Survival Trends for Resectable Pancreatic Cancer Using a Multidisciplinary Conference: the Impact of Post-operative Chemotherapy.

PURPOSE: Despite advances in various treatment modalities, surgical resection for pancreatic ductal adenocarcinoma (PDA) remains the only curative treatment. Data remains limited regarding survival rates for resectable PDA when managed by a multidisciplinary pancreas conference (MDPC). The aim of this study is to assess survival rates, identify significant predictors of mortality, and assess the benefits of adjuvant chemotherapy for resectable PDA following presentation at a MDPC. METHODS: All patients presented from April 2013 to August 2016 with resectable PDA were discussed at a MDPC at a tertiary care center and were followed prospectively until November 2017. Survival analysis was performed using Kaplan-Meier for age, tumor size, tumor differentiation, T-stage, lymph node status, and completion of adjuvant chemotherapy cycles. Independent predictors of survival were determined using multivariate Cox regression modeling. RESULTS: After MDPC consensus and exclusions, total of 64 patients underwent successful surgery. Amongst this cohort, 1-, 2-, and 3-year survival was 78.13%, 46.30%, and 27.27%, respectively. A total of 37 patients (58%) initiated and 16 patients (25%) finished chemotherapy following surgery. Log-rank analysis revealed that tumor size, age, surgical margins, lymph node status, and number of adjuvant chemotherapy cycles received significantly influenced post-operative survival. Tumor size (p < 0.001), lymph node status (p = 0.035), and number of adjuvant chemotherapy cycles (p = 0.041) remained significant after multivariate Cox regression model. CONCLUSIONS: Our results suggest that patients with PDA with tumor size > 50 mm and/or lymph node involvement have poor outcomes despite being surgically resectable. Successful completion of adjuvant chemotherapy has better survival outcomes as compared with incomplete or no adjuvant chemotherapy. The role of alternative management such as down-staging with neoadjuvant therapy should be considered.

Performance of a Multidisciplinary Pancreatic Cancer Conference in Predicting and Managing Resectable Pancreatic Cancer.

OBJECTIVES: Surgery is the curative treatment for pancreatic ductal adenocarcinoma (PDA). Guidelines recommend utilizing a multidisciplinary pancreatic cancer conference (MDPC) in treatment; however, data are limited. The objective of this study was to assess the accuracy of an MDPC. METHODS: Patients with PDA presented at an MDPC were prospectively collected from April 2013 to August 2016. Patients were included if the MDPC predicted them to have resectable PDA and underwent upfront surgery. Secondary aims were to compare differences in tumor characteristics, time to surgery, and resection rates with patients prior to MDPC implementation (pre-MDPC). RESULTS: A total of 278 patients were presented at the MDPC. After excluding borderline and nonresectable cases, 91 patients were predicted as resectable on evaluation, and 70 were fit for surgery. The MDPC predicted resection in 91.4%. The MDPC had larger tumor size (32.6 vs 24.0 mm), greater proportion of stage II tumor, and a shorter time from diagnosis to resection (27.3 vs 35.5 days) compared with the pre-MDPC. Microscopically negative resections were similar between MDPC and pre-MDPC (85.9% vs 88.0%) despite advanced tumor size and stage. CONCLUSIONS: The MDPC demonstrates a high resection rate. Compared with a pre-MDPC, MDPC provides shorter time to surgery and selects for advanced tumors.

A case of primary intrahepatic gastrinoma.

Gastrinoma is an uncommon but important cause of peptic ulcer disease. These tumors are most commonly located in the duodenum or pancreas. We present a case of a primary intrahepatic gastrinoma. Only 20 such cases have been previously reported in the literature. Metastatic hepatic gastrinomas are much more common, but it is important to differentiate between a primary and metastatic lesion because of the worse prognosis associated with a metastatic lesion.

Computed tomography appearance of spontaneous adrenal hemorrhage in a pheochromocytoma.

Pheochromocytomas are adrenal tumors that are diagnosed with time-consuming 24-h urine collection studies. Adrenal hemorrhage is a rare but serious complication of pheochromocytomas that has been reported in only about 50 cases [Sutton MG, Sheps SG, Lie JT. Prevalence of clinically unsuspected pheochromocytomas. Review of a 50-year autopsy series. Mayo Clin Proc 1981;56:354-360]. We had a patient with a classic presentation of pheochromocytoma complicated with hypertensive crisis leading to spontaneous adrenal hemorrhage. We report the computed tomographic (CT) findings of ruptured pheochromocytoma that helped us in early detection and treatment of this life-threatening complication.

CT Evaluation of Laryngotracheal Trauma.

Laryngotracheal injuries are rare, and typically associated with multisystem trauma. They may be blunt or penetrating in nature, and are in the great majority of cases related to motor vehicle accidents or ÒclotheslineÓ injuries with a small percentage due to direct blows sustained during assaults or athletic contests, hanging or manual strangulation, or other less common etiologies including iatrogenic causes. Missed diagnoses or mismanagement may result in the patient's death or significant long-term morbidity. The radiologist must be familiar with the normal computed tomographic (CT) appearance of laryngotracheal anatomy to correctly interpret CT studies following injury, and must also be aware of the central role that CT plays in diagnosis, management, and selection of therapy. This should include an understanding of the Shaefer classification of laryngeal injuries that is based on a combination of the CT and endoscopic findings. Although an acceptable evaluation of the traumatized larynx is obtainable with most commercially available CT scanners, optimal studies are produced by CT devices capable of spiral technique and subsecond scan times, particularly in regard to their ability to generate thin retrospectively reconstructed two-dimensional (2D) axial sections, 2D coronal and sagittal images, and three-dimensional (3D) images. Our discussion of laryngotracheal injuries is divided into four parts. Part 1 deals with injuries to the endolaryngeal soft tissues structures, including the mucosa, vocal cords, and deep compartments. The ability of CT to demonstrate endolaryngeal edema and hematoma, vocal cord injuries, subcutaneous emphysema, and aspirated radiopaque foreign bodies is discussed along with its inability to demonstrate the site of mucosal perforations or degloving injuries. Part II deals with fractures of the hyoid bone, epiglottis, and thyroid and cricoid cartilages, while Part III discusses dislocations of the cricoarytenoid and cricothyroid joints. Finally, Part IV discusses laryngotracheal separation, the most immediately life-threatening laryngotracheal injury, and the difficulties inherent in making this diagnosis prospectively by CT.