Jeghers syndrome and familial atypical multiple mole melanoma, (2) hereditary pancreatitis and cystic fibrosis, in which genetically determined early-age changes of the pancreas can predispose to the development of PC, and (3) familial pancreatic cancer syndrome (FPC). According to a recent consensus conference, high-risk individuals from PC-prone families should be enrolled in board-approved, prospective, controlled screening programs at expert centres. Based on the available data, prophylactic pancreatectomy is not indicated, since the underlying causative gene defect of the FPC syndrome is still unknown and the penetrance of PC in other tumour predisposition syndromes is either low or yet undetermined. In case of the diagnosis of a PC or high-grade precursor lesions, a prophylactic extension of the resection can be considered, since patients with hereditary PC often develop multifocal pancreatic lesions.

Family history of pancreatic cancer in a high-risk cancer clinic: implications for risk assessment

Detailed family history is a critical element of cancer risk assessment. The relative importance of pancreatic cancer (PC) in a close family member, particularly in hereditary breast-ovarian syndrome (HBOS), is not clearly defined. We use a case-control design to investigate the importance of a family history of PC to cancer risk assessment. Case and control families were identified from the University of Chicago Cancer Risk database (1994-2005). Pedigrees were analyzed for personal and familial clinical cancer data. Cases included all new subjects (probands) reporting a close relative (first or second degree) with PC. Controls included the probands enrolled in the database immediately prior to and subsequent to each case (i.e. two controls for each case). From 1,231 pedigrees, 103 PC were reported by the proband in 87 unique families. Many probands reported multiple or early-onset PCs: one third (28/87) of case families met criteria for a familial PC syndrome [> or =2 first-degree relatives with PC (n = 10) or PC diagnosed < or =50 (n = 18)]. Of these families, the majority (75%) concurrently met criteria suggestive of hereditary breast-ovarian syndrome (HBOS). Because of a family history consistent with HBOS, at least one individual from each of 29 case and 55 control families underwent genetic testing for BRCA1/2. Among case families, 19 of 29 (66%) had a BRCA1/2 mutation compared with 16 of 55 (29%) controls. A significant association between family history of PC and a BRCA1/2 mutation was seen (OR 3.78, 1.32-10.9). This point estimate was strengthened but less precise in the non-Ashkenazi Jewish subset of tested families (OR 6.03, 1.68-22.14). In a high-risk population, a family history of PC, though infrequently reported, is nonetheless clinically meaningful. In risk assessment for HBOS, identifying a family history of PC should strongly raise the suspicion of an unrecognized BRCA1/2 mutation.

[Early pancreatic cancer: can the methods currently available identify this disease?]

OBJECTIVES

Call attention of the gastroenterologists and surgeons on the patients with high risk of developing pancreatic carcinoma, and whether or not forms of surveillance and prevention of this disease, which can be applied to daily clinical practice. DATA SURVEY: It was used the database of PubMed (US National Library of Medicine), looked up the publications of recent years for the groups at risk, molecular biological testing and methods of image used in the identification of small tumors of the pancreas.

BACKGROUND

The survival rates of adenocarcinoma of the pancreas remain negligible, even after the significant advances in diagnosis by imaging, treatment and understanding of the molecular biology of this disease. Although embryonic strategies for surveillance and prevention for people with high risk of pancreatic cancer has developed.

CONCLUSIONS

This review summarizes how to identify people at high risk of developing this disease and what is the state of the art of genetic counseling and screening through techniques of image available.

BRCA2 mutations as a universal risk factor for pancreatic cancer has a limited role in Korean ethnic group

OBJECTIVES

BRCA2 mutations are the well-known cause of inherited susceptibility to pancreatic cancer. However, the true association of BRCA2 mutations with pancreatic cancer may vary among different ethnic groups. As such, we aimed to determine the role of BRCA2 mutations as a risk factor for sporadic and familial pancreatic cancer in Korean patients.

METHODS

Between January 1998 to October 2002, 110 patients with pancreatic ductal adenocarcinoma gave informed consent for pedigree cancer survey. Analysis of BRCA2 mutations was done in 60 of those patients, all of whom agreed to genetic test. BRCA 2 mutation was analyzed by denaturing high-performance liquid chromatography and direct sequencing.

RESULTS

Among the 110 patients, 8 cases (7.2%) were confirmed as familial pancreatic cancer. There were no pathogenic BRCA2 truncation mutations in 60 patients with BRCA2 mutation analysis. However, 2 single polymorphic amino acid changes, C1342A(H372N), A3199G(N991D), a silent polymorphism A7470G(S2414S), a splice site mutation intron 16:-14(T to C) polymorphism, and an intron 16:-12 (T to C) unclassified variant were detected in both 9 of 53 sporadic and 1 of 7 familial pancreatic cancer patients.

CONCLUSIONS

Our results suggest that the BRCA2 mutation may not contribute to increases in the risk for both sporadic and familial pancreatic cancer in Korea.

The role of palladin in actin organization and cell motility

Palladin is a widely expressed protein found in stress fibers, focal adhesions, growth cones, Z-discs, and other actin-based subcellular structures. It belongs to a small gene family that includes the Z-disc proteins myopalladin and myotilin, all of which share similar Ig-like domains. Recent advances have shown that palladin shares with myotilin the ability to bind directly to F-actin, and to crosslink actin filaments into bundles, in vitro. Studies in a variety of cultured cells suggest that the actin-organizing activity of palladin plays a central role in promoting cell motility. Correlative evidence also supports this hypothesis, as palladin levels are typically up-regulated in cells that are actively migrating: in developing vertebrate embryos, in cells along a wound edge, and in metastatic cancer cells. Recently, a mutation in the human palladin gene was implicated in an unusually penetrant form of inherited pancreatic cancer, which has stimulated new ideas about the role of palladin in invasive cancer.

Endoscopic ultrasound and IL-8 in pancreatic juice to diagnose chronic pancreatitis

BACKGROUND/AIM

Pancreatic juice (PJ) [IL-8] has been proposed as a marker for pancreatic diseases. We compared the accuracy of PJ [IL-8] and endoscopic ultrasound (EUS) to diagnose chronic pancreatitis (CP).

METHODS

79 patients with symptoms suspicious for CP were enrolled. PJ emptied into the duodenum was collected during an upper endoscopy with IV secretin and [IL-8] was measured. CP was diagnosed when PJ [IL-8] was >20 pg/ml. CP was diagnosed at EUS when >or=4 of the 9 established criteria were present. CP was diagnosed by using composite gold standard: ERCP, histology, CT or MRI, and clinical follow-up (mean 20 months).

RESULTS

38 patients had CP, whereas 41 patients had no pancreatic disease. To diagnose CP, PJ [IL-8] was significantly less sensitive compared to EUS (47 vs. 71%), but equally accurate (71 vs. 80%) and specific (93 vs. 88%). By combining PJ [IL-8] and EUS, sensitivity and specificity significantly increased to 82% (either IL-8 or EUS positive) and 100% (both IL-8 and EUS positive).

CONCLUSIONS

Both PJ [IL-8] and EUS are accurate diagnostic modalities for CP. PJ collection can be performed at the time of EUS. PJ [IL-8] and EUS are complementary with higher sensitivity and specificity when used together.

Early detection and staging of adenocarcinoma of the pancreas

Early diagnosis is likely to improve the outcome and survival in patients who have pancreatic cancer. The sensitivity and specificity of current screening methods, however, limit their applicability to individuals at high risk for developing pancreatic cancer. Further development of serum markers may lead to improved diagnostic accuracy and allow screening to be implemented more broadly. Proteomic profiling and evaluation of panels of markers hold particular promise for the future. This article provides a review of current methods and results for the early detection and staging of pancreatic cancer, and discusses some potential areas for future development.

Total pancreatectomy: indications, operative technique, and postoperative sequelae

Total pancreatectomy has been used to treat both benign and malignant disease of the pancreas, but its use has been limited by concerns about management of the a-pancreatic state with its attendant total endocrine and exocrine insufficiency. Here, we review the indications for total pancreatectomy, operative technique, and improvements in the postoperative management of patients. Total pancreatectomy remains a viable option in the treatment of intractable pain associated with chronic pancreatitis, multicentric or extensive neuroendocrine tumors, patients with familial pancreatic cancer with premalignant lesions, and in patients with intraductal papillary mucinous neoplasia with diffuse ductal involvement or invasive disease. Improvements in postoperative management include auto-islet cell transplantation, advances in insulin formulations, and the use of glucagon rescue therapy which allow much tighter control of blood glucose than previously possible. This markedly lessens the risk of life-threatening hypoglycemia and decreases the risk of long-term complications, resulting in improved quality of life for these patients.

Peutz-Jeghers syndrome and screening for pancreatic cancer

BACKGROUND

Cancer risk, including pancreatic, is high in those with Peutz-Jeghers syndrome (PJS). It has been suggested that such patients should undergo screening for pancreatic cancer.

METHODS

The risk of pancreatic cancer in PJS, pancreatic screening and potential screening strategies were reviewed. Cost-effectiveness was assessed according to American Gastroenterology Association guidelines and a risk stratification model proposed by the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer.

RESULTS

The risk of pancreatic cancer is increased in PJS but screening would cost over US 35,000 dollars per life saved. Risk stratification reduces cost by 100,000 dollars and costs fall to 50,000 dollars per life saved if deaths from other forms of cancer are avoided.

CONCLUSION

Screening should be performed only on a research basis to evaluate the benefit and cost-effectiveness in high-risk groups.

An update on familial pancreatic cancer and the management of asymptomatic relatives

Families of patients with pancreatic adenocarcinoma (PC) often ask about their own risk of developing this disease. There is now a sufficient body of evidence to inform relatives of their relative risk of developing PC. The purpose of this review is to provide practical advice for the clinician when confronted with questions about the risk of PC in relatives, and the role of genetic testing and screening in high-risk individuals.

A family history of pancreatic cancer

BACKGROUND

A 65-year-old white male with a family history of pancreatic cancer and a personal history of two episodes of acute pancreatitis was referred to our department in January 2005 by his primary-care physician for an assessment of his pancreatic cancer risk.

INVESTIGATIONS

Physical exam, laboratory investigations, CT scan, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography.

DIAGNOSIS

Familial pancreatic cancer.

MANAGEMENT

Subtotal pancreatectomy, referral to genetic counselor, and continued surveillance.