Early onset pancreatic cancer-exploring contemporary treatment and outcomes using real-world data.

BACKGROUND: Pancreatic cancer incidence is increasing in younger populations. Differences between early onset pancreatic cancer (EOPC) and later onset pancreatic cancer (LOPC), and how these should inform management warrant exploration in the contemporary setting. METHODS: A prospectively collected multi-site dataset on consecutive pancreatic adenocarcinoma patients was interrogated. Patient, tumour, treatment, and outcome data were extracted for EOPC (≤50 years old) vs LOPC (>50 years old). RESULTS: Of 1683 patients diagnosed between 2016 and 2022, 112 (6.7%) were EOPC. EOPC more frequently had the tail of pancreas tumours, earlier stage disease, surgical resection, and trended towards increased receipt of chemotherapy in the curative setting compared to LOPC. EOPC more frequently received 1st line chemotherapy, 2nd line chemotherapy, and chemoradiotherapy than LOPC in the palliative setting. Recurrence-free survival was improved for the tail of pancreas EOPC vs LOPC in the resected setting; overall survival was superior for EOPC compared to LOPC across the resected, locally advanced unresectable and metastatic settings. CONCLUSIONS: EOPC remains a small proportion of pancreatic cancer diagnoses. The more favourable outcomes in EOPC suggest these younger patients are overall deriving benefits from increased treatment in the curative setting and increased therapy in the palliative setting.

Paradigms in trauma laparoscopy for anterior abdominal stab wounds: A scoping review.

INTRODUCTION: Anterior abdominal stab wounds (AASW) are a heterogeneous presentation with evolving management over time and heterogenous practice between centres. The aim of this scoping review was to identify, characterise and classify paradigms for trauma laparoscopies for AASW. METHODOLOGY: Studies were screened from Embase, Medline, Scopus, Cochrane Library and Web of Science from 1 January 1947 until 1 January 2023. Extracted data included indications for trauma laparoscopies vs laparotomies, and criteria for conversion to an open procedure. RESULTS: Of 72 included studies, 35 (48.6 %) were published in the United States, with an increasing number from South Africa since 2014. Screening tests to determine an indication for surgery included local wound exploration, computed tomography, and serial clinical examination. Two studies proposed no absolute contraindications to laparoscopy, whereas most papers supported trauma laparoscopies over laparotomies in hemodynamically stable patients with positive or equivocal screening tests. However, clinical decision trees were used inconsistently both between and within many hospital centres. Triggers for conversion to laparotomy were diverse. Older studies typically reported conversion if peritoneal breach was identified. More recent studies reported advances in technical skills and technology allowed attempt at laparoscopic repair for organ and/or vascular injury. CONCLUSION: This review emphasises that there are many different paradigms of practice for AASW laparoscopy, which are evolving over time. Significant heterogeneity of these studies highlights that meta-analysis of outcomes for trauma laparoscopy is not appropriate unless the included studies report homogenous treatment paradigms and patient cohorts. The decision to perform a trauma laparoscopy should be based on surgeon/hospital experience, patient factors, and resource availability.

Consensus statement: support for supervisors of surgical training in Australia and Aotearoa New Zealand.

The Supervisor Support Consensus Statement has been developed after consultation with supervisors of surgical training for the Royal Australasian College of Surgeons (RACS) programmes in Australia and Aotearoa New Zealand and other key stakeholders. Six key areas have been recognized with specific recommendations crafted to improve the support and recognition of Supervisors: 1. Clarity of role, 2. Education and Training, 3. Local support, 4. RACS support, 5. Recognition and valuing of the Supervisor role, 6. Risk Management. The purpose of this consensus statement is to clearly articulate supervisor opinions on the support they require to undertake this important role. It has been produced by an independent writing group of experienced surgical supervisors and educators, with support from RACS education department. The consensus statement is a response to a needs assessment of supervisors of surgical training. The statements in this consensus document have been generated from comments and feedback from supervisors that have been refined through process of extensive consultation using a Delphi methodology. We advise specialty training Committees consider these statements and mandate them as part of their accreditation of terms. The role of the supervisor of training requires greater recognition, and incorporation in the Enterprise Bargaining Agreement (EBA) in Australia and the ASMS Te Whatu Ora SECA in Aotearoa New Zealand would ensure the provisions in this document are enacted. The six areas identified have transferability to other specialities and countries and are valuable when considering how to support supervisors involved in training our next generation of specialist doctors.

Role of neoadjuvant peptide receptor radionuclide therapy in unresectable and metastatic gastro-entero-pancreatic neuroendocrine neoplasms: A scoping review.

Peptide receptor radionuclide therapy (PRRT) is an established therapy for metastatic neuroendocrine neoplasms (NEN). The role of PRRT as a neoadjuvant treatment prior to surgery or other local therapies is uncertain. This scoping review aimed to define the landscape of evidence available detailing the utility of PRRT in the neo-adjuvant setting, including the clinical contexts, efficacy, and levels of evidence. A comprehensive literature search of PUBMED, SCOPUS, and EMBASE through to December 2022 was performed to identify reports of PRRT use as neoadjuvant therapy prior to local therapies. Observational studies and clinical trials were included. A total of 369 records were identified by the initial search, and 17 were included in the final analysis, comprising 179 patients treated with neoadjuvant PRRT. Publications included case reports, retrospective cohort series and a phase 2 trial. Definitions of unresectable disease were variable. Radioisotopes used included 177Lu (n = 142) and 90Y (n = 36), used separately (n = 178) or in combination (n = 1). A combination of PRRT with chemotherapy was also explored (n = 2). Toxicity data was reported in 11/17 studies. Survival analysis was reported in 3/17 studies. Surgical resection following PRRT was reported for both the primary tumor (n = 71) and metastases (n = 12). Resection rates could not be calculated as not all publications reported whether resection was completed. Published literature exploring the use of PRRT in the neoadjuvant setting is mostly limited to case reports and retrospective cohort studies. From these limited data there is reported to be a role of PRRT in neoadjuvant setting in the literature. However, the low quality of evidence precludes any definite conclusion on the grade of disease, site of primary, isotope used or use of concomitant chemotherapy that can benefit from this application. Further prospective studies will require collaboration between multiple centers to gain sufficient high-quality evidence.

SCANPatient: study protocol for a multi-centre, batched, stepped wedge, comparative effectiveness, randomised clinical trial of synoptic reporting of computerised tomography (CT) scans assessing cancers of the pancreas.

BACKGROUND: Complete surgical removal of pancreatic ductal adenocarcinoma (PDAC) is central to all curative treatment approaches for this aggressive disease, yet this is only possible in patients technically amenable to resection. Hence, an accurate assessment of whether patients are suitable for surgery is of paramount importance. The SCANPatient trial aims to test whether implementing a structured synoptic radiological report results in increased institutional accuracy in defining surgical resectability of non-metastatic PDAC. METHODS: SCANPatient is a batched, stepped wedge, comparative effectiveness, cluster randomised clinical trial. The trial will be conducted at 33 Australian hospitals all of which hold regular multi-disciplinary team meetings (MDMs) to discuss newly diagnosed patients with PDAC. Each site is required to manage a minimum of 20 patients per year (across all stages). Hospitals will be randomised to begin synoptic reporting within a batched, stepped wedge design. Initially all hospitals will continue to use their current reporting method; within each batch, after each 6-month period, a randomly selected group of hospitals will commence using the synoptic reports, until all hospitals are using synoptic reporting. Each hospital will provide data from patients who (i) are aged 18 or older; (ii) have suspected PDAC and have an abdominal CT scan, and (iii) are presented at a participating MDM. Non-metastatic patients will be documented as one of the following categories: (1) locally advanced and surgically unresectable; (2) borderline resectable; or (3) anatomically clearly resectable (Note: Metastatic disease is treated as a separate category). Data collection will last for 36 months in each batch, and a total of 2400 patients will be included. DISCUSSION: Better classifying patients with non-metastatic PDAC as having tumours that are either clearly resectable, borderline or locally advanced and unresectable may improve patient outcomes by optimising care and treatment planning. The borderline resectable group are a small but important cohort in whom surgery with curative intent may be considered; however, inconsistencies with definitions and an understanding of resectability status means these patients are often incorrectly classified and hence overlooked for curative options. TRIAL REGISTRATION: The SCANPatient trial was registered on 17th May 2023 in the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12623000508673).