Chronic calcifying pancreatitis and pancreatic carcinoma in Japan

Painless chronic pancreatitis

BACKGROUND

Painless chronic pancreatitis (CP) is a rare form of the disease.

AIM

To evaluate the prevalence and the characteristics of this overlooked form of pancreatitis.

METHODS

Patients with a diagnosis of CP and absence of pain were selected, excluding patients suffering from autoimmune pancreatitis. Clinical data, imaging features, and exocrine and endocrine function were therefore analyzed.

RESULTS

Among 781 patients observed between 2010 and 2016, 74 patients with painless CP (9.5%) were selected. Mean age at diagnosis was 60.8 (SD 10.8) years. 38(51%) individuals did not report any symptom, 36(49%) were affected by symptoms other than pain. Pancreatic calcifications were diagnosed in 70 patients (95%), main pancreatic duct dilation in 55(74%), and pancreatic atrophy in 39(53%).Thirty-six patients (55%) had severe exocrine pancreatic insufficiency(EPI). Diabetes was observed in 34 out of 72 patients (47%). During a mean follow-up of 2.9 (SD 2.8) years, only a mild pancreatitis was diagnosed in a 71-year old female. No patient underwent endoscopic treatment or surgery, developed pancreatic cancer or died.

CONCLUSIONS

In a tertiary center painless CP is observed in 10% of cases, and it is frequently associated with EPI. The probability of onset of pain is very low in a short-term follow-up.

Dairy products and pancreatic cancer risk: a pooled analysis of 14 cohort studies

Pancreatic cancer has few early symptoms, is usually diagnosed at late stages, and has a high case-fatality rate. Identifying modifiable risk factors is crucial to reducing pancreatic cancer morbidity and mortality. Prior studies have suggested that specific foods and nutrients, such as dairy products and constituents, may play a role in pancreatic carcinogenesis. In this pooled analysis of the primary data from 14 prospective cohort studies, 2212 incident pancreatic cancer cases were identified during follow-up among 862 680 individuals. Adjusting for smoking habits, personal history of diabetes, alcohol intake, body mass index (BMI), and energy intake, multivariable study-specific hazard ratios (MVHR) and 95% confidence intervals (CIs) were calculated using the Cox proportional hazards models and then pooled using a random effects model. There was no association between total milk intake and pancreatic cancer risk (MVHR = 0.98, 95% CI = 0.82-1.18 comparing ≥500 with 1-69.9 g/day). Similarly, intakes of low-fat milk, whole milk, cheese, cottage cheese, yogurt, and ice-cream were not associated with pancreatic cancer risk. No statistically significant association was observed between dietary (MVHR = 0.96, 95% CI = 0.77-1.19) and total calcium (MVHR = 0.89, 95% CI = 0.71-1.12) intake and pancreatic cancer risk overall when comparing intakes ≥1300 with <500 mg/day. In addition, null associations were observed for dietary and total vitamin D intake and pancreatic cancer risk. Findings were consistent within sex, smoking status, and BMI strata or when the case definition was limited to pancreatic adenocarcinoma. Overall, these findings do not support the hypothesis that consumption of dairy foods, calcium, or vitamin D during adulthood is associated with pancreatic cancer risk.

The epidemiology and socioeconomic impact of chronic pancreatitis

Epidemiological studies have been published worldwide in recent decades describing the incidence, mortality, aetiology and trends of chronic pancreatitis. Accumulated evidence suggests that chronic pancreatitis is increasing in incidence and hospital admission rates are rising accordingly. Alcoholic chronic pancreatitis was previously more common in the developed world than elsewhere, but is now increasing worldwide due to growing per capita alcohol consumption in each nation. Supporting alcohol and smoking cessation in individual patients is essential to slow disease progression and improve overall health, as most patients will die of cirrhosis, cardiovascular disease or smoking related cancers rather than chronic pancreatitis. The socioeconomic impact of chronic pancreatitis is difficult to quantify as little data exists, however given the rising incidence the costs to health care and society are likely to increase. This chapter will describe the epidemiology and aetiology of chronic pancreatitis worldwide and discusses the factors that influence its socioeconomic impact.

Pancreas cancer, tobacco smoking and consumption of alcoholic beverages: a case-control study

A population-based case-control study investigated pancreas cancer in relation to consumption of alcoholic beverages, tobacco smoking and pancreatitis, utilizing historical proxy data for 662 decedent Finnish pancreas cancer cases and 1770 cancer controls. Tobacco smoking increased the risk, with an attributable case fraction of 0.27. The data are consistent with a joint effect of early and late stage carcinogens in tobacco smoke. Consumption of distilled beverages did not increase risk, but heavy drinking of wine or beer did. History of pancreatitis was a strong risk factor.

Etiologic links between chronic pancreatitis and pancreatic cancer

In all forms of pancreatitis there appears to be a cellular dysfunction, glandular destruction, and, presumably, increased cell turnover. Increased cell division has been suggested as a potential precursor of cancer in many organs. The excess risk of pancreatic cancer that has been documented in epidemiologic studies in patients with various types of pancreatitis is consistent with this hypothesis. The uncertainties in epidemiologic studies notwithstanding, the existence of a clear association between pancreatitis and the subsequent risk of pancreatic cancer is found too often to be only randomized. The clinical relevance of a causal relationship between chronic pancreatitis and pancreatic cancer is, however, limited, since the prognosis of chronic pancreatitis cannot be separated from that of chronic alcoholism.

Longitudinal Gompertzian analysis of mortality from pancreatic cancer in Japan, 1955-1993

Age-specific mortality rates from pancreatic cancer (PanC) in Japan from 1955 through 1993 were subjected to longitudinal Gompertzian analysis. Age-specific PanC mortality rate distributions between age 30 and 70 years were highly Gompertzian for each and every year for both men and women. Between 1955 and 1993, age-adjusted PanC mortality rates increased 5.1 times for men and 4.3 times for women. The environmental factor for PanC mortality increased 68% for men and 89% for women over this period. Gompertzian analysis suggests that rising mortality from PanC in Japan may be related to rapidly changing lifestyles among Japanese. Pure alcohol consumption was the identified environmental factor most strongly correlated with PanC mortality.

Increasing incidence of pancreatic cancer among women in Olmsted County, Minnesota, 1940 through 1988

To determine trends in the incidence of pancreatic cancer and associated survival, we conducted a population-based study in Olmsted County, Minnesota. From 1940 through 1988, 219 residents of Olmsted County (120 men and 99 women) were diagnosed as having exocrine pancreatic cancer. All patients were Caucasians, and 92% had a histologically confirmed diagnosis. The mean annual adjusted incidence of pancreatic cancer per 100,000 population was 8.5 overall (11.3 for men and 6.6 for women). During the course of the study, the incidence rates increased in women (P < 0.05) and in both genders combined (P = 0.06) but not in men (P = 0.4). The male:female ratio decreased from approximately 2:1 for 1940 through 1949 to 1.5:1 for 1980 through 1988. The incidence was significantly associated with increasing age (P < 0.001) and male gender (P < 0.001) but not calendar period (P = 0.19). The overall median duration of survival was 2.8 months. The 1-year survival rate was only 14%, and no patient lived for more than 55 months after pancreatic cancer was diagnosed. Men and women had similar survival rates. The increased incidence of pancreatic cancer among women may be due in part to the increasing life span of women and the increasing occurrence of pancreatic cancer in the aged.

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis without calcifications is described. Pancreatolithiasis, or calcified pancreas, is recognized as a high risk factor for pancreatic cancer. However, epidemiologic studies have found that carcinoma of the pancreas associated with chronic pancreatitis was rare. The question is whether chronic pancreatitis without calcifications is actually a precancerous background lesion or not. This case suggests that hyperplasia of the pancreatic ductal epithelium may be a precancerous lesion for pancreatic cancer in some patients with chronic pancreatitis.

Coffee and alcohol as determinants of risk of pancreas cancer: a case-control study from Toronto

Results are reported from a population-based study of 249 cases of pancreas cancer and 505 controls carried out in Toronto, Canada, between 1983 and 1986. Lifetime consumption of coffee and alcohol and medical histories were assessed by personal interviews. No evidence of any association was found with different types of coffee or alcohol after adjusting for smoking, calories and fibre intake. There was a significant increased risk associated with a history of diabetes mellitus within 5 years of cancer development. A protective effect of a history of some allergic conditions, hay fever, eczema and asthma, was observed, although the relative risks were not significant (p value greater than 0.10).

Alcohol, beer and cancer of the pancreas

The relationship between total alcohol consumption and intake of beer, wine and spirits and the risk of cancer of the pancreas was re-assessed in a pooled analysis of 3 case-control studies of pancreatic cancer from Italy, France and Switzerland, providing a total data-set of 494 cases and 1,704 controls. Logistic regression was used to obtain relative risks adjusted for study, age, sex, smoking and socio-economic status. Relative to non-drinkers, the risk estimates for subsequent levels of alcohol consumption were close to unity, and there was no evidence of a trend in risk with dose: the point estimate for more than 8 drinks per day was 0.8 (95% Confidence Interval, CI = 0.5-1.3). Likewise, no consistent association was observed for consumption of wine, beer or spirits: the relative risks for the highest consumption levels were 1.0 for wine, 0.9 for beer and 0.9 for spirits. No significant interaction was observed with study centre, sex or smoking habits. Given the large size of the data-set, of the consistency and the replication of findings across the 3 different studies, and of the elevated alcohol consumption of these populations, the present analysis gives reassuring evidence on the alcohol and pancreatic cancer issue in relation to total consumption of alcohol, of beer and of other alcoholic beverages.

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.

A case-control study of pancreatic cancer and cigarettes, alcohol, coffee and diet

A pancreatic cancer case-control study was conducted in the Minneapolis-St. Paul area. Family members were interviewed about the subject's usage of cigarettes, alcohol, coffee, and other dietary factors in the two years prior to death (cases, n = 212) or prior to interview (controls, n = 220). The adjusted odds ratio for two packs or more of cigarettes per day was 3.92 (95% CI = 1.18, 13.01) and four or more drinks per day OR 2.69 (95% CI = 1.00, 7.27). Coffee was not a risk factor (seven cups or more per day; OR 0.58 (95% CI = 0.27, 1.27). A positive trend was observed for beef and pork consumption, and a negative trend from cruciferous vegetables.

The interpretation of retrograde pancreatography in the elderly

Endoscopic retrograde pancreatography is regarded as the most specific technique in the diagnosis of chronic pancreatitis. In the elderly the relevance of endoscopic retrograde pancreatography changes in establishing the diagnosis is disputed. The pancreatograms of 101 patients aged seventy-five years or more, who had endoscopic retrograde pancreatography for suspected biliary or pancreatic pathology, were reviewed. Only four patients subsequently proved to have unequivocal chronic pancreatitis. There was no significant difference in the size or contour of the main pancreatic duct, or in side branch changes between those patients presenting with common bile duct stones, incidental biliary pathology and pain of probable pancreatic origin. Three definite diagnostic criteria for the diagnosis of chronic pancreatitis emerged--duct obstruction with a stricture, gross irregularity of the main pancreatic duct and the presence of large cavities.

Epidemiology of pancreatic cancer

New studies continue to examine the puzzle of pancreatic cancer, and the results to date have provided us with clues but no clear answers other than the detrimental effects of tobacco. Many of those clues, however, are promising, particularly with regard to diet. It is hoped that in the future better dietary assessment methods will help sort out the complicated, but important, contribution of diet.

Pancreatic cancer, alcohol, diabetes mellitus and gall-bladder disease

A case-control study comprising 216 cases of pancreatic cancer and 279 controls was conducted to investigate the relationship of pancreatic cancer with certain chronic medical conditions and with the consumption of tea, coffee and alcoholic beverages. Significant positive associations with pre-existing diabetes mellitus and gall-bladder disease were observed and there was weak evidence of association with liver disease. The relative risks for diabetes mellitus and gallstones diagnosed at least one year previously were 4.1 (p = 0.005) and 2.8 (p = 0.01) respectively. Cases drank significantly more beer than controls (p = 0.005) and there was evidence of a positive trend in risk with total alcohol consumption. Smoking was a clear risk factor, but cases and controls were very similar with respect to tea and coffee drinking habits.

Coffee consumption and risk of pancreatic cancer

The relationship between pancreatic cancer and coffee, decaffeinated coffee and tea drinking habits was evaluated using data from a hospital-based case-control study conducted in Northern Italy on 150 histologically confirmed cases and 605 controls with acute, non-neoplastic, other than digestive tract diseases unrelated to coffee consumption or to any of the known or potential risk factors for cancer of the pancreas. Compared with subjects who did not drink coffee, the multivariate relative risks were 1.7 for those who drank less than 2 cups per day, but only 1.4, and 1.1 respectively for drinkers of 3 or 4 and 5 or more cups. Likewise, there was no association with duration of consumption of coffee, decaffeinated coffee or tea. These findings were reviewed together with published evidence from other case-control studies (or cohort studies analyzed as case-control) of coffee and pancreatic cancer. When appropriate statistical methods were used to pool information, and the data from the first study which was the basis of the hypothesis were omitted, the relative risk of pancreatic cancer based on 1,464 cases was 1.2 for moderate coffee drinkers and 1.4 for heavy drinkers, and we suspect that at least part of this moderate residual association is confounded by cigarette smoking. Thus, although the present investigation and a general overview of published epidemiological evidence are compatible with a small effect of coffee on pancreatic carcinogenesis, interpretation of these findings is not obvious on account of the possibility of residual confounding and other sources of bias.

Nutritional data and etiology of chronic pancreatitis in Mexico

Alcoholism and malnutrition have been implicated commonly in the etiology of chronic pancreatitis (CP). The geographical distribution and clinical and nutritional features differ between the alcoholic and tropical forms of CP. This work presents the etiology and nutritional characteristics of CP in Mexico, a country in which both alcoholism and childhood malnutrition are common. Two well-defined groups of patients have been identified: an alcoholic group composed mainly of males with a mean age at clinical onset of 41 years and a high dietary intake of fat, protein, carbohydrates, and calories; and a nonalcoholic group with a female preponderance, a mean age at onset of 23 years, and a higher intake of protein than controls. We conclude that alcoholic chronic pancreatitis in Mexico is similar to that reported in other temperate countries. Although the nonalcoholic group resembles that observed in tropical countries in many ways, our patients are not malnourished, further questioning the role of childhood malnutrition in the pathogenesis of this type of chronic pancreatitis.

Pancreatic lithiasis in the aged. Its clinicopathology and pathogenesis

The incidence of pancreatic calculi in autopsy material was found to increase in proportion to age after 70 yr: 0% under 69 yr of age (0 of 134), 4.2% in the 70s (5 of 119), 7.7% in the 80s (9 of 117), and 16.7% in the 90s (8 of 48). Most of the stones were found scattered throughout the peripheral ducts. Pancreatic lithiasis in the aged was clinically characterized by lack of signs and symptoms, absence of alcoholism, and was unassociated with hypercalcemia. Extensive parenchymal atrophy and fibrosis were limited to the areas upstream from the calculi. The stones were found in the ducts just above the sites of obstruction where squamous metaplasia was invariably present. Immunohistologic study showed intense staining for lactoferrin in the protein plugs and in the cytoplasm of cuboidal or squamous cells of ducts containing the plugs. Ductal stenosis, either primarily caused or secondarily exacerbated by squamous metaplasia, and lactoferrin-positive cells appeared to play a role in the pathogenesis of pancreatic lithiasis in the aged.

Epithelial dysplasias in chronic pancreatitis

The present 280 specimens of chronic pancreatitis were examined to determine the type and frequency of epithelial dysplasia of the duct system. The epitheilal dysplasias were divided into 3 degrees of severity according to cytological and histological criteria. Dysplasia was demonstrable in 40.1% of the 280 specimens. Of these 32.9% were classified as dysplasia grade I and 7.1% as dysplasia grade II. Dysplasia grade III did not occur. The epithelial proliferations were correlated with the topography, the stage of the scarring and the degree of obstruction of pancreatic secretion. An increase in dysplasia was evident in relation to the stage of the scarring and to the obstruction of secretory outflow. In correlation with the topography of the chronic pancreatitis there was the highest frequency of epithelial dysplasias in uniformly scarred glands (47.7%). Papillary and pseudopapillary hyperplasias with atypia were demonstrated in 17.9 vs. 4.5% of the cases with epithelial proliferations.

Current knowledge of pancreatic carcinogenesis in the hamster and its relevance to the human disease

Syrian hamsters present a unique species for induction of pancreatic tumors that in many aspects resemble human pancreatic cancer. The specific response of Syrian hamsters, in contrast to may other rodents, for development of pancreatic ductal (ductular) tumors is not yet known. All pancreatic carcinogens thus far tested show certain common features. They are all nitrosamines that possess or can be metabolized to compounds with 2-oxopropyl- or 2-hydroxypropyl substituents. All but one, N-nitroso-methyl(2-oxopropyl)amine, occur or metabolize to nitrosamines with the ability to cyclize and form structures resembling glucose. Hence it is suggested that this cyclic structure may be responsible for the pancreatic carcinogenicity of these nitrosamines, as has been proposed for the pancreatotropic effect of streptozotocin. It is also of further interest that one pancreatic ductal (ductular) carcinogen, N-nitroso-2-methoxy-2,6-dimethylmorpholine, which possesses a totally cyclic structure, acts, like streptozotocin, as beta-cell cytotoxic and diabetogenic when given in a high single dose. Modification of pancreatic tumor induction has been demonstrated by specific procedures. A high fat diet significantly increases both the incidence and number of induced cancers. Methods for early diagnosis and therapy are being developed and their significance and applicabilities for clinical use will be of major importance. Compared with the other most common types of human cancer, pancreatic cancer has extraordinary characteristics, which make the disease one of the most mysterious of maladies. Consequently, pancreatic cancer represents a serious international problem and requires urgent resolution, especially with regard to its etiology, early diagnosis, prevention, and therapy.

Demographic characteristics of cancer of the pancreas: mortality, incidence, and survival

Mortality and incidence rates for pancreatic cancer in the United States were examined by various demographic characteristics. Disease rates have continued to increase over time but at a much slower pace than in earlier years. Most recently available rates for blacks were significantly higher than for whites and rates for males of each race were higher than for females. Income and education levels had little influence on incidence rates among either blacks or whites. Incidence rates were not significantly higher in urban as compared with rural areas of Iowa and Colorado. The two-year survival rate for pancreatic cancer was about 5% in recent years and did not vary significantly by race or sex. Smoking and diabetes, the two risk factors most consistently associated with the pancreatic cancer, explain only a small proportion of the disease. Much epidemiologic work remains to be done.

Lifestyle factors and cancer of the pancreas: a hypothetical mechanism

The interaction of a genetically determined protease inhibitor, the enzymes whose functions are modified by that inhibitor and lifestyle factors, such as cigarette smoking, high lipid diet and alcohol consumption, are considered key factors in a proposed protease-antiprotease imbalance mechanism for pancreatic oncogenesis. Epidemiologic and experimental laboratory evidence in support of the mechanism is presented along with a discussion of suggested research initiatives to further test the hypothesis.