Pancreatic cancer: Advances in treatment

Pancreatic cancer is a leading cause of cancer mortality and the incidence of this disease is expected to continue increasing.While patients with pancreatic cancer have traditionally faced a dismal prognosis,over the past several years various advances in diagnosis and treatment have begun to positively impact this disease.Identification of effective combinations of existing chemotherapeutic agents,such as the FOLFIRINOX and the gemcitabine+nab-paclitaxel regimen,has improved survival for selected patients although concerns regarding their toxicity profiles remain.A better understanding of pancreatic carcinogenesis has identified several pre-malignant precursor lesions,such as pancreatic intraepithelial neoplasias,intraductal papillary mucinous neoplasms,and cystic neoplasms.Imaging technology has also evolved dramatically so as to allow early detection of these lesions and thereby facilitate earlier management.Surgery remains a cornerstone of treatment for patients with resectable pancreatic tumors,and advances in surgical technique have allowed patients to undergo resection with decreasing perioperative morbidity and mortality.Surgery has also become feasible in selected patients with borderline resectable tumors as a result of neoadjuvant therapy.Furthermore,pancreatectomy involving vascular reconstruction and pancreatectomy with minimally invasive techniques have demonstrated safety without significantly compromising oncologic outcomes.Lastly,a deeper understanding of molecular aberrations contributing to the development of pancreatic cancer shows promise for future development of more targeted and safe therapeutic agents.

Pancreatic endometrial cyst mimics mucinous cystic neoplasm of the pancreas

Pancreatic cysts include a variety of benign, premalignant, and malignant lesions. Endometrial cysts in the pancreas are exceedingly rare lesions that are difficult to diagnose pre-operatively. This report describes the findings in a 43-year-old patient with a recent episode of acute pancreatitis who presented with a large cyst in the tail of the pancreas. Imaging demonstrated a loculated pancreatic cyst, and cyst fluid aspiration revealed an elevated amylase and carcinoembryonic antigen. The patient experienced an interval worsening of abdominal pain, fatigue, diarrhea, and a 15-pound weight loss 3 mo after the initial episode of pancreatitis. With concern for a possible pre-malignant lesion, the patient underwent a laparoscopic distal pancreatectomy with splenectomy, which revealed a 16cm×12cm×4cm lesion. Final histopathology was consistent with an intra-pancreatic endometrial cyst. Here we discuss the overlapping imaging and laboratory features of pancreatic endometrial cysts and mucinous cystic neoplasms of the pancreas.

Delayed gastric emptying following pancreaticoduodenectomy:Incidence,risk factors,and healthcare utilization

AIM To characterize incidence and risk factors for delayed gastric emptying(DGE) following pancreaticoduodenectomy and examine its implications on healthcare utilization. METHODS A prospectively-maintained database was reviewed. DGE was classified using International Study Group of Pancreatic Surgery criteria. Patients who developed DGE and those who did not were compared. RESULTS Two hundred and seventy-six patients underwent pancreaticoduodenectomy(PD)(> 80% pyloruspreserving, antecolic-reconstruction). DGE developed in 49 patients(17.8%): 5.1% grade B, 3.6% grade C. Demographic, clinical, and operative variables were similar between patients with DGE and those without. DGE patients were more likely to present multiplecomplications(32.6% vs 4.4%, ≥ 3 complications, P < 0.001), including postoperative pancreatic fistula(POPF)(42.9% vs 18.9%, P = 0.001) and intra-abdominal abscess(IAA)(16.3% vs 4.0%, P = 0.012). Patients with DGE had longer hospital stay(median, 12 d vs 7 d, P < 0.001) and were more likely to require transitional care upon discharge(24.5% vs 6.6%, P < 0.001). On multivariate analysis, predictors for DGE included POPF [OR = 3.39(1.35-8.52), P = 0.009] and IAA [OR = 1.51(1.03-2.22), P = 0.035].CONCLUSION Although DGE occurred in < 20% of patients after PD, it was associated with increased healthcare utilization. Patients with POPF and IAA were at risk for DGE. Anticipating DGE can help individualize care and allocate resources to high-risk patients.