Pancreas-protocol imaging at a high-volume center leads to improved preoperative staging of pancreatic ductal adenocarcinoma

Use of Diagnostic Laparoscopy and Peritoneal Washings for Pancreatic Cancer

Pancreatic adenocarcinoma is an aggressive malignancy that often presents with advanced disease. Accurate staging is essential for treatment planning and shared decision-making with patients. Staging laparoscopy is a minimally invasive procedure that can detect radiographically occult metastatic disease. Its routine use with the collection of peritoneal washings in patients with pancreatic cancer remains controversial. We, herein, review the current literature concerning staging laparoscopy and peritoneal washings in patients with pancreatic cancer.

Outcomes After Multimodality Treatment of Pancreatic Cancer in an Unselected Single-Center Cohort

Background

Pancreatic ductal adenocarcinoma (PDAC) remains a lethal and rarely resectable malignancy. Here we explore the outcomes of surgery, as compared to definitive radiotherapy (dRT) or systemic therapy only in PDAC.

Methods

Pancreatic surgery and radiotherapy in Southwest Finland have been centralized to Turku University Hospital. Previously validated population-based electronic health records database was searched for all unselected PDAC patients from the years 2009-2019. Main outcome was median overall survival (mOS). Demographics, pathology, surgery, and oncological treatment data were collected.

Results

We identified 1006 patients with PDAC, 49% male, median age 71 years and 77% presenting with metastatic disease. In total, 405 patients were treated; 92 resected, 26 dRT without resection and 287 systemic therapy only. mOS was 34.6 months for resected, 26.7 months for dRT, and 7.5 months for systemic therapy patients. Among the 88 patients with locally advanced inoperable PDAC, dRT was independently associated with longer mOS (26.7 months) as compared to systemic therapy only (mOS 10.6 months). Among the 287 patients treated with systemic therapy only, combination chemotherapy was independently associated with longer mOS (11.6 months) as compared to gemcitabine-monotherapy (6.8 months). In patients progressing to second-line systemic treatment after gemcitabine failure, mOS was the same (5.0 months) with single or combination regimens.

Conclusion

Surgery remains the only curative approach for PDAC. In locally advanced PDAC, dRT was associated with longer survival as compared to systemic therapy only. Concerning first-line systemic therapy, our results support the use of combination chemotherapy over single-agent therapy.

Surgical management of pancreatic ductal adenocarcinoma: a narrative review

Background and Objective

Pancreatic ductal adenocarcinoma (PDAC) is the third-leading cause of cancer-related death in the United States and is projected to become the second-leading cause of cancer-related death by 2030. Despite advances in systemic and radiation therapy, for patients with surgically resectable PDAC, complete surgical resection is the only potentially curative treatment option. The conduct of a safe, technically excellent pancreatectomy is essential to achieve optimal perioperative outcomes and long-term survival. In this narrative review, evidence from large, well-executed studies and clinical trials examining the technical aspects of pancreatectomy is reviewed.

Methods

A search was conducted in PubMed, Medline, and Cochrane Review databases to identify English-language randomized clinical trials, meta-analyses, and systematic reviews assessing surgical aspects of pancreatectomy for PDAC published between 2010 to 2023.

Key Content and Findings

We identified retrospective and prospective studies evaluating the technical aspects of surgery for PDAC. In this review, we evaluate data on surgical techniques of pancreatectomy for PDAC, including the role of minimally invasive techniques, extent of lymphadenectomy, reconstruction options after pancreatoduodenectomy, and the role of surgical drainage.

Conclusions

Surgical resection has a critical role in the treatment of operable PDAC. While pancreatic cancer surgery is an active area of research, conducting a technically excellent surgical resection maintains paramount importance for both oncological and perioperative outcomes. In this review, we summarize the latest evidence on surgical technique for operable PDAC.

Annotation-Efficient Deep Learning Model for Pancreatic Cancer Diagnosis and Classification Using CT Images: A Retrospective Diagnostic Study

The aim of this study was to develop a novel deep learning (DL) model without requiring large-annotated training datasets for detecting pancreatic cancer (PC) using computed tomography (CT) images. This retrospective diagnostic study was conducted using CT images collected from 2004 and 2019 from 4287 patients diagnosed with PC. We proposed a self-supervised learning algorithm (pseudo-lesion segmentation (PS)) for PC classification, which was trained with and without PS and validated on randomly divided training and validation sets. We further performed cross-racial external validation using open-access CT images from 361 patients. For internal validation, the accuracy and sensitivity for PC classification were 94.3% (92.8-95.4%) and 92.5% (90.0-94.4%), and 95.7% (94.5-96.7%) and 99.3 (98.4-99.7%) for the convolutional neural network (CNN) and transformer-based DL models (both with PS), respectively. Implementing PS on a small-sized training dataset (randomly sampled 10%) increased accuracy by 20.5% and sensitivity by 37.0%. For external validation, the accuracy and sensitivity were 82.5% (78.3-86.1%) and 81.7% (77.3-85.4%) and 87.8% (84.0-90.8%) and 86.5% (82.3-89.8%) for the CNN and transformer-based DL models (both with PS), respectively. PS self-supervised learning can increase DL-based PC classification performance, reliability, and robustness of the model for unseen, and even small, datasets. The proposed DL model is potentially useful for PC diagnosis.

The Impact of a Centralised Pancreatic Cancer Service: a Case Study of Wales, UK

INTRODUCTION

The centralisation of pancreatic cancer (PC) services still varies worldwide. This study aimed to assess the impact that a centralisation has had on patients in South Wales, UK.

METHODS

A retrospective cohort analysis of patients in South Wales, UK, with PC prior to (2004-2009), and after (2010-2014) the formation of a specialist centre. Patients were identified using record linkage of electronic health records.

RESULTS

The overall survival (OS) of all 3413 patients with PC increased from a median (IQR) 10 weeks (3-31) to 11 weeks (4-35), p = 0.038, after centralisation. The OS of patients undergoing surgical resection or chemotherapy alone did not improve (93 weeks (39-203) vs. 90 weeks (50-95), p = 0.764 and 33 weeks (20-57) vs. 33 weeks (19-58), p = 0.793). Surgical resection and chemotherapy rates increased (6.1% vs. 9.2%, p < 0.001 and 19.7% vs. 27.0%, p < 0.001). The 30-day mortality rate trended downwards (7.2% vs. 3.6%, p = 0.186). The percentage of patients who received no treatment reduced (75.2% vs. 69.6%, p < 0.001).

CONCLUSION

The centralisation of PC services in South Wales is associated with a small increase in OS and a larger increase in PC treatment utilisation. It is concerning that many patients still fail to receive any treatments.

Effect of centralization and regionalization of pancreatic surgery on resection rates and survival

BACKGROUND

Centralization of pancreatic surgery in the Netherlands has been ongoing since 2011. The aim of this study was to assess how centralization has affected the likelihood of resection and survival of patients with non-metastatic pancreatic head and periampullary cancer, diagnosed in hospitals with and without pancreatic surgery services.

METHODS

An observational cohort study was performed on nationwide data from the Netherlands Cancer Registry (2009-2017), including patients diagnosed with non-metastatic pancreatic head or periampullary cancer. The period of diagnosis was divided into three time intervals: 2009-2011, 2012-2014 and 2015-2017. Hospital of diagnosis was classified as a pancreatic or non-pancreatic surgery centre. Analyses were performed using multivariable logistic and Cox regression models.

RESULTS

In total, 10 079 patients were included, of whom 3114 (30.9 per cent) were diagnosed in pancreatic surgery centres. Between 2009-2011 and 2015-2017, the number of patients undergoing resection increased from 1267 of 3169 (40.0 per cent) to 1705 of 3566 (47.8 per cent) (P for trend < 0.001). In multivariable analysis, in 2015-2017, unlike the previous periods, patients diagnosed in pancreatic and non-pancreatic surgery centres had a similar likelihood of resection (odds ratio 1.08, 95 per cent c.i. 0.90 to 1.28; P = 0.422). In this period, however, overall survival was higher in patients diagnosed in pancreatic surgery than in those diagnosed in non-pancreatic surgery centres (hazard ratio 0.92, 95 per cent c.i. 0.85 to 0.99; P = 0.047).

CONCLUSION

After centralization of pancreatic surgery, the resection rate for patients with pancreatic head and periampullary cancer diagnosed in non-pancreatic surgery centres increased and became similar to that in pancreatic surgery centres. Overall survival remained higher in patients diagnosed in pancreatic surgery centres.

Diagnosis of Pancreatic Ductal Adenocarcinoma by Immuno-Positron Emission Tomography

Diagnosis of pancreatic ductal adenocarcinoma (PDAC) by current imaging techniques is useful and widely used in the clinic but presents several limitations and challenges, especially in small lesions that frequently cause radiological tumors infra-staging, false-positive diagnosis of metastatic tumor recurrence, and common occult micro-metastatic disease. The revolution in cancer multi-"omics" and bioinformatics has uncovered clinically relevant alterations in PDAC that still need to be integrated into patients' clinical management, urging the development of non-invasive imaging techniques against principal biomarkers to assess and incorporate this information into the clinical practice. "Immuno-PET" merges the high target selectivity and specificity of antibodies and engineered fragments toward a given tumor cell surface marker with the high spatial resolution, sensitivity, and quantitative capabilities of positron emission tomography (PET) imaging techniques. In this review, we detail and provide examples of the clinical limitations of current imaging techniques for diagnosing PDAC. Furthermore, we define the different components of immuno-PET and summarize the existing applications of this technique in PDAC. The development of novel immuno-PET methods will make it possible to conduct the non-invasive diagnosis and monitoring of patients over time using in vivo, integrated, quantifiable, 3D, whole body immunohistochemistry working like a "virtual biopsy".

The Role of Imaging in Current Treatment Strategies for Pancreatic Adenocarcinoma

In pancreatic cancer, imaging plays an essential role in surveillance, diagnosis, resectability evaluation, and treatment response evaluation. Pancreatic cancer surveillance in high-risk individuals has been attempted using endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI). Imaging diagnosis and resectability evaluation are the most important factors influencing treatment decisions, where computed tomography (CT) is the preferred modality. EUS, MRI, and positron emission tomography play a complementary role to CT. Treatment response evaluation is of increasing clinical importance, especially in patients undergoing neoadjuvant therapy. This review aimed to comprehensively review the role of imaging in relation to the current treatment strategy for pancreatic cancer, including surveillance, diagnosis, evaluation of resectability and treatment response, and prediction of prognosis.

The implications of missed or misinterpreted cases of pancreatic ductal adenocarcinoma on imaging: a multi-centered population-based study

OBJECTIVES

To assess the proportion of missed/misinterpreted imaging examinations of pancreatic ductal adenocarcinoma (PDAC), and their association with the diagnostic interval and survival.

METHODS

Two hundred fifty-seven patients (mean age, 71.8 years) diagnosed with PDAC in 2014-2015 were identified from the Nova Scotia Cancer Registry. Demographics, stage, tumor location, and dates of initial presentation, diagnosis, and, if applicable, surgery and death were recorded. US, CT, and MRI examinations during the diagnostic interval were independently graded by two radiologists using the RADPEER system; discordance was resolved in consensus. Mean diagnostic interval and survival were compared amongst RADPEER groups (one-way ANOVA). Kaplan-Meier analysis was performed for age (< 65, 65-79, ≥ 80), sex, tumor location (proximal/distal), stage (I-IV), surgery (yes/no), chemotherapy (yes/no), and RADPEER score (1-3). Association between these covariates and survival was assessed (multivariate Cox proportion hazards model).

RESULTS

RADPEER 1-3 scores were assigned to 191, 27, and 39 patients, respectively. Mean diagnostic intervals were 53, 86, and 192 days, respectively (p = 0.018). There were only 3/257 (1.2%) survivors. Mean survival was not different between groups (p = 0.43). Kaplan-Meier analysis showed worse survival in RADPEER 1-2 (p = 0.007), older age (p < 0.001), distal PDAC (p = 0.016), stage (p < 0.0001), and no surgery (p < 0.001); survival was not different with sex (p = 0.083). Cox analysis showed better survival in RADPEER 3 (p = 0.005), women (p = 0.002), surgical patients (p < 0.001), and chemotherapy (p < 0.001), and worse survival in stage IV (p = 0.006).

CONCLUSION

Imaging-related delays occurred in one-fourth of patients and were associated with longer diagnostic intervals but not worse survival, potentially due to overall poor survival in the cohort.

KEY POINTS

• One-fourth of patients (66/257, 25.7%) with pancreatic ductal adenocarcinoma (PDAC) underwent imaging examinations that demonstrated manifestations of the disease, but findings were either missed or misinterpreted; RADPEER 2 and 3 scores were assigned to 10.5% and 15.2% of patients, respectively. • Patients with imaging examinations assigned RADPEER 3 scores were associated with significantly longer diagnostic intervals (192 ± 323 days) than RADPEER 1 (53 ± 86 days) and RADPEER 2 (86 ± 120 days) (p < 0.001). • Imaging-related diagnostic delays were not associated with worse survival; however, this may have been confounded by the overall poor survival in our cohort (only 3/257 (1.2%) survivors).

Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center propensity score matching study

Laparoscopic distal pancreatectomy (LDP) for benign and low-grade malignant pancreatic diseases has been increasingly utilized. However, the use of LDP for pancreatic ductal adenocarcinoma (PDAC) remains controversial and has not been widely accepted. In this study, the outcomes of LDP versus conventional open distal pancreatectomy (ODP) for left-sided PDAC were examined. A retrospective review of patients who underwent LDP or ODP for left-sided PDAC between January 2010 and January 2019 was conducted. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors including age, sex, ASA grade, tumor size, and combined resection. Demographic data, their pathological and short-term clinical parameters, and long-term oncological outcomes were compared between the LDP and ODP groups. A total of 197 patients with PDAC were enrolled. There were 115 (58.4%) patients in the LDP group and 82 (41.6%) patients in the ODP group. After 1:1 PSM, 66 well-matched patients in each group were evaluated. The LDP group had lesser blood loss (195 vs. 210 mL, p < 0.01), shorter operative time (193.6 vs. 217.5 min; p = 0.02), and shorter hospital stay (12 vs. 15 days, p < 0.01), whereas the overall complication rates were comparable between groups (10.6% vs.16.7%, p = 0.31). There were no significant differences between the LDP and ODP groups regarding 3-year recurrence-free or overall survival rate (p = 0.89 and p = 0.33, respectively). LDP in the treatment of left-sided PDAC is a technically safe, feasible and favorable approach in short-term surgical outcomes. Moreover, patients undergoing LDP than ODP for PDAC had comparable oncological metrics and similar middle-term survival rate.

Pancreatic cancer surgical management

Pancreatic ductal adenocarcinoma (PDAC) remains a dismal prognosis and surgery is the only chance for cure. However, only few of the patients have localized tumor eligible for curative complete resection. Preoperative management and well-staging of the disease are the cornerstone for appropriate surgery and major issues to define the best therapeutic strategy. This review focuses on the surgical and optimal perioperative management of PDAC and summarizes updates data on the subject.

Diagnostic and therapeutic recommendations in pancreatic ductal adenocarcinoma. Recommendations of the Working Group of the Polish Pancreatic Club

These recommendations refer to the current management in pancreatic ductal adenocarcinoma (PDAC), a neoplasia characterised by an aggressive course and extremely poor prognosis. The recommendations regard diagnosis, surgical, adjuvant and palliative treatment, with consideration given to endoscopic and surgical methods. A vast majority of the statements are based on data obtained in clinical studies and experts' recommendations on PDAC management, including the following guidelines: International Association of Pancreatology/European Pancreatic Club (IAP/EPC), American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN) and Polish Society of Gastroenterology (PSG) and The National Institute for Health and Care Excellence (NICE). All recommendations were voted on by members of the Working Group of the Polish Pancreatic Club. Results of the voting and brief comments are provided with each recommendation.

Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma?

RATIONALE AND OBJECTIVES

To determine the impact of second-opinion assessment on cancer staging and patient management in patients with pancreatic ductal adenocarcinoma.

METHODS AND MATERIALS

This retrospective study was approved by our institutional review board with a waiver of informed consent. Second-opinion reports between January 1, 2009 and December 31, 2013, alongside outside reports for 65 consecutive cases of biopsy-proven pancreatic adenocarcinomas, were presented in random order to two experienced abdominal surgeons who independently reviewed them blinded to the origin of the report, images of the examinations, and patient identifier. Each surgeon filled in a questionnaire for each report recommending cancer staging and patient management. Recommended patient management and staging were evaluated against reference standards (actual patient management at 6 months following second-opinion assessment, and pathology or other clinical and imaging reference standards at 6 months or longer, respectively) using Cohen kappa.

RESULTS

Cancer staging differed in 13% (9 of 65) of cases for surgeon 1 and in 18.4% (12 of 65) for surgeon 2. Patient management changed in 38.4% (25 of 65) of cases for surgeon 1 and in 20% (13 of 65) for surgeon 2. When compared to the pathologic staging gold standard, second opinion was correct in 85.7% (six of seven) of the time for both surgeons. Recommended patient management from second-opinion reports showed good agreement with the reference standard (weighted k = 0.6467 [0.4014-0.892] and weighted k = 0.6262 [0.3954-0.857] for surgeon 2).

CONCLUSION

Second-opinion review by subspecialized oncologic radiologists can impact patient care, specifically in terms of management decision.

Access to radical resections of pancreatic cancer is region-dependent despite the public healthcare system in Finland

BACKGROUND

Surgical resection is the best treatment option to improve the prognosis of pancreatic cancer (PC). Our aim was to analyse whether PC treatment strategies show regional variation in Finland, a country with a nationwide public healthcare system.

METHODS

All patients diagnosed with PC in 2003 and 2008 were identified from the Finnish Cancer Registry. The data regarding tumour, treatment, demographics and timespans to treatment were recorded from the patient archives. Patients were included in the healthcare district where the diagnosis was made. The healthcare districts were classified according to experience in pancreatic surgery into three groups (high level of experience region (HLER), n=2; medium level of experience region (MLER), n=6, and low level of experience region (LLER), n=13).

RESULTS

Patients included numbered 1546 (median age 72 years (range 34-97), 45% men). Demographics and the ratio of stage IV disease (53%) were similar between the regional groups. Despite this, the proportion of radical surgery was greater in HLERs than in the MLERs and LLERs (18% vs 8%-11%; p<0.01). Logistic regression analysis including age, American Society of Anesthesiologists classification, stage and level of experience showed that more radical resections were performed in the HLERs. Preoperative bile drainage showed no regional differences (p=0.137). Palliative chemotherapy only was used more frequently in MLER and LLER than in HLERs (24% vs 33%-30%; p<0.01).

CONCLUSION

Access to PC curative treatment was more likely for patients in healthcare districts including a hospital with high level of experience in pancreatic surgery. This highlights the importance of centralized treatment guidance.

Staging pancreatic carcinoma by computed tomography

Pancreatic carcinoma is becoming more common in our environment; the mortality rate for this tumor has barely changed over the last 20 years. Early diagnosis and accurate staging are crucial to ensure an appropriate therapeutic approach, which should aim to improve survival in patients in whom complete resection is possible and to minimize surgical morbidity and mortality in those with a high risk of residual disease after the intervention. Various imaging techniques are used for tumor staging: multidetector computed tomography (CT), magnetic resonance imaging, positron emission tomography (PET)-CT, endoscopic ultrasound, and diagnostic laparoscopy. Currently, multidetector CT is the technique of choice for the study of pancreatic tumors; thus, this article aims to review the state of the art in staging adenocarcinoma of the pancreas, focusing mainly on the applications and limitations of this technique.

Effect of centralization on long-term survival after resection of pancreatic ductal adenocarcinoma

BACKGROUND

Centralization of pancreatic surgery has resulted in improved short-term outcomes in a number of healthcare systems. The aim of this study was to see whether hospital volume influenced long-term prognosis, use of adjuvant therapy or histopathological evaluation of patients undergoing surgical resection for pancreatic ductal adenocarcinoma (PDAC).

METHODS

Patients undergoing surgical resection of PDAC in Finland between 2002 and 2008 were identified from national registers. Demographic, histopathological, operative and oncological data were recorded, and the histopathological slides of patients who survived for more than 4 years were reviewed. Operative volume was defined according to the annual rate of pancreatoduodenectomy as: high-volume centres (HVCs; 20 or more resections per year), medium-volume centres (MVCs; 6-19 resection annually) and low-volume centres (LVCs; 5 or fewer resections annually).

RESULTS

Some 467 patients who had undergone resectional surgery for PDAC at 22 centres were included. Patient demographics and resection types did not differ between centres. Thirty- and 90-day mortality rates were significantly lower in HVCs compared with LVCs: 0 versus 5·5 per cent (P = 0·001) and 2·5 versus 11·0 per cent (P = 0·003) respectively. Tumours in HVCs were generally at a more advanced stage than those in LVCs (stage IIB: 65·7 versus 40·6 per cent respectively; P < 0·001), but with no greater use of adjuvant therapy. Significantly more patients survived for 2 years (43·3 versus 29·7 per cent; P = 0·034) and 3 years (25·4 versus 14·1 per cent; P = 0·045) after surgery in HVCs than in LVCs. More information was missing in the histopathological reports from LVCs and MVCs than in those from HVCs (P ≤ 0·002).

CONCLUSION

Both short- and long-term survival was significantly better for patients operated on in HVCs. Histopathological analysis appears to be more comprehensive in HVCs.

Optimal Imaging Modalities for the Diagnosis and Staging of Periampullary Masses

Imaging plays a central role in the management of patients with suspected or known periampullary masses, including the initial diagnosis, staging, and follow-up to assess treatment response or recurrence. Use of appropriate imaging tools, application of optimal imaging protocols, and knowledge about imaging findings are essential for the diagnosis and accurate staging of these masses. Structured reporting of the imaging studies offers several advantages over freestyle dictations ensuring completeness of the relevant imaging findings, which would in turn help in deciding the best individual treatment strategy for each patient.

Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE

To provide evidence-based recommendations to oncologists and others for treatment of patients with locally advanced, unresectable pancreatic cancer.

METHODS

American Society of Clinical Oncology convened an Expert Panel of medical oncology, radiation oncology, surgical oncology, gastroenterology, palliative care, and advocacy experts and conducted a systematic review of the literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events.

RESULTS

Twenty-six randomized controlled trials met the systematic review criteria.

RECOMMENDATIONS

A multiphase computed tomography scan of the chest, abdomen, and pelvis should be performed. Baseline performance status and comorbidity profile should be evaluated. The goals of care, patient preferences, psychological status, support systems, and symptoms should guide decisions for treatments. A palliative care referral should occur at first visit. Initial systemic chemotherapy (6 months) with a combination regimen is recommended for most patients (for some patients radiation therapy may be offered up front) with Eastern Cooperative Oncology Group performance status 0 or 1 and a favorable comorbidity profile. There is no clear evidence to support one regimen over another. The gemcitabine-based combinations and treatments recommended in the metastatic setting (eg, fluorouracil, leucovorin, irinotecan, and oxaliplatin and gemcitabine plus nanoparticle albumin-bound paclitaxel) have not been evaluated in randomized controlled trials involving locally advanced, unresectable pancreatic cancer. If there is local disease progression after induction chemotherapy, without metastasis, then radiation therapy or stereotactic body radiotherapy may be offered also with an Eastern Cooperative Oncology Group performance status ≤ 2 and an adequate comorbidity profile. If there is stable disease after 6 months of induction chemotherapy but unacceptable toxicities, radiation therapy may be offered as an alternative. Patients with disease progression should be offered treatment per the ASCO Metastatic Pancreatic Cancer Treatment Guideline. Follow-up visits every 3 to 4 months are recommended. Additional information is available at www.asco.org/guidelines/LAPC and www.asco.org/guidelines/MetPC and www.asco.org/guidelineswiki.

Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE

To provide evidence-based recommendations to oncologists and others on potentially curative therapy for patients with localized pancreatic cancer.

METHODS

ASCO convened a panel of medical oncology, radiation oncology, surgical oncology, palliative care, and advocacy experts and conducted a systematic review of literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events.

RESULTS

Nine randomized controlled trials met the systematic review criteria.

RECOMMENDATIONS

A multiphase computed tomography scan of the abdomen and pelvis or magnetic resonance imaging should be performed for all patients to assess the anatomic relationships of the primary tumor and for the presence of intra-abdominal metastases. Baseline performance status, comorbidity profile, and goals of care should be evaluated and established. Primary surgical resection is recommended for all patients who have no metastases, appropriate performance and comorbidity profiles, and no radiographic interface between primary tumor and mesenteric vasculature. Preoperative therapy is recommended for patients who meet specific characteristics. All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of contraindications. Adjuvant chemoradiation may be offered to patients who did not receive preoperative therapy with microscopically positive margins (R1) after resection and/or who had node-positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy. Patients should have a full assessment of symptoms, psychological status, and social supports and should receive palliative care early. Patients who have completed treatment and have no evidence of disease should be monitored. Additional information is available at www.asco.org/guidelines/PCPC and www.asco.org/guidelineswiki.

Diagnostic Laparoscopy with Ultrasound Still Has a Role in the Staging of Pancreatic Cancer: A Systematic Review of the Literature

Background. The reported incidence of noncurative laparotomies for pancreatic cancer using standard imaging (SI) techniques for staging remains high. The objectives of this study are to determine the diagnostic accuracy of diagnostic laparoscopy with ultrasound (DLUS) in assessing resectability of pancreatic tumors. Study Design. We systematically searched the literature for prospective studies investigating the accuracy of DLUS in determining resectability of pancreatic tumors. Results. 104 studies were initially identified and 19 prospective studies (1,573 patients) were included. DLUS correctly predicted resectability in 79% compared to 55% for SI. DLUS prevented noncurative laparotomies in 33%. Of those, the most frequent DLUS findings precluding resection were liver metastases, vascular involvement, and peritoneal metastases. DLUS had a morbidity rate of 0.8% with no mortalities. DLUS remained superior to SI when analyzing studies published only in the last five years (100% versus 81%), enrolling patients after the year 2000 (74% versus 58%), or comparing DLUS to modern multidimensional CT (100% versus 78%). Conclusion. DLUS seems to still have a role in the preoperative staging of pancreatic cancer. With its ability to detect liver metastases, vascular involvement, and peritoneal metastases, the use of DLUS leads to less noncurative laparotomies.

Hospital of diagnosis and likelihood of surgical treatment for pancreatic cancer

Background

Surgical resection for pancreatic cancer offers the only chance of cure. Assessment of the resectability of a pancreatic tumour is therefore of great importance. The aim of the study was to investigate whether centre of diagnosis influences the likelihood of surgery and whether this affects long-term survival.

Methods

Patients diagnosed with non-metastasized pancreatic cancer (M0) between 2005 and 2013 in the Netherlands were selected from the Netherlands Cancer Registry. Hospitals were classified as a pancreatic centre (at least 20 resections/year) or a non-pancreatic centre (fewer than 20 resections/year). The relationship between centre of diagnosis and likelihood of surgery was analysed by multivariable logistic regression. Influence of centre on overall survival was assessed by means of multivariable Cox regression analysis.

Results

Some 8141 patients were diagnosed with non-metastasized pancreatic cancer, of whom 3123 (38·4 per cent) underwent surgery. Of the 2712 patients diagnosed in one of 19 pancreatic centres, 52·4 per cent had exploratory laparotomy compared with 31·4 per cent of 5429 patients diagnosed in one of 74 non-pancreatic centres (P &lt; 0·001). A pancreatectomy was performed in 42·8 and 24·6 per cent of the patients respectively (P &lt; 0·001). Multivariable analysis revealed that patients diagnosed in a pancreatic centre had a higher chance of undergoing surgery (odds ratio 2·21, 95 per cent c.i. 1·98 to 2·47). Centre of diagnosis was not associated with improved long-term survival (hazard ratio 0·95, 95 per cent c.i. 0·91 to 1·00).

Conclusion

Patients with non-metastasized pancreatic cancer had a greater likelihood of having surgical treatment when the diagnosis was established in a pancreatic centre.

[Pancreatic cancer. Evidence based management guidelines of the Hungarian Pancreatic Study Group]

Pancreatic cancer is a disease with a poor prognosis usually diagnosed at a late stage. Therefore, screening, diagnosis, treatment and palliation of pancreatic cancer patients require up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available scientific evidence and international guidelines. The preparatory and consultation board appointed by the Hungarian Pancreatic Study Group translated and complemented/modified the recent international guidelines. 37 clinical statements in 10 major topics were defined (Risk factors and genetics, Screening, Diagnosis, Staging, Surgical care, Pathology, Systemic treatment, Radiation therapy, Palliation and supportive care, Follow-up and recurrence). Evidence was graded according to the National Comprehensive Cancer Network (NCCN) grading system. The draft of the guideline was presented and discussed at the consensus meeting in September 12, 2014. Statements were accepted with either total (more than 95% of votes, n = 15) or strong agreement (more than 70% of votes, n = 22). The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association

Pancreatic ductal adenocarcinoma is an aggressive malignancy with a high mortality rate. Proper determination of the extent of disease on imaging studies at the time of staging is one of the most important steps in optimal patient management. Given the variability in expertise and definition of disease extent among different practitioners as well as frequent lack of complete reporting of pertinent imaging findings at radiologic examinations, adoption of a standardized template for radiology reporting, using universally accepted and agreed on terminology for solid pancreatic neoplasms, is needed. A consensus statement describing a standardized reporting template authored by a multi-institutional group of experts in pancreatic ductal adenocarcinoma that included radiologists, gastroenterologists, and hepatopancreatobiliary surgeons was developed under the joint sponsorship of the Society of Abdominal Radiologists and the American Pancreatic Association. Adoption of this standardized imaging reporting template should improve the decision-making process for the management of patients with pancreatic ductal adenocarcinoma by providing a complete, pertinent, and accurate reporting of disease staging to optimize treatment recommendations that can be offered to the patient. Standardization can also help to facilitate research and clinical trial design by using appropriate and consistent staging by means of resectability status, thus allowing for comparison of results among different institutions.

Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the society of abdominal radiology and the american pancreatic association

Pancreatic ductal adenocarcinoma is an aggressive malignancy with a high mortality rate. Proper determination of the extent of disease on imaging studies at the time of staging is one of the most important steps in optimal patient management. Given the variability in expertise and definition of disease extent among different practitioners as well as frequent lack of complete reporting of pertinent imaging findings at radiologic examinations, adoption of a standardized template for radiology reporting, using universally accepted and agreed on terminology for solid pancreatic neoplasms, is needed. A consensus statement describing a standardized reporting template authored by a multi-institutional group of experts in pancreatic ductal adenocarcinoma that included radiologists, gastroenterologists, and hepatopancreatobiliary surgeons was developed under the joint sponsorship of the Society of Abdominal Radiologists and the American Pancreatic Association. Adoption of this standardized imaging reporting template should improve the decision-making process for the management of patients with pancreatic ductal adenocarcinoma by providing a complete, pertinent, and accurate reporting of disease staging to optimize treatment recommendations that can be offered to the patient. Standardization can also help to facilitate research and clinical trial design by using appropriate and consistent staging by means of resectability status, thus allowing for comparison of results among different institutions.

Ultrasonic dissection versus conventional dissection techniques in pancreatic surgery: a randomized multicentre study

OBJECTIVE

: This prospective randomized multicenter trial was performed to assess the potential benefits of ultrasonic energy dissection compared with conventional dissection techniques in pancreatic surgery.

BACKGROUND

: Surgical procedures for tumors of the pancreatic head involve time-consuming manual dissection. The primary hypothesis was that use of ultrasonic tissue and vessel dissection would lead to substantial saving in operative time during pancreatic resection.

METHODS

: Patients eligible for pancreaticoduodenectomy (PD) or pylorus-preserving PD (PPPD) were randomized to group A (dissection with ultrasonic device) or group B (conventional dissection) from March 2009 to May 2011. The primary endpoint was overall duration of operation time. Secondary endpoints were time to end of resection phase, intraoperative blood loss, number of transfused units of blood, and postoperative morbidity.

RESULTS

: Analysis of primary and secondary endpoints included 101 patients, who received either PD or PPPD. Demographical characteristics and clinical parameters were similar in both groups. The use of an ultrasonic dissection device did not significantly reduce overall operation time (median 316 minutes in group A and 319 minutes in group B, P = 0.95) and did not significantly increase the costs of surgery. Analysis of secondary endpoints revealed no difference in postoperative course.

CONCLUSIONS

: Tissue dissection and vessel closure using an ultrasonic device is equivalent to dissection with conventional techniques in pancreatic surgery.

Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.

Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.