Efficacy and cost-effectiveness of immediate surgery versus a wait-and-see strategy for sporadic nonfunctioning T1 pancreatic endocrine neoplasms

Economic Burden of Pancreatic Cancer in Europe: a Literature Review

PURPOSE

Pancreatic cancer is characterized by its high mortality, usually attributed to its diagnosis in already advanced stages. This article aims at presenting an overview of the economic burden of pancreatic cancer in Europe.

METHODS

A systematic literature review was conducted. It made use of the search engines EconLit, Google Scholar, PubMed and Web of Science, and retrieved articles published after December 31st, 1992, and before April 1st, 2020. Study characteristics and cost information were extracted. Cost per patient and cost per patient per month (PPM) were calculated, and drivers of estimate heterogeneity was analysed. Results were converted into 2019 Euros.

RESULTS

The literature review yielded 26 studies on the economic burden attributable to pancreatic cancer in Europe. Cost per patient was on average 40,357 euros (median 15,991), while figures PPM were on average 3,656 euros (median 1,536). Indirect costs were found to be on average 154,257 euros per patient or 14,568 euros PPM, while direct costs 20,108 euros per patient and 2,004 euros PPM. Nevertheless, variation on cost estimations was large and driven by study methodology, patient sample characteristics, such as type of tumour and cancer stage and cost components included in analyses, such as type of procedure.

CONCLUSION

Pancreatic cancer direct costs PPM are in the upper bound relative to other cancer types; however, direct per patient costs are likely to be lower because of shorter survival. Indirect costs are substantial, mainly attributed to high mortality.

Survival after active surveillance versus upfront surgery for incidental small pancreatic neuroendocrine tumours

BACKGROUND

The safety of observing small non-functioning pancreatic neuroendocrine tumours (NF-Pan-NETs) remains under debate.

METHODS

This was a multicentre retrospective study of patients with small incidental NF-Pan-NETs. Survival of patients who underwent upfront surgery versus active surveillance was compared. The risk of death was matched with that in the healthy population. The excess hazard rate and probability of a normal lifespan (NLP) were calculated. Propensity score matching (PSM) with a 1 : 1 ratio was used to minimize the risk of selection bias.

RESULTS

Some 222 patients (43.7 per cent) underwent upfront surgery and 285 (56.3 per cent) were observed. The excess hazard rate for the entire cohort was quantifiable as 0.04 (95 per cent c.i. 0 to 0.08) deaths per 1000 persons per year, and the NLP was 99.7 per cent. Patients in the active surveillance group were older (median age 65 versus 58 years; P < 0.001), and more often had co-morbidity (45.3 versus 24.8 per cent; P = 0.001), and smaller tumours (median 12 versus 13 mm; P < 0.001), less frequently located in the pancreatic body-tail (59.5 versus 69.6 per cent; P = 0.008, 59.3 versus 73.9 per cent; P = 0.001). Median follow-up was longer for patients who underwent upfront surgery (5.6 versus 2.7 years; P < 0.001). After PSM, 118 patients per group were included. The excess hazard rates were 0.2 and 0.9 deaths per 1000 persons per year (P = 0.020) for patients in the active surveillance and upfront surgery groups respectively. Corresponding NLPs were 99.9 and 99.5 per cent respectively (P = 0.011).

CONCLUSION

Active surveillance of small incidental NF-Pan-NETs is a reasonable alternative to resection.

Load Balancing Cloud Storage Data Distribution Strategy of Internet of Things Terminal Nodes considering Access Cost

With the rapid development of Internet of Things (IoT) technology, IoT terminal nodes are facing many challenges in data storage, distribution, and data management. In particular, in the IoT terminal nodes considering access cost, the corresponding data distribution and storage are professional, complex, and miscellaneous. Based on the abovementioned current situation, this article innovatively proposes a complex sensor data placement algorithm based on the cloud storage distribution of IoT terminal nodes. Under this algorithm, the accurate division of IoT data I/O methods is realized through reasonable configuration. Through the adaptive sensing algorithm, while fully considering the access cost of the algorithm, the performance of the IoT data storage system is further optimized. In the corresponding terminal node load balancing problem, this article innovatively proposes the terminal node data sorting and distribution algorithm through the node data. The sorting and distribution algorithm realizes the precise segmentation of the IoT data to be processed, thereby realizing the improvement of data reading and processing speed. Based on the proposed algorithm, this article designs a load balancing cloud storage data distribution optimization system of IoT terminal nodes considering access cost and carries out experimental verification in a real environment. The experimental results show that the data pattern division accuracy corresponding to the proposed distribution strategy is improved to 97.13% and the corresponding data access efficiency is improved to 98.3%, compared with the traditional distribution strategy. Therefore, the data distribution strategy proposed in this article has obvious performance advantages and further promotion value.

Sporadic non-functioning pancreatic neuroendocrine tumours: multicentre analysis

BACKGROUND

Outcomes after surgery for sporadic pancreatic neuroendocrine neoplasms (Pan-NENs) were evaluated.

METHODS

This multicentre study included patients who underwent radical pancreatic resection for sporadic non-functioning Pan-NENs. In survival analysis, the risk of mortality in this cohort was analysed in relation to that of the matched healthy Italian population. Relative survival (RS) was calculated as the rate between observed and expected survival. Factors related to RS were investigated using multivariable modelling.

RESULTS

Among 964 patients who had pancreatic resection for sporadic non-functioning Pan-NENs, the overall RS rate was 91.8 (95 per cent c.i. 81.5 to 96.5) per cent. 2019 WHO grade (hazard ratio (HR) 5.75 (s.e. 4.63); P = 0.030) and European Neuroendocrine Tumour Society (ENETS) TNM stage (6.73 (3.61); P < 0.001) were independent predictors of RS. The probability of a normal lifespan for patients with G1, G2, G3 Pan-NENS, and pancreatic neuroendocrine carcinomas (Pan-NECs) was 96.7, 54.8, 0, and 0 per cent respectively. The probability of a normal lifespan was 99.8, 99.3, 79.8, and 46.8 per cent for those with stage I, II, III, and IV disease respectively. The overall disease-free RS rate was 73.6 (65.2 to 79.5) per cent. 2019 WHO grade (HR 2.10 (0.19); P < 0.001) and ENETS TNM stage (HR 2.50 (0.24); P < 0.001) significantly influenced disease-free RS. The probability of disease-free survival was 93.2, 84.9, 45.2, and 6.8 per cent for patients with stage I, II, III, and IV disease, and 91.9, 45.2, 9.4, and 0.7 per cent for those with G1, G2, G3 Pan-NENS, and Pan-NECs, respectively.

CONCLUSION

A surgical approach seems without benefit for Pan-NECs, and unnecessary for small G1 sporadic Pan-NENs. Surgery alone may be insufficient for stage III-IV and G3 Pan-NENs.

Multiple solid pancreatic lesions: Prevalence and features of non-malignancies on dynamic enhanced CT

OBJECTIVE

To determine the prevalence of multiple solid pancreatic lesions on dynamic enhanced CT performed for suspected pancreatic diseases, and to identify CT features of non-malignancies.

METHODS

We investigated 8096 consecutive patients who underwent dynamic enhanced CT pancreas protocol at a tertiary center over 40 months. The final clinical /pathological diagnosis served as reference standard. The diagnostic accuracy of dynamic enhanced CT for non-malignancies was calculated. A univariate and multivariate analysis was conducted to identify features that predict non-malignancies.

RESULTS

Multiple solid pancreatic lesions were identified in 121 patients. The prevalence of non-malignancies was 19.8% (24/121). The most common non-malignancy was autoimmune pancreatitis (n = 21; 17.4%). Common lesions with malignant potential included neuroendocrine neoplasia (n = 62; 51.2%), ductal adenocarcinoma (n = 15; 12.4%), metastasis (n = 9; 7.4%), and lymphoma (n = 7; 5.8%). Dynamic enhanced CT had a sensitivity of 79.2% and a specificity of 92.8% for diagnosing non-malignancies. Elevated serum IgG4 level (p < 0.001), hypo-enhancement in arterial phase (p = 0.001), hyper-enhancement in equilibrium phase (p = 0.009) and location in both proximal and distal pancreas (p = 0.036) were predictors of non-malignancies, whereas pancreatic duct morphology and vascular invasion status were not.

CONCLUSION

Multiple solid pancreatic lesions were rare, with a wide spectrum. Dynamic enhanced CT provides clues for identifying non-malignancies.

Surveillance strategy for small asymptomatic non-functional pancreatic neuroendocrine tumors - a systematic review and meta-analysis

BACKGROUND

Non-functional pancreatic neuroendocrine tumors (NF-PNET) are rare neoplasms being increasingly diagnosed. Surgical treatment or expectant management are both suggested for small NF-PNETs. The aim of this study was to evaluate the outcome of surveillance strategy for small NF-PNETs.

METHODS

A systematic search was performed up to March 2016 in MEDLINE, EMBASE and the Cochrane Library according to the PRISMA guidelines. Data was pooled using the random-effects model.

RESULTS

Nine articles including 344 patients with sporadic and 64 patients with MEN1 related NF-PNET were selected. Tumor growth was observed in 22% and 52%, development of metastases were reported on 0% and 9%, and rate of secondary surgical resection was 12% and 25% in patients with sporadic or MEN1 related NF-PNETs, respectively. All metastases (1 distant, 4 nodal) were reported by a single study in patients with MEN1. Reason for secondary surgery was tumor growth in half of patients undergoing surgery.

DISCUSSION

Expectant management of small asymptomatic, sporadic, NF-PNETs could be a reasonable option in highly selected patients. However, the level of evidence is low and longer follow-up is needed to identify patients could benefit from upfront surgery instead of expectant treatment.

Is surgery the best treatment for sporadic small (≤2 cm) non-functioning pancreatic neuroendocrine tumours? A single centre experience

BACKGOUND

There is currently there is substantial controversy regarding the best management of non-functioning pancreatic neuroendocrine tumours ≤2 cm.

METHODS

Retrospective study involving 102 surgically treated patients affected by non-functioning pancreatic neuroendocrine tumours. Patients having small tumours (≤2 cm) (Group A) and those having large tumours (>2 cm) (Group B) were compared regarding demographics, clinical and pathological factors with the aim of evaluating the risk of malignancy and survival times.

RESULTS

The small tumours were T3-4 in 11% and G2-3 in 36.6% of cases; lymph node and distant metastases were present in 31% and 8% of the cases, respectively. When small and large tumours were compared, significant differences were found in relation to the presence of symptoms (P = 0.012), tumour status (P > 0.001), grading (P > 0.001) and years lost due to disability (P = 0.002). Multivariate analysis of the factors predicting malignancy and survival times showed that tumour size was related only to grading (P < 0.001). The years of life lost and disability adjusted life years were influenced by age at of diagnosis, the presence of symptoms and years lost due to disability only by grading.

CONCLUSIONS

Tumour size alone did not seem to be reliable in predicting malignancy because, first, small tumours (≤2 cm) could present lymph node or distant metastases, and could be G2-3 in a non-negligible percentage of cases and second, their risk of malignancy and survival time are similar to large tumours. Additional parameters have to be considered in order to establish the proper management of small tumours, such as age at diagnosis, presence of symptoms and grading.

Surgery management for sporadic small (≤2 cm), non-functioning pancreatic neuroendocrine tumors: a consensus statement by the Chinese Study Group for Neuroendocrine Tumors (CSNET)

The incidence of small (≤2 cm), non-functioning pancreatic neuroendocrine tumors (NF-pNETs) increased in the last decades. Before making appropriate strategy for patients with NF-pNETs ≤2 cm, pathological confirmation is vital. Incidentally diagnosed, sporadic small NF-pNETs may bring aggressive behavior and poor prognosis, such as extrapancreatic extension, lymph nodal metastasis, distant metastasis and recurrence, even causing disease-related death. Understanding and formulating an appropriate strategy for the patients with sporadic small, non-functioning pancreatic neuroendocrine tumors have been controversial for some time. Although several studies have reported that patients with NF-pNETs ≤2 cm had less rate of malignant behavior compared with larger ones (>2 cm); and the surgery approach may leading to surgery-related pancreatic complications; but there is still a lack of level I evidence to convince surgeons to abandon all cases with sporadic small NF-pNETs. Based on an updated literature search and review, the members of the Chinese Study Group for Neuroendocrine Tumors (CSNET) from high-volume centers have reached a consensus on the issue of the management strategy for the sporadic small NF-pNETs. We recommend that, except for some selected patients with NF-pNETs <1 cm, incidentally discovered and unacceptable surgical risks, all others with NF-pNETs ≤2 cm should undergo tumor resection with lymph node dissection or at least lymph node sampling and careful postoperative surveillance.

The Health Gain Obtainable from Pancreatic Resection for Adenocarcinoma in the Elderly

BACKGROUND

In treating pancreatic ductal adenocarcinoma (PDAC), age does not represent a contraindication to surgery, even if aging is known to increase postoperative mortality and morbidity. Furthermore, long-term outcome remains poor and there is much debate on whether to operate or not in elderly patients. The aim of this study was to provide a general framework to evaluate the health gain obtainable from surgery for PDAC in relationship with age and tumor stage.

METHODS

A Monte Carlo simulation model was built taking into consideration pertinent literature from population-based studies regarding surgical and non-surgical outcomes for stages I-II PDAC. The health gain obtainable from surgery, in comparison to the choice of not resecting patients, was measured through number needed-to-treat (NNT) calculation.

RESULTS

Considering the typical stage I-II PDAC characteristics, the model showed that the mean lifespan after surgery was 28.1 ± 3.9 months and 9.3 ± 1.5 months after non-surgical therapies. The NNT with surgery in order to prevent one death at 5 years was 6 (95% CI 4-10), indicating an overall high gain obtainable from surgery. Sensitivity analyses on patient age and tumor stage suggested that starting from 76 years onward, the NNT progressively increases, resulting in a low cure rate of surgery in the elderly and becoming potentially harmful for patients aged above 80 years. These figures were more pronounced for tumor stages IIA and IIB.

CONCLUSIONS

The present general framework suggests that the lifespan benefit obtainable from pancreatectomy in elderly patients is uncertain especially with the advancing of the tumor stage.