Risk Factors for Pancreatic Cancer and the Necessity of Long-Term Surveillance in Patients With Pancreatic Cystic Lesions.

OBJECTIVES: Pancreatic cystic lesions (PCLs) are a risk factor for pancreatic cancer (PC). Which PCLs should be surveilled and necessity of long-term observation are still controversial. METHODS: From January 2000 to March 2016, we enrolled 1137 patients with PCLs observed for 1 year. We defined PCLs with cyst size of greater than 30 mm, main pancreatic duct (MPD) of greater than 5 mm or mural nodule as high-risk group, and others as low-risk group (LRG). Kaplan-Meier method and Cox proportional hazard model were applied to assess incidence and risk factors of PC. RESULTS: In 107 high-risk group and 1030 LRG patients, mean observation period was 4.3 years and 5.0 years, respectively, and 5-year PC incidence was 12.0% and 2.8%, respectively. In LRG, MPD of greater than 3 mm, diabetes mellitus, and presumed branch-duct intraductal papillary mucinous neoplasia (BD-IPMN), defined as PCLs fulfilling any of multilocular formation, multiplicity, or MPD communication, were independent risk factors for PC. In 450 LRG observed for 5 years, 10-year PC incidence was higher in PCLs with our identified risk factors. There was no PC occurrence in PCLs not presumed BD-IPMN after 5-year observation. CONCLUSIONS: Continuous surveillance is needed after 5-year observation, especially in LRG with our identified risk factors. For discontinuing surveillance, PCLs not presumed BD-IPMN at fifth year could be candidates.

Subclassification of patients with intermediate-stage (Barcelona Clinic Liver Cancer stage-B) hepatocellular carcinoma using the up-to-seven criteria and serum tumor markers.

BACKGROUND: Intermediate-stage [Barcelona Clinic Liver Cancer stage-B (BCLC-B)] hepatocellular carcinoma (HCC) comprises of a heterogeneous population of patients with a wide range of tumor burdens. We therefore formulated a subclassification of BCLC-B HCC using the up-to-seven criteria and tumor markers according to the results of a retrospective analysis of these patients. METHODS: This study included 125 patients newly diagnosed with BCLC-B HCC who underwent transarterial chemoembolization. Among them, 39 and 86 were within or beyond the up-to-seven criteria, respectively. Multivariate Cox proportional hazards analysis was performed to investigate factors that contributed to better prognosis associated with the criteria. RESULTS: Cumulative overall survival (OS) and disease-free survival rates were significantly higher for patients within the up-to-seven criteria compared with those beyond (p = 0.034 and p = 0.001, respectively). Multivariate analysis revealed that low concentrations of des-γ-carboxy prothrombin (DCP) (<150 mAU/ml) and α-fetoprotein (AFP) (<100 ng/ml) were independent contributors to better OS of patients within or beyond the up-to-seven criteria, respectively. Accordingly, the patients were classified as follows: group A (patients within the up-to-seven criteria with DCP <150 mAU/ml), group C (patients beyond the up-to-seven criteria with AFP ≥100 ng/ml), and group B (other patients). OS differed significantly among groups (p < 0.001), and the median survival times of group A, B, and C were 4.2, 2.7, and 1.5 years, respectively. CONCLUSION: The subclassification system incorporating the up-to-seven criteria combined with DCP and AFP levels may serve as better predictors of prognosis that may guide efforts to improve treatment strategies.

Optimal number of needle passes in endoscopic ultrasound-guided fine needle aspiration for pancreatic lesions.

OBJECTIVES: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is accurate in cytological diagnosis of pancreatic lesions. Our aim was to determine optimal number of needle passes in EUS-FNA for pancreatic lesions without onsite cytopathologist, who is not routinely available to participate in the procedure. METHODS: Results of all needle passes in EUS-FNAs for 117 pancreatic neoplasms in 115 patients were reviewed retrospectively. Factors that required 2 or more needle passes for correct diagnosis were identified by multivariate logistic regression analysis. In each lesion group defined by the factors that required 2 or more passes and were known at the time of EUS-FNA, number of needle passes was regarded as optimal when an increase in diagnostic sensitivity by an additional needle pass did not reach 10%. RESULTS: Size of 15 mm or less (OR 4.58, 95% CI 1.70-12.3, P < 0.01), location of head (OR 5.02, 95% CI 1.82-13.9, P < 0.01), and neuroendocrine tumor (NET) (OR 5.04, 95% CI 1.38-18.4, P = 0.01) independently required 2 or more needle passes. Optimal numbers of needle passes for lesions of 15 mm or less in the head, those of more than 15 mm in the head, those of 15 mm or less in the body or tail, and those of more than 15 mm in the body or tail were 3, 2, 2, and 1, respectively. When these numbers of needle passes were performed, 93% of pancreatic lesions were correctly diagnosed. CONCLUSIONS: Optimal numbers of needle passes in EUS-FNA for pancreatic lesions without onsite cytopathologist were between 1 and 3.

Duodenal Hemorrhage from Pancreatic Cancer Infiltration Controlled through Combination Therapy with Gemcitabine and S-1.

2.6% of pancreatic cancer patients have the primary manifestation of gastrointestinal bleeding. It is not feasible to stop the duodenal hemorrhage caused by the pancreatic cancer infiltration. A 43-year-old woman who was diagnosed as having pancreatic cancer with multiple hepatic metastases and duodenal infiltration was administered gemcitabine and S-1 combination therapy. During the chemotherapy, initially, bleeding occurred due to duodenal infiltration. However, we continued the chemotherapy and duodenal infiltration was markedly reduced in size and did not rebleed. Aggressive chemotherapy contributed to maintenance of performance status as well as improvement of quality of life for the patient.