Acute Pancreatitis as a Possible Indicator of Pancreatic Cancer: The Importance of Mass Detection

Pancreatic Cancer and Its Mimics

Pancreatic ductal adenocarcinoma (PDAC) is the most common primary pancreatic malignancy, ranking fourth in cancer-related mortality in the United States. Typically, PDAC appears on images as a hypovascular mass with upstream pancreatic duct dilatation and abrupt duct cutoff, distal pancreatic atrophy, and vascular encasement, with metastatic involvement including lymphadenopathy. However, atypical manifestations that may limit detection of the underlying PDAC may also occur. Atypical PDAC features include findings related to associated conditions such as acute or chronic pancreatitis, a mass that is isointense to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components. Several neoplastic and inflammatory conditions can mimic PDAC, such as paraduodenal "groove" pancreatitis, autoimmune pancreatitis, focal acute and chronic pancreatitis, neuroendocrine tumors, solid pseudopapillary neoplasms, metastases, and lymphoma. Differentiation of these conditions from PDAC can be challenging due to overlapping CT and MRI features; however, certain findings can help in differentiation. Diffusion-weighted MRI can be helpful but also can be nonspecific. Accurate diagnosis is pivotal for guiding therapeutic planning and potential outcomes in PDAC and avoiding biopsy or surgical treatment of some of these mimics. Biopsy may still be required for diagnosis in some cases. The authors describe the typical and atypical imaging findings of PDAC and features that may help to differentiate PDAC from its mimics. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Zins in this issue.

Preoperative acute pancreatitis and hyperenzymemia are associated with poor prognosis in patients with nonfunctional pancreatic neuroendocrine tumors

BACKGROUND

We aimed to investigate the prevalence of acute pancreatitis (AP) and hyperenzymemia as well as their clinical impact on postoperative survival outcomes in patients with pancreatic neuroendocrine tumors (PNETs).

METHODS

A retrospective cohort study of 218 patients who underwent radical surgical resection for nonfunctional PNETs (NF-PNETs) was conducted. Multivariate survival analysis was performed by the Cox proportional hazard model, with results expressed as hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Of the 151 patients who met the inclusion criteria, the incidences of preoperative AP and hyperenzymemia were 7.9% (12/152) and 23.2% (35/151), respectively. The mean recurrence-free survival (RFS, 95% CI) for patients in control, AP, and hyperenzymemia groups was 136 (127-144), 88 (74-103), and 90 (61-122) months, with a 5-year RFS rate of 86.5%, 58.3%, and 68.9%, respectively. In the multivariable-adjusted Cox hazard model that included tumor grade and lymph node status, the adjusted HR of AP and hyperenzymemia for recurrence was 2.58 (95% CI: 1.47-7.86, p = 0.008) and 2.43 (95% CI: 1.08-7.06, p = 0.040).

CONCLUSION

Preoperative AP and hyperenzymemia are associated with poor RFS following radical surgical resection in NF-PNETs patients.

Acute Pancreatitis Recurrences Augment Long-Term Pancreatic Cancer Risk

INTRODUCTION

In animal models, inflammation caused by experimental acute pancreatitis (AP) promotes pancreatic carcinogenesis that is preventable by suppressing inflammation. Recent studies noted higher long-term risk of pancreatic ductal adenocarcinoma (PDAC) after AP. In this study, we evaluated whether the long-term PDAC risk after AP was influenced by the etiology of AP, number of recurrences, and if it was because of progression to chronic pancreatitis (CP).

METHODS

This retrospective study used nationwide Veterans Administration database spanning 1999-2015. A 2-year washout period was applied to exclude patients with preexisting AP and PDAC. PDAC risk was estimated in patients with AP without (AP group) and with underlying CP (APCP group) and those with CP alone (CP group) and compared with PDAC risk in patients in a control group, respectively, using cause-specific hazards model.

RESULTS

The final cohort comprised 7,147,859 subjects (AP-35,550 and PDAC-16,475). The cumulative PDAC risk 3-10 years after AP was higher than in controls (0.61% vs 0.18%), adjusted hazard ratio (1.7 [1.4-2.0], P < 0.001). Adjusted hazard ratio was 1.5 in AP group, 2.4 in the CP group, and 3.3 in APCP group. PDAC risk increased with the number of AP episodes. Elevated PDAC risk after AP was not influenced by the etiology of AP (gallstones, smoking, or alcohol).

DISCUSSION

There is a higher PDAC risk 3-10 years after AP irrespective of the etiology of AP, increases with the number of episodes of AP and is additive to higher PDAC risk because of CP.

Does acute pancreatitis herald pancreatic ductal adenocarcinoma? A multicenter electronic health research network study

BACKGROUND AND OBJECTIVES

High mortality in pancreas ductal adenocarcinoma (PDAC) is related to delayed diagnosis and lack of cost-effective early detection strategies. Retrospective studies have demonstrated an association between PDAC and acute pancreatitis (AP). Herein, we explore the incidence of PDAC in patients with non-biliary and non-alcoholic AP.

METHODS

A population-based, retrospective cohort study was conducted utilizing TriNetX (Cambridge, MA). Patients ≥40 years with AP (ICD-10-CM code: K85) and without biliary AP (K85.1), alcohol-induced AP (K85.2) or chronic pancreatitis (K86.0, K86.1), were identified. The primary outcome was incidence of PDAC (C25) in patients at defined intervals following AP. We compared the rate of early-stage diagnosis (stage 1-2) and surgical resection among patients with and without preceding AP.

RESULTS

The incidence of PDAC ranged from 2.16% (1 year) to 3.43% (5 years). Patients with PDAC and AP in preceding year were more likely to undergo surgical resection relative to those without AP (10.1% vs. 6.3%, risk ratio 1.62: 95% confidence interval, CI 1.47-1.79). Early-stage diagnosis of PDAC was more frequent in patients with preceding AP; however, difference was insignificant (p = 0.48; 95% CI 0.64-2.58).

CONCLUSION

AP is infrequently associated with PDAC and can precede a diagnosis of PDAC in a minority of patients without another known etiology of pancreatitis. Patients with a recent AP are more likely to undergo surgical resection of PDAC and a trend toward diagnosis at an earlier stage compared to patients with PDAC and without AP. The impact of AP-related PDAC on survival is unknown.

Analysis of Progression Time in Pancreatic Cancer including Carcinoma In Situ Based on Magnetic Resonance Cholangiopancreatography Findings

BACKGROUND

Pancreatic cancer (PC) exhibits extremely rapid growth; however, it remains largely unknown whether the early stages of PC also exhibit rapid growth speed equivalent to advanced PC. This study aimed to investigate the natural history of early PCs through retrospectively assessing pre-diagnostic images.

METHODS

We examined the data of nine patients, including three patients with carcinoma in situ (CIS), who had undergone magnetic resonance cholangiopancreatography (MRCP) to detect solitary main pancreatic duct (MPD) stenosis >1 year before definitive PC diagnosis. We retrospectively analyzed the time to diagnosis and first-time tumor detection from the estimated time point of first-time MPD stenosis detection without tumor lesion.

RESULTS

The median tumor size at diagnosis and the first-time tumor detection size were 14 and 7.5 mm, respectively. The median time to diagnosis and first-time tumor detection were 26 and 49 months, respectively.

CONCLUSIONS

No studies have investigated the PC history, especially that of early PCs, including CIS, based on the initial detection of MPD stenosis using MRCP. Assessment of a small number of patients showed that the time to progression can take several years in the early PC stages. Understanding this natural history is very important in the clinical setting.

Acute Pancreatitis as the Initial Presentation of Pancreatic Adenocarcinoma does not Impact Short- and Long-term Outcomes of Curative Intent Surgery: A Study of the French Surgical Association

BACKGROUND

Acute pancreatitis (AP) can be one of the earliest clinical presentation of pancreatic ductal adenocarcinoma (PDAC). Information about the impact of AP on postoperative outcomes as well as its influences on PDAC survival is scarce. This study aimed to determine whether AP as initial clinical presentation of PDAC impact the short- and long-term outcomes of curative intent pancreatic resection.

PATIENTS AND METHODS

From 2004 to 2009, 1449 patients with PDAC underwent pancreatic resection in 37 institutions (France, Belgium and Switzerland). We used univariate and multivariate analysis to identify factors associated with severe complications and pancreatic fistula as well as overall and disease-free survivals.

RESULTS

There were 764 males (52,7%), and the median age was 64 years. A total of 781 patients (53.9%) developed at least one complication, among whom 317 (21.8%) were classified as Clavien-Dindo ≥ 3. A total of 114 (8.5%) patients had AP as the initial clinical manifestation of PDAC. This situation was not associated with any increase in the rates of postoperative fistula (21.2% vs 16.4%, P = 0.19), postoperative complications (57% vs 54.2%, P = 0.56), and 30 day mortality (2.6% vs 3.4%, P = 1). In multivariate analysis, AP did not correlate with postoperative complications or pancreatic fistula. The median length of follow-up was 22.4 months. The median overall survival after surgery was 29.9 months in the AP group and 30.5 months in the control group. Overall recurrence rate and local recurrence rate did not differ between groups.

CONCLUSION

AP before PDAC resection did not impact postoperative morbidity and mortality, as well as recurrence rate and survival.

Long Non-coding RNA FENDRR Modulates Autophagy Through Epigenetic Suppression of ATG7 via Binding PRC2 in Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory, complicated pancreatic disease, carrying significant morbidity and mortality. However, the molecular and cellular mechanisms involved in AP pathogenesis remain to be elucidated. Here, we explore the role of FOXF1 adjacent non-coding developmental regulatory RNA (FENDRR) in AP progression. Caerulein with or without LPS- induced or taurolithocholic acid 3-sulfate (TLC-S)-induced AP mouse models and cell models were performed for the validation of FENDRR expression in vivo and in vitro, respectively. Histopathological examinations of pancreatic tissues were performed to evaluate the severity of AP. Transmission electron microscopy was utilized to visualize the autophagic vacuoles. siRNA specifically targeting FENDRR was further applied. Flow cytometry was employed to assess cell apoptosis. ELISA, immunoflureoscence, and western blotting analysis were also performed to determine the levels of inflammatory cytokines and autophagy activity. RNA immunoprecipitation (RIP) and chromatin immunoprecipitation (ChIP) assays were carried out to reveal the epigenetic regulation of FENDRR on ATG7. Additionally, silencing FENDRR was also verified in AP mouse models. Higher FENDRR and impaired autophagy were displayed in both AP mouse models and cell models. FENDRR knockdown dramatically attenuated caerulein- or TLC-S-induced AR42J cells apoptosis and autophagy suppression. Further mechanistic experiments implied that the action of FENDRR is moderately attributable to its repression of ATG7 via direct interaction with the epigenetic repressor PRC2. Moreover, the silencing of FENDRR significantly induced the promotion of ATG7, thus alleviating the development of AP in vivo. Our study highlights FENDRR as a novel target that may contribute to AP progression, suggesting a therapeutic target for AP treatment.

Clinical characteristics and outcome of tumor-associated acute pancreatitis: a single-center cohort study

Background

What features should alert clinicians to suspect underlying tumors in patients with acute pancreatitis (AP) was largely unknown. This study aimed to assess the clinical characteristics and outcome in patients with tumor-associated AP.

Methods

Patients who presented with AP and were diagnosed with tumor after admission were included according to the inclusion and exclusion criteria and followed up by hospital notes, telephone, WeChat and/or e-mail. The clinical characteristics and outcome were analyzed with multivariable logistic regression and were compared with AP patients without tumor.

Results

Out of a cohort of 1,792 AP patients we identified 103 who had a neoplastic etiology. The 103 patients had a median age of 57 (range, 13-81) and 65 were males. AP was mild in 92 patients, moderately severe in 7 and severe in 4. The three most common tumors included pancreatic cancer (PC) (40), periampullary carcinoma (PAC) (25), and neoplastic pancreatic cysts (NPC) (22). The following ranked features were predictive of a tumor etiology: dilation of main pancreatic duct (MPD) (OR 417.83, 95% CI: 80.40-2,171.42), vascular invasion (OR 82.04, 95% CI: 6.05-1,113.14), mild AP (8.29, 95% CI: 1.98-34.73), and anemia (OR 5.73, 95% CI: 2.02-16.26). The median survival period of AP patients with PC, PAC, and NPC was 10.0 (7.0-23.5), 21.0 (5.0-37.0), and 35.0 (30.0-96.0) months, respectively.

Conclusions

Mild AP patients with dilation of MPD, vascular invasion, and anemia were more frequently suggested a tumor etiology. Thus, clinical vigilance is needed for timely detection of tumor-associated pancreatitis with these characteristics.

Endoscopic pancreatic duct stenting for pain palliation in selected pancreatic cancer patients: a systematic review and meta-analysis

Background

Abdominal pain is a debilitating symptom affecting ∼80% of pancreatic cancer (PC) patients. Pancreatic duct (PD) decompression has been reported to alleviate this pain, although this practice has not been widely adopted. We aimed to evaluate the role, efficacy, and safety of endoscopic PD decompression for palliation of PC post-prandial obstructive-type pain.

Methods

A systematic review until 7 October 2020 was performed. Two independent reviewers selected studies, extracted data, and assessed the methodological quality.

Results

We identified 12 publications with a total of 192 patients with PC presenting with abdominal pain, in whom PD decompression was attempted, and was successful in 167 patients (mean age 62.5 years, 58.7% males). The use of plastic stents was reported in 159 patients (95.2%). All included studies reported partial or complete improvement in pain levels after PD stenting, with an improvement rate of 93% (95% confidence interval, 79%–100%). The mean duration of pain improvement was 94 ± 16 days. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) were post-sphincterotomy bleeding (1.8%), post-ERCP pancreatitis (0.6%), and hemosuccus pancreaticus (0.6%). AEs were not reported in two patients who underwent endoscopic ultrasound-guided PD decompression. In the 167 patients with technical success, the stent-migration and stent-occlusion rates were 3.6% and 3.0%, respectively. No AE-related mortality was reported. The methodological quality assessment showed the majority of the studies having low or unclear quality.

Conclusion

In this exploratory analysis, endoscopic PD drainage may be an effective and safe option in selected patients for the management of obstructive-type PC pain. However, a randomized–controlled trial is needed to delineate the role of this invasive practice.

The Severity of Acute Pancreatitis According to Modified Balthazar Classification in Patients With Pancreatic Cancer

OBJECTIVE

Although acute pancreatitis (AP) is a self-limited disease under supportive and medical treatment, it can have life-threatening potential in some patients. Results of studies reporting outcomes of AP-associated pancreatic malignancy are controversial. The aim of this study was to evaluate the severity and prognosis of pancreatic cancer (PC)-related AP by modified Balthazar score.

METHODS

A total of 354 patients hospitalized and followed up in our clinic between 2013 and 2019 were included in the study. Demographic data of all patients were recorded. The etiology of all cases was determined. According to the etiology, the cases were divided into 2 groups: AP related to pancreatic malignancy and AP due to nonmalignant causes. The patients underwent computed tomography of the abdomen within the first 12 hours of admission and after 3 to 7 days. Patients were evaluated and classified by modified Balthazar classification.

RESULTS

Malignancy-related AP was detected in 18 (5.1%) patients. A total of 336 cases (94.9%) were related to nonmalignant causes. There was no statistically significant difference in the severity of AP in both groups at admission and after 3 days (p > 0.05). The changes (regression, progression, or no change) in the disease severity at the first and the subsequent imaging were examined. There was no significant relationship between the 2 groups (p > 0.05).

CONCLUSION

AP may be the clinical manifestation of PC or PC may induce AP in various ways. It was shown that the underlying malignancy did not adversely affect the severity and course of AP.

A case of high-grade pancreatic intraepithelial neoplasia diagnosed based on focal pancreatic parenchymal atrophy after acute pancreatitis

A 60-year-old male visited a previous hospital with upper abdominal pain. He was diagnosed with localized mild acute pancreatitis. Three months later, abdominal contrast-enhanced computed tomography showed focal parenchymal atrophy of the pancreas with distal pancreatic duct dilation. No obvious solid mass could be found at the site of the pancreatic duct stenosis on imaging examinations. Endoscopic retrograde pancreatography showed focal mild stenosis with distal pancreatic duct dilation in the tail of the pancreas. Carcinoma in situ of the pancreas was strongly suspected, especially based on the presence of focal atrophy of the pancreas around the site of stenosis of the main pancreatic duct and the distal pancreatic duct dilation. Laparoscopic distal pancreatectomy was performed. Histologically, high-grade pancreatic intraepithelial neoplasia was found in the epithelium of the stenotic main pancreatic duct and its branches. This case suggests that localized acute pancreatitis and focal atrophy of the pancreas with distal dilation of the pancreatic duct could be important clinical manifestations of pancreatic carcinoma in situ.

Predictors of underlying pancreatic cancer in patients with acute pancreatitis: a Danish nationwide cohort study

BACKGROUND

To identify demographic characteristics, comorbidities, medical procedures, and prescription drug use that may act as predictors of underlying pancreatic cancer in acute pancreatitis.

METHODS

A cohort study of all patients admitted to Danish hospitals with incident acute pancreatitis during 1999-2015. The ability of age, sex, selected comorbidities, medical procedures, and prescription drug use to predict underlying pancreatic cancer in acute pancreatitis (i.e., pancreatic cancer diagnosed up to one year after acute pancreatitis) was examined. The absolute risk and odds ratio (OR) with 95% confidence interval (CI) of cancer was computed for each variable.

RESULTS

28,231 patients with incident acute pancreatitis, of which 283 (1.0%) had underlying pancreatic cancer, were included. Age >50 years was a predictor of pancreatic cancer with highest risk in patients aged 56-70 years. New-onset chronic pancreatitis (multivariable OR: 2.36 [95% CI: 1.35-4.14]) and new-onset diabetes (multivariable OR: 1.94 [95% CI: 1.30-2.92]) were also predictors of pancreatic cancer. Diagnoses of biliary or alcohol-related diseases were predictors of no underlying pancreatic cancer. Most variables examined had no or limited predictive ability.

CONCLUSION

Age, new-onset chronic pancreatitis, new-onset diabetes, and absence of biliary or alcohol-related diseases were predictors of underlying pancreatic cancer in acute pancreatitis patients.

Balthazar Score and Neutrophil-Lymphocytes Ratio in Acute Pancreatitis

Acute pancreatitis is a pathological entity that poses numerous diagnostic and treatment problems. Severe form is a real challenge for a physician because it has multiple obscure causes, as well as a complex pathophysiology. Thus, the diagnosis is difficult and the choice of the right time for surgical treatment is controversial, the treatment being more frequently nonspecific, supportive for the various affected systems and organs. On a group of 337 patients, laboratory and imaging investigations were performed to diagnose and determine the severity score of acute pancreatitis and the correlation level between the neutrophil-lymphocytes ratio values and the Balthazar score, as a valid assessment method for local and systemic inflammatory changes. The distribution’s study of acute pancreatitis by gender according to etiology confirms the predominance of the acute ethanolic pancreatitis in male, but also the higher proportion (54%) of male pancreatitis (181 man vs. 156 women) with gender ratio male/female 1.16/1. The neutrophil-lymphocytes ratio mean value varied according with the Balthazar severity score, that got higher as acute pancreatitis got more advanced and with a certain cut-off value can be considered a simple indicator to determine the severity of acute pancreatitis.

Recurrence and survival after surgery for pancreatic cancer with or without acute pancreatitis

BACKGROUND

In pancreatic cancer, acute pancreatitis (AP) is a serious morbidity, but its negative effect on long-term outcomes remains to be elucidated.

AIM

To investigate the effects of AP on the tumor recurrence pattern of pancreatic ductal adenocarcinoma (PDAC) and tumor-specific survival.

METHODS

The medical records of 219 patients with curative pancreatectomy for pancreatic cancer at the Pancreatic Surgery Center of West China Hospital from July 2012 to December 2016 were analyzed retrospectively. The severity of acute pancreatitis was classified according to the Atlanta classification of AP. The patient demographics and tumor characteristics were assessed. Early recurrence was defined as a relapse within 12 mo after surgery. Overall and disease-free survival and recurrence patterns were analyzed. Mild acute pancreatitis was excluded because its negative effects can be negligible.

RESULTS

Early recurrence in AP group was significantly higher than in non-AP group (71.4% vs 41.2%; P = 0.009). Multivariate analysis of postoperative early recurrence showed that moderate or severe AP was an independent risk factor for an early recurrence [odds ratio (OR): 4.13; 95% confidence interval (CI): 1.41-12.10; P = 0.01]. The median time to recurrence was shorter in patients with AP than in those without (8.4 vs 12.8 mo; P = 0.003). Multivariate analysis identified AP as an independent prognostic factor for overall survival [relative risk (RR): 2.35; 95%CI: 1.45-3.83] and disease-free survival (RR: 2.24; 95%CI: 1.31-3.85) in patients with PDAC.

CONCLUSION

Patients with moderate or severe acute pancreatitis developed recurrences earlier than those without. Moderate or severe AP is associated with shorter overall and disease-free survival of patients with PDAC.

Glucose metabolism during tumorigenesis in the genetic mouse model of pancreatic cancer

AIM

More than 40% of pancreatic ductal adenocarcinoma (PDAC) patients have glucose intolerance or diabetes. The association has led to two hypotheses: PDAC causes diabetes or diabetes shares risk factors for the development of PDAC. In order to elucidate the relationship between diabetes and PDAC, we investigated the glucose metabolism during tumorigenesis in the LSL-KrasG12D/+; LSL-Trp53R172H/+; and Pdx-1-Cre (KPC) mouse, a genetically engineered model of PDAC.

METHODS

Male and female KPCs have been fed with standard diet (SD) or high-fat diet (HFD). The imaging-based 4-class tumor staging was used to follow pancreatic cancer development. Not fasting glycemia, 4-h fasting glycemia, insulin, C-peptide, glucose tolerance after OGTT and abdominal fat volume were measured during tumorigenesis.

RESULTS

PDAC development did not lead to an overt diabetic phenotype or to any alterations in glucose tolerance in KPC fed with SD. Consumption of HFD induced higher body weight/abdominal fat volume and worsened glucose homeostasis both in control CRE mice and only in early tumorigenesis stages of the KPC mice, excluding that the cancer development itself acts as a trigger for the onset of dysmetabolic features.

CONCLUSION

Our data demonstrate that carcinogenesis in KPC mice is not associated with paraneoplastic diabetes.

National Trends and Hospitalizations Related to Pancreatic Cancer in Acute Pancreatitis Patients: A Nationwide Inpatient Sample Study

Background

Pancreatic cancer (PC) is one of the common cancers in the United States (U.S.) and is associated with high mortality and morbidity. In spite of the modest improvement in survival, cancer care costs including PC continue to rise and inpatient costs contribute a significant chunk to cancer care, which is often ignored. Acute pancreatitis (AP) is a rare manifestation of PC. This study aims to determine the national trends and associated health care utilization of PC patients hospitalized with AP in the U.S.

Methods

We used National Inpatient Sample (NIS) to extract data for patients hospitalized with a primary diagnosis of PC in AP in 2016 using International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes. The analysis included disease etiologies, age, race, sex, hospital region, hospital size, institution type, mortality, length of hospital stay (LOS), and commonly associated comorbidities were correlated.

Results

There were 250 patients with a discharge diagnosis of PC in patients admitted with AP. Most of the patients were whites (76.6%) with the mean age of 39.42 ± 2.51 years, had Medicare (63.26%) as primary insurance, were from Southern region (46%) and had higher Charlson comorbidity index (CCI) (76.00% with CCI > = 3). The mean hospital charges were $48,462.13, and mean LOS was 5.24 days. The LOS was significantly impacted by race, hospital region, endoscopic retrograde cholangiopancreatography (ERCP), and comorbidities such as dementia, smoking, and seizure. Out of the 250 patients admitted with PC, 245 patients (98%) were discharged alive.

Conclusions

Our study shows a downward trend in LOS, hospital charges, and in-hospital mortality as compared to other studies despite PC and AP presenting together versus PC with or without other etiologies.

Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer

Pancreatic cancer (PC) has a poor prognosis due to delayed diagnosis. Early diagnosis is the most important factor for improving prognosis. For early diagnosis of PC, patients with clinical manifestations suggestive of PC and high risk for developing PC need to be selected for examinations for PC. Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can be performed for diagnosing PC, but the diagnostic ability of these examinations for PC is limited. Endoscopic diagnostic procedures, such as endoscopic ultrasonography, including fine-needle aspiration, and endoscopic retrograde pancreatocholangiography, including Serial Pancreatic-juice Aspiration Cytologic Examination (SPACE), could be recommended for a detailed examination to diagnose pancreatic carcinoma earlier.

Significant increased CA199 levels in acute pancreatitis patients predicts the presence of pancreatic cancer

Background and study aims

Carbohydrate antigen 19-9 (CA199) has been identified as a tumor marker for pancreatic cancer but also increases in benign lesions of the digestive system. However, literature associated with the relationship between CA199 and acute pancreatitis (AP) is limited. This study aimed to focus on serum CA199 level measurements in AP patients and the associated clinical significance.

Materials and methods

From January 2006 to December 2015, 1,609 consecutive patients with AP were admitted to our department and included in the study. The relationships among the etiology of AP, the disease severity, the incidence of pancreatic cancer during hospitalization and CA199 levels were analyzed.

Results

Serum CA199 levels were measured for 693 of 1,609 AP patients. Of those patients, 186 (26.8%) had elevated CA199 levels (> 37 U/ml). Patients with high CA199 levels were older and had predominantly biliary causes in comparison with patients with normal CA199 levels. There were no definite specific correlations between CA199 levels and disease severity in AP. In addition, serum levels of CA199 positively correlated with serum alanine aminotransferase, aspartate transaminase, glutamyl transpeptidase, alkaline phosphatase and creatinine levels. After stratification, the incidence of pancreatic cancer increased proportionally to CA199 levels in AP patients.

Conclusions

Serum CA199 levels was elevated in patients with AP, especially in patients with biliary pancreatitis. AP patients with significantly increased CA199 levels may have a higher risk for the presence of pancreatic cancer. We recommended routinely monitoring CA199 levels during hospitalization for AP patients.

Acute pancreatitis-onset carcinoma in situ of the pancreas with focal fat replacement diagnosed using serial pancreatic-juice aspiration cytologic examination (SPACE)

A 59-year-old woman was admitted for acute pancreatitis. Abdominal computed tomography and magnetic resonance imaging revealed a swollen pancreatic parenchyma with dilatation of the main pancreatic duct (MPD) of the pancreas tail, which was separated from the normal pancreas body side by a locally atrophic part of the pancreas. Magnetic resonance cholangiopancreatography showed MPD stricture in the pancreas tail with dilatation of the upstream MPD. Endoscopic ultrasonography revealed that the MPD stricture of the pancreas tail was surrounded by a blurred and hypoechoic area. Endoscopic retrograde cholangiopancreatography was performed for serial pancreatic-juice aspiration cytologic examination (SPACE). The result indicated adenocarcinoma. Distal pancreatectomy was performed, and the histopathological examination showed high-grade PanIN (carcinoma in situ of the pancreatic duct) of the pancreas tail with atrophy and fibrosis of the pancreatic parenchyma, and local fat replacement adjacent to the lesion. The final histopathological diagnosis was carcinoma in situ of the pancreatic duct of the pancreas tail. Acute pancreatitis and local fatty change of the pancreatic parenchyma with MPD stricture are important clinical manifestations of pancreatic carcinoma in situ (PCIS) and performing SPACE in cases of MPD stricture without a recognizable mass is preferable for a diagnosis of PCIS.

Acute pancreatitis in patients with pancreatic cancer: Timing of surgery and survival duration

Acute pancreatitis (AP) is a rare manifestation of pancreatic cancer (PC). The relationship between AP and PC remains less distinct.From January 2009 to November 2015, 47consecutive patients with PC who presented with AP were reviewed for this study. Clinical features, clinicopathologic variables, postoperative complications, and follow-up evaluations of patients were documented in detail from our database. In order to identify cutoff threshold time for surgery, receiver operating curve (ROC) was built according to patients with or without postoperative complications. Cumulative rate of survival was calculated by using the Kaplan-Meier method. The study was conducted in accordance with the principles of the Declaration of Helsinki and the guidelines of West China Hospital.This study included 35 men (74.5%) and 12 women (25.5%) (mean age: 52 years), with a median follow-up of 40 months. AP was clinically mild in 45 (95.7%) and severe in 2 (4.3%). The diagnosis of PC was delayed by 2 to 660 days (median 101 days). Thirty-nine (83.0%) cases underwent surgery. Eight (17.0%) cases performed biopsies only. Of 39 patients, radical surgery was performed in 32 (82.1%) cases and palliative in 7 (19.9%) cases. Two (8.0%) patients were needed for vascular resection and reconstruction. Postoperative complications occurred in 12 (30.8%) patients. About 24.5 days was the best cutoff point, with an area under curve (AUC) of 0.727 (P = 0.025, 95% confidence interval: 0.555-0.8999). The survival rate of patients at 1 year was 23.4%. The median survival in patients with vascular resection and reconstruction was 18 months, compared with 10 months in patients without vascular resection (P = 0.042). For the primary stage (T), Tix was identified in 3 patients, the survival of whom were 5, 28, 50 months, respectively. And 2 of them were still alive at the follow-up period.The severity of AP was mainly mild. Surgical intervention after 24.5 days may benefit for reducing postoperative complications. Patients with vascular resection and reconstruction, thus achieving tumor-free margins, had a long-time survival.

Endoscopic sphincterotomy (ES) may not alter the natural history of idiopathic recurrent acute pancreatitis (IRAP)

BACKGROUND

The role of endoscopic sphincterotomy (ES) in idiopathic recurrent acute pancreatitis (IRAP) is unclear. We hypothesized that ES will alter the natural history of IRAP.

METHODS

We retrospectively studied the course of 50 IRAP patients from the NAPS2 study from UPMC based on whether they underwent ES or were managed medically. Data included age at first AP, rate of attacks, and history of severe AP. Primary outcomes were any subsequent AP and rate of attacks; secondary outcome was chronic pancreatitis (CP) diagnosis during follow-up. Similar data was abstracted for alcoholic RAP.

RESULTS

When compared with medically managed IRAP patients (n = 24, 48%), those who underwent ES (n = 26, 52%) had similar rate of attacks/year (median 1.54 vs. 1.41, p = 0.63), but significantly more attacks (median 3 vs. 2, p = 0.04) at baseline. During follow-up (median 7 years), rate of attacks/year decreased significantly, and were similar in both groups (median 0.16 vs. 0, p = ns). Predictors for rate of attacks during follow-up were sex (ratio 0.54 in females, p = 0.045) and rate of attacks at baseline (ratio for doubling 1.2, p = 0.025), but not ES. Alcoholic RAP patients had lower rate of attacks at baseline, but higher risk of subsequent AP (80 vs. 46%, p = 0.021) and rate of attacks/year (median 0.25 vs. 0, p = 0.016) during follow-up. Progression to CP occurred in IRAP and ES, medically managed IRAP, and alcoholic RAP in 27%, 8% and 27% respectively (p = ns).

CONCLUSIONS

ES, chosen in patients with higher burden of attacks, does not seem to impact the natural history of IRAP.