Giovanni Butturini

Symptoms and Quality of Life in Chronic Pancreatitis Assessed by Structured Interview and the EORTC QLQ-C30 and QLQ-PAN26

BACKGROUND AND AIMS:Chronic pancreatitis (CP) produces disabling symptoms and requires major clinical interventions over a number of years. There is consensus that quality-of-life (QoL) assessment should be part of assessing the treatment and outcome of CP. These symptoms and treatments resemble those of pancreatic cancer, for which there are validated QoL assessment instruments. The aim of our study was to assess the appropriateness of using the EORTC QoL assessment system for pancreatic cancer (the EORTC QLQ-C30 and QLQ-PAN26) for patients with CP, and to document important issues that affect QoL in these patients.METHODS:A structured literature review was undertaken to determine current approaches to QoL in pancreatic disease. Sixty-six patients with newly diagnosed or treated CP were asked to complete the EORTC QLQ-C30 and QLQ-PAN26 in four countries (Germany, Italy, South Africa, and United Kingdom). Patients were asked to review the appropriateness of the content and structure of the instruments, during a directed interview. Standard psychometric tests were used to assess the reliability and validity of the instruments. Peer review was undertaken to review findings and adapt the QLQ-PAN26 on the basis of the responses obtained.RESULTS:The literature review highlighted the potential value of the EORTC QLQ-C30 and identified the lack of a CP-specific instrument, which had been appropriately developed. There was overwhelming consensus among experts that the EORTC assessment system appeared suitable for use in CP patients. This was endorsed by all patients. Patients identified additional issues related to guilt about the use of alcohol and the burden of trying to abstain. All but one scale (jaundice) exhibited adequate internal consistency (r > 0.70) Construct validity of the QLQ-C30 and QLQ-PAN26 showed strong associations between conceptually related scales (r > 0.6, p < 0.001) and significantly discriminated between patients on the basis of performance status and requirement for opiate analgesia. Significant issues affecting QoL in CP patients, in addition to recognized symptoms of the disease, were fear of future health problems, difficulty sleeping, and fatigue.CONCLUSION:The EORTC QLQ-C30 and QLQ-PAN26 appear to be an appropriate assessment system for CP, with the addition of items to cover guilt about alcohol consumption, and the burden of abstention. Patients QoL is adversely affected by the fear of future health problems, difficulty sleeping, and fatigue.

UK guidelines for the management of acute pancreatitis

Correspondence to: Mr C D Johnson, University Surgical Unit, Mail Point 816, Southampton General Hospital, Southampton BH24 4EW, UK; c.d.johnson@ soton.ac.uk . . . . . . . . . . . . . . . . . . . . . . . 1.0 REVISED RECOMMENDATIONS AND AUDIT STANDARDS 1.1 Recommendations 2003 (*Unchanged from the 1998 recommendations) Diagnosis N *The correct diagnosis of acute pancreatitis should be made in all patients within 48 hours of admission (recommendation grade C). N The aetiology of acute pancreatitis should be determined in at least 80% of cases and no more than 20% should be classified as idiopathic (recommendation grade B). N Although amylase is widely available and provides acceptable accuracy of diagnosis, where lipase estimation is available it is preferred for the diagnosis of acute pancreatitis (recommendation grade A). N Where doubt exists, imaging may be used: ultrasonography is often unhelpful and pancreatic imaging by contrast enhanced computed tomography provides good evidence for the presence or absence of pancreatitis (recommendation grade C).

The Evolution of Surgical Strategies for Pancreatic Neuroendocrine Tumors (Pan-NENs)

Objective: The objective of the present analysis is 2-fold: first, to define the evolution of time trends on the surgical approach to pancreatic neuroendocrine neoplasms (Pan-NENs); second, to perform a complete analysis of the predictors of oncologic outcome. Background: Reflecting their rarity and heterogeneity, Pan-NENs represent a clinical dilemma. In particular, there is a scarcity of data regarding their long-term follow-up after surgical resection. Methods: From the Institutional Pan-NEN database, 587 resected cases from 1990 to 2015 were extracted. The time span was arbitrarily divided into 3 discrete clusters enabling a balanced comparison between patient groups. Analyses for predictors of recurrence and survival were performed, together with conditional survival analyses. Results: Among the 587 resected Pan-NENs, 75% were nonfunctioning tumors, and 5% were syndrome-associated tumors. The mean age was 54 years (±14 years), and 51% of the patients were female. The median tumor size was 20u200amm (range 4 to 140), 62% were G1, 32% were G2, and 4% were G3 tumors. Time trends analysis revealed that the number of resected Pan-NENs constantly increased, while the size (from 25 to 20u200amm) and G1 proportion (from 65% to 49%) decreased during the study period. After a mean follow-up of 75 months, recurrence analysis revealed that nonfunctioning tumors, tumor grade, N1 status, and vascular invasion were all independent predictors of recurrence. Regardless of size, G1 nonfunctioning tumors with no nodal involvement and vascular invasion had a negligible risk of recurrence at 5 years. Conclusions: Pan-NENs have been increasingly diagnosed and resected during the last 3 decades, revealing reliable predictors of outcome. Functioning and nodal status, tumor grade, and vascular invasion accurately predict survival and recurrence with resulting implications for patient follow-up.

Radiofrequency Ablation of Pancreatic Mass

Stage III pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis, and no gold standard treatment has been established so far. Radiofrequency ablation (RFA) is a new treatment option for locally advanced pancreatic cancer (LAPC), but its application is still very limited. We report our experience on 200 patients treated with pancreatic RFA as cytoreductive intent associated with chemoradiotherapy in a multimodal setting. In our series, median survival was 19 months and progression-free survival was 13 months. The results do not seem to depend on the rate of the ablated area. Postoperative course was uneventful in 76 % of cases, abdominal complications occurred in 23 % of patients, and the mortality rate was 2 %. However, after the last technical changes (temperature 80 °C, limited ablation, use of single cool-tip needle, safety distance from the duodenum), we found a significant reduction of morbidity (from 25% to 13%) and mortality (from 2% to 0%). RFA with endoscopic ultrasound approach (EUS-RFA) has been recently proposed, but the experience is still very limited. The advantages of EUS-RFA are being a less invasive approach, more precise placement of the needle due to high-resolution images, and short hospital stay. Moreover, the procedure is potentially repeatable.

Rare Secondary Tumors of the Pancreas

Secondary neoplasms involving the pancreas are less common than primary neoplasms. The pancreas is rarely the only metastatic site and metastases can reach the pancreas by lymphatic or hematogenous routes. Several tumors have been demonstrated to metastasize to the pancreas; however, there are differences in the prevalence of the various tumor types that colonize the pancreas, depending upon the population considered (autopsy records vs. surgical specimens).

Rare Variants of Ductal Adenocarcinoma of the Pancreas

Histologic variants of ductal adenocarcinoma are neoplasms characterized by a specific histological pattern different from that of conventional pancreatic cancer, which is typically an adenocarcinoma. It has been estimated that these variants account for 2–10% of all pancreatic ductal cancers.

Tumor-like Lesions of the Pancreas

Autoimmune pancreatitis (AIP) is a “one of a kind” inflammatory disease of the pancreas since it differs clinically, pathologically, and instrumentally from all other types of pancreatitis. Many papers have been published since the introduction of the term “autoimmune pancreatitis” by Yoshida et al. in 1995 [1], focusing mainly on the dramatic and quick response to steroid therapy.

Rare Primary Tumors of the Pancreas

Although pancreatic acinar cells represent > 80% of pancreatic tissue, acinar cell carcinomas (ACCs) account only for 1% of primary pancreatic neoplasms [1–5]. The average age at diagnosis is approximately 60 years old, with the majority of patients being men.