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Background: The purpose of this study was to define the learning curves for laparoscopic pancreaticoduodenectomy (LPD) with and without laparoscopic reconstruction, using paired surgical teams consisting of advanced laparoscopic-trained surgeons and advanced oncologic-trained surgeons., Methods: All patients undergoing PD without vein resection at a single institution were retrospectively analyzed. LPD was introduced by initially focusing on laparoscopic resection followed by open reconstruction (hybrid) for 18 months prior to attempting a totally LPD (TLPD) approach. Cases were compared with Chi square, Fisher's exact test, and Kruskal-Wallis analysis of variance (ANOVA)., Results: Between March 2010 and June 2013, 140 PDs were completed at our institution, of which 56 (40 %) were attempted laparoscopically. In 31/56 procedures we planned to perform only the resection laparoscopically (hybrid), of which 7 (23 %) required premature conversion before completion of resection. Following the first 23 of these hybrid cases, a total of 25 TLPDs have been performed, of which there were no conversions to open. For all LPD, a significant reduction in operative times was identified following the first 10 patients (median 478.5 vs. 430.5 min; p = 0.01), approaching open PD levels. After approximately 50 cases, operative times and estimated blood loss were consistently lower than those for open PD., Conclusions: In our experience of building an LPD program, the initial ten cases represent the biggest hurdle with respect to operative times. For an experienced teaching center using a staged and team-based approach, LPD appears to offer meaningful reductions in operative time and blood loss within the first 50 cases.

Background: Concomitant placement of feeding jejunostomy tubes (FJT) during pancreaticoduodenectomy is common, yet there are limited data regarding catheter-specific morbidity and associated outcomes. This information is crucial to appropriately select patients for feeding tube placement and to optimize perioperative nutrition strategies., Methods: A review of all patients undergoing pancreaticoduodenectomy with FJT placement was completed. Patients were grouped by the occurrence of FJT-related morbidity. Multivariable logistic regression was performed to identify predictors of FJT morbidity; these complications were then further defined. Finally, associated postoperative outcomes were compared between groups., Results: In total, 126 patients were included, of which 18 (14 %) had complications directly related to their FJT, including pericatheter infection (n = 6), pneumatosis intestinalis (n = 4), severe tube feed intolerance (n = 3), and primary catheter malfunction (n = 7). Following adjustment with logistic regression, preoperative hypoalbuminemia was identified as the only independent predictor of FJT complications (OR 2.23, p = 0.035). Patients with FJT complications were more likely to be initiated on total parenteral nutrition (TPN; 55.6 vs. 7.4 %, p -0.035) and to require TPN at discharge (16.7 vs. 0%, p = 0.003). Correspondingly, these patients resumed an oral diet later (14 vs. 8 days, p = 0.06). Both reoperation (50.0 vs. 6.5%, p < 0.001) and readmission (50.0 vs. 22.4%, p = 0.041) rates were higher among patients with FJT complications., Conclusions: FJT-related morbidity is common among patients undergoing pancreaticoduodenectomy and is associated with inferior outcomes and other performance metrics. Preoperative malnutrition appears to predict FJT complications, creating an ongoing dilemma regarding FJT placement. In the future, it will be important to better define criteria for FJT placement during pancreaticoduodenectomy.

Objectives: We tested three hypotheses: (1) blacks with pancreatic cancer are recommended surgical resection less often than whites; (2) when recommended surgical resection, blacks refuse surgery more often than whites; and lastly, (3) racial differences in refusal of surgical resection have decreased over time., Methods: A retrospective cohort study was conducted on patients with potentially resectable, nonmetastatic pancreatic adenocarcinoma of the Surveillance, Epidemiology, and End Results registry from 1988 to 2009. Univariate and multivariable logistic regression analyses were performed to assess whether differences in the proportion of whites versus blacks refusing surgery among patients recommended for resection changed over time., Results: A total of 35,944 patients were included; most were white (87.6 %). After adjusting for covariates including tumor stage, pancreatic cancer resection was less often recommended to and performed in blacks compared with whites (adjusted odds ratio (aOR) 0.88, 95 % confidence interval (CI) 0.82-0.95; aOR 0.83, 95 % CI 0.76-0.91, respectively). Blacks also underwent surgical resection less often when surgery was recommended (aOR 0.73, 95 % CI 0.64-0.85). Racial disparities in surgery recommendation and its performance did not decrease from 1988 to 2009. In multivariable adjusted analyses, blacks refused surgery more often when it was recommended (aOR in 1988 4.75, 95 % CI 2.51-9.01); this disparity decreased over time (aOR 0.93 per year, 95 % CI 0.89-0.97)., Conclusions: Although racial disparities in pancreatic cancer surgery refusal have diminished over the past two decades, significant disparities in the recommendation and performance of surgery persist. It is likely that both provider- and patient-level factors have a substantial impact on surgery recommendation and its acceptance. The identification of such factors is critical to design a framework for eliminating disparities in cancer-directed surgery for pancreatic cancer.

Objective: To assess trends in the frequency of concomitant vascular reconstructions (VRs) from 2000 through 2009 among patients who underwent pancreatectomy, as well as to compare the short-term outcomes between patients who underwent pancreatic resection with and without VR., Design: Single-center series have been conducted to evaluate the short-term and long-term outcomes of VR during pancreatic resection. However, its effectiveness from a population-based perspective is still unknown. Unadjusted, multivariable, and propensity score-adjusted generalized linear models were performed., Setting: Nationwide Inpatient Sample from 2000 through 2009., Patients: A total of 10,206 patients were involved., Main Outcome Measures: Incidence of VR during pancreatic resection, perioperative in-hospital complications, and length of hospital stay., Results: Overall, 10,206 patients were included in this analysis. Of these, 412 patients (4.0%) underwent VR, with the rate increasing from 0.7% in 2000 to 6.0% in 2009 (P < .001). Patients who underwent pancreatic resection with VR were at a higher risk for intraoperative (propensity score-adjusted odds ratio, 1.94; P = .001) and postoperative (propensity score-adjusted odds ratio, 1.36; P = .008) complications, while the mortality and median length of hospital stay were similar to those of patients without VR. Among the 25% of hospitals with the highest surgical volume, patients who underwent pancreatic surgery with VR had significantly higher rates of postoperative complications and mortality than patients without VR., Conclusions: The frequency of VR during pancreatic surgery is increasing in the United States. In contrast with most single-center analyses, this population-based study demonstrated that patients who underwent VR during pancreatic surgery had higher rates of adverse postoperative outcomes than their counterparts who underwent pancreatic resection only. Prospective studies incorporating long-term outcomes are warranted to further define which patients benefit from VR.

Background: Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source., Methods: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities., Results: 3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22-3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05-1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team., Conclusions: Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

The objective of this study was to compare survival between all patients with radiographically resectable adenocarcinoma of the proximal pancreas who underwent preoperative chemoradiation therapy (PRE-OP CRT) or surgical exploration first (SURGERY) with "intention to resect." Pancreatic cancer patients who undergo resection after PREOP CRT live longer than patients who undergo resection without PREOP CRT, a difference that may be attributable to patient selection. We retrospectively identified 236 patients with pancreatic head adenocarcinoma seen between 1999 and 2007 with sufficient data to be confirmed medically and radiographically resectable. The outcomes of 144 patients who underwent PREOP CRT were compared to those of 92 patients who proceeded straight to SURGERY. The groups were similar in age and gender. Tumors were slightly larger in the PREOP CRT group (mean 2.5 cm vs. 2.1 cm, P < 0.01), and there were trends toward more venous abutment (54% vs. 39%, P = 0.06) and a higher Charlson comorbidity index (P = 0.1). In the PREOP CRT group, 76 patients (53%) underwent resection, 28 (19%) had metastatic and 17 (12%) locally unresectable disease after PREOP CRT, and 23 (16%) were not explored due to performance status or loss to follow-up. In the SURGERY group, 68 patients (74%) underwent resection. Sixteen patients (17%) had metastatic and eight patients (9%) locally unresectable disease at exploration. In patients who underwent resection, the PREOP CRT group had smaller pathologic tumor size and lower incidence of positive lymph nodes than the SURGERY group but no difference in positive margins or need for vascular resection. Median overall survival (OS) in patients undergoing resection was 27 months in the PREOP CRT group and 17 months in the SURGERY group (P = 0.04). Median OS in all patients treated with PREOP CRT or surgically explored with intention to resect was 15 and 13 months, respectively, with superimposable survival curves. Despite a lower resection rate, the PREOP CRT group as a whole had a similar OS to the SURGERY group as a whole. For patients who underwent resection, those in the PREOP CRT had longer survival than those in the SURGERY group, suggesting that PREOP CRT allows better patient selection for resection. PREOP CRT should be considered an acceptable alternative for most patients with resectable pancreatic cancer., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Once thought to have unresectable disease, pancreatic cancer patients with portal venous involvement are now reported to have comparable survival after pancreaticoduodenectomy (PD) with vascular reconstruction (VR) as compared with patients without vascular involvement. We hypothesize that a multidisciplinary approach involving a vascular surgeon will minimize morbidity and improve patency of VRs., Methods: We identified 204 patients who underwent PD for pancreatic adenocarcinoma from 1997 to 2008. Patients who underwent PD with VR (N = 42) were compared with those who underwent standard PD (N = 162). VRs were performed by a vascular surgeon and involved primary repair (N = 8), vein patch (N = 25), or interposition grafting (N = 9) with femoral or other venous conduit., Results: Patients undergoing PD with VR had larger tumors (3.0 cm vs. 2.5 cm, P < 0.01) but did not have different rates of tumor-free margins (73% vs. 72%, P = 0.84) or lymph nodes metastases (50% vs. 38%, P = 0.14). The VR group had higher median blood loss (875 mL vs. 550 mL, P = 0<0.01), but no differences in mortality, complication rates, length of stay, or readmission rates were found in a median follow-up of 29 months. Overall survival rates were similar. Predictors of mortality on multivariate analysis included increasing histological grade (P = 0.01), positive lymph nodes (P = 0.01), and increasing tumor size (P = 0.01), but not VR (P = 0.28). When evaluated by computed tomography scans within 6 months postoperatively, 97% of reconstructions remained patent., Conclusions: The need for VR is not a contraindication to potentially curative resection in patients with pancreatic adenocarcinoma. Assistance of a vascular surgeon during VR may allow moderate-volume centers to achieve outcomes comparable with high-volume centers., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Management and outcomes of patients with invasive intraductal papillary mucinous neoplasm (IPMN) of the pancreas are not well established. We investigated whether adjuvant radiotherapy (RT) improved cancer-specific survival (CSS) and overall survival (OS) among patients undergoing surgical resection for invasive IPMN., Methods: The Surveillance, Epidemiology, and End Results (SEER) registry was used in this retrospective cohort study. All adult patients with resection of invasive IPMN from 1988 to 2007 were included. CSS and OS were analyzed using Kaplan-Meier curves. Unadjusted and propensity-score-adjusted Cox proportional-hazards modeling were used for subgroup analyses., Results: 972 patients were included. Adjuvant RT was administered to 31.8% (n=309) of patients. There was no difference in overall median CSS or OS in patients who received adjuvant RT (5-year CSS: 26.5 months; 5-year OS: 23.5 months) versus those who did not (CSS: 28.5 months, P=0.17; OS: 23.5 months, P=0.23). Univariate predictors of survival were lymph node (LN) involvement, T4-classified tumors, and poorly differentiated tumor grade (all P<0.05). In the propensity-score-adjusted analysis, adjuvant RT was associated with improved 5-year CSS [hazard ratio (HR): 0.67, P=0.004] and 5-year OS (HR: 0.73, P=0.014) among all patients with LN involvement, though further analysis by T-classification demonstrated no survival differences among patients with T1/T2 disease; patients with T3/T4-classified tumors had improved CSS (HR: 0.71, P=0.022) but no difference in OS (HR: 0.76, P=0.06)., Conclusion: On propensity-score-adjusted analysis, adjuvant RT was associated with improved survival in selected subsets of patients with invasive IPMN, particularly those with T3/T4 tumors and LN involvement.

Objectives: To compare outcomes and the use of multimodality therapy in young and elderly people with pancreatic cancer undergoing surgical resection., Design: Retrospective, single-institution study., Setting: National Cancer Institute/National Comprehensive Cancer Network cancer center., Participants: Two hundred three individuals who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma at Duke University Medical Center comprised the study population. Participants were divided into three groups based on age (<65, n = 97; 65-74, n = 74; ≥75, N = 32)., Measurements: Perioperative outcomes, the use of multimodality therapy, and overall survival of the different age groups were compared., Results: Similar rates of perioperative mortality and morbidity were observed in all age groups, but elderly adults were more likely to be discharged to a rehabilitation or skilled nursing facility. A similar proportion of participants received neoadjuvant therapy, but a smaller proportion of elderly participants received adjuvant therapy. Overall survival was similar between the age groups. Predictors of poorer overall survival included coronary artery disease, positive resection margin, and less-differentiated tumor histology. Treatment with neoadjuvant and adjuvant therapy were predictors of better overall survival., Conclusion: Carefully selected elderly individuals experience similar perioperative outcomes and overall survival to those of younger individuals after resection of pancreatic cancer. There appears to be a significant disparity in the use of adjuvant therapy between young and elderly individuals., (© 2012, Copyright the Authors Journal compilation © 2011, The American Geriatrics Society.)

Introduction: The lack of accurate markers makes preoperative differentiation between pancreatic cancer and non-malignant head lesions clinically challenging. In this study, we investigated the incidence of benign disease in patients that underwent resection for presumed pancreatic cancer diagnosed by EUS and EUS-guided FNA., Methods: Medical records of consecutive patients who underwent pancreaticoduodenectomy at Duke University were reviewed. Demographics, clinicopathologic characteristics, preoperative imaging, EUS, EUS-guided FNA, and postoperative outcomes were analyzed., Results: Seven percent of the total 494 patients studied were found to have benign disease on postoperative pathology. Fifty-nine percent of these patients with benign disease underwent preoperative EUS. EUS was positive for a head mass in 70%, demonstrated enlarged lymph nodes in 27%, and showed signs concerning for vascular invasion in 13%. FNA was suspicious or indeterminate for cancer in 63% of patients. Postoperative complications occurred in 47% and one patient died after surgery. The overall pancreatic leak rate was 15%., Conclusions: Even with aggressive use of preoperative evaluation, there is still a small subset of patients where malignancy cannot be excluded without pancreaticoduodenectomy.

Introduction: Proposed criteria for resection of pancreatic cystic lesions have included symptoms, size (>3 cm), and suspicious features by endoscopic ultrasound (EUS). The objective of this study was to evaluate risk factors for malignancy in a large series of patients undergoing resection of suspected pancreatic cystic neoplasms., Methods: Medical records of patients selected for resection of pancreatic cystic lesions at Duke University Medical Center from 2000 to 2008 were reviewed. Lesions with solid components on cross-sectional imaging were excluded. Malignancy was defined as invasive or in situ carcinoma., Results: After review, 101 patients were confirmed to have undergone resection for suspected cystic neoplasms of the pancreas. Preoperative EUS was performed in 71 patients. Sixteen patients (16%) had malignant lesions (preoperative size 1.5-5.9 cm). There was no clear association between size and malignancy. Male gender, biliary ductal dilatation (BDD), pancreatic ductal dilatation (PDD), and suspicious cytology (but not age, symptoms, or size) were associated with increased risk of malignancy. When factors available for all patients were incorporated into a multivariate model, only BDD and PDD were independent risk factors for malignancy. Only one patient with malignancy had neither BDD nor PDD but did have solid components by EUS., Conclusions: In patients selected for resection, size was not an independent risk factor for malignancy. While size might be appropriate for stratification of asymptomatic patients with simple cysts, size should not be used as a selection criterion for patients who have cysts with solid components or with associated BDD or PDD.

Background: To study the frequency and outcomes of percutaneous imaging-guided drainage following pancreaticoduodenectomy and to assess if fluid collection location correlates with pancreatic duct leak., Methods: IRB approval was obtained. Three hundred and seventy-three subjects (age 21-84 years) who underwent pancreaticoduodenectomy were included in this retrospective study. Eighty-three of these subjects underwent post-operative imaging-guided drainage (CT 77; US 6). Medical and imaging records were reviewed. Procedural details including collection location, size, catheter size, drain duration, fluid type, fluid chemistry, and fluid culture were recorded. Collection location was correlated with fluid amylase., Results: The frequency of imaging-guided percutaneous drainage following Whipple was 22.2%. The immediate technical and overall success rates for fluid collection drainage were 97.6% and 79.6%, respectively. Rate of complication was 4.8% (4/83). 74.7% (62/83) of fluid collections were proven abscesses, and 61.4% (51/83) were complicated by pancreatic fistula. Collections near the pancreatic resection site were more likely to have elevated fluid amylase., Conclusion: Approximately one-fifth of subjects requires percutaneous drainage following pancreaticoduodenectomy. Percutaneous imaging-guided drainage is an effective means of managing post-pancreaticoduodenectomy fluid collections. Collections near the pancreas resection site often have a pancreatic duct leak.

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.

Background: Theoretical benefits of preoperative chemoradiation therapy (preop CRT) for pancreatic cancer include improved efficacy, resectability, and patient selection. The goal of this study was to evaluate the applicability of a nomogram, which was developed for patients undergoing resection without preop CRT and which incorporates several post-resection pathological factors, to a population of patients who received preop CRT prior to resection., Methods: From 1994 to 2004, 82 patients with biopsy-proven, radiographically localized adenocarcinoma of the pancreatic head underwent preop CRT followed by pancreaticoduodenectomy (PD); 50 concurrent patients underwent PD without preop CRT. Mean nomogram-predicted disease-specific survival (DSS) rates were compared with observed DSS rates from the time of resection., Results: Despite having more locally advanced tumors on initial staging (21 vs. 8%; P < .05), patients who received preop CRT had smaller resected tumors (mean 2.3 vs. 3.1 cm; P < .01), were less likely to have T3 tumors (54 vs. 80%, P < .01), were less likely to have positive lymph nodes (29 vs. 58%, P < .01), and had fewer positive lymph nodes (mean .4 vs. 1.9, P < .01), all factors that imply treatment effect and favorably impact on nomogram-predicted DSS. Observed DSS was similar to predicted DSS in both groups., Conclusions: The similarity in observed and predicted DSS following resection in patients who received preop CRT suggests that the effects of preop CRT-whether treatment, selection, or no effect-are reflected by the nomogram. The ability of the nomogram to evaluate the effects of preop CRT on survival is limited by the potential effects of preop CRT on factors within the nomogram.

Purpose: Overexpression of epidermal growth factor receptor (EGFR) has been associated with aggressive tumor phenotypes, chemotherapy, and radiation resistance, as well as poor survival in preclinical and clinical models. The EGFR inhibitor gefitinib potentiates chemotherapy and radiation tumor cytotoxicity in preclinical models, including pancreatic and colorectal cancer. We initiated two phase I trials assessing the combination of gefitinib, capecitabine, and radiation in patients with localized pancreatic and rectal cancer., Patients and Methods: Patients with pathologically confirmed adenocarcinoma of the pancreas and rectum were eligible. Pretreatment staging included computed tomography, endoscopic ultrasound, and surgical evaluation. Patients received 50.4 Gy of external-beam radiation therapy to the tumor in 28 fractions. Capecitabine and gefitinib were administered throughout the radiation course. Following completion, patients were restaged and considered for resection. Primary end points included determination of dose-limiting toxicity (DLT) and a phase II dose; secondary end points included determination of non-DLTs and preliminary radiographic and pathologic response rates., Results: Ten patients were entered in the pancreatic study and six in the rectal study. DLT was seen in six of 10 patients in the pancreatic study and two of six patients in the rectal study. The primary DLT in both studies was diarrhea. Two patients developed arterial thrombi., Conclusion: The combination of gefitinib, capecitabine, and radiation in pancreatic and rectal cancer patients resulted in significant toxicity. A recommended phase II dose was not determined in either of our studies. Further investigation with this combination should be approached with caution.

Background: Neoadjuvant chemoradiotherapy (neo-CRT) is being used with increasing frequency for periampullary tumors, but how it alters the complication rate of pancreaticoduodenectomy (PD) is unclear., Methods: A retrospective analysis was conducted of 79 patients with periampullary malignancies who received 5-fluorouracil-based neo-CRT followed by PD., Results: There was no difference in mortality between PD after neo-CRT (3.8%) and conventional PD for either malignant (4.5%) or benign (2.2%) disease. Focusing only on patients with malignancy, the neo-CRT group had a significantly lower pancreatic leak rate than the conventional group (10% vs. 43%; P < .001). Intra-abdominal abscesses were less common in the neo-CRT group (8.8% vs. 21%; P = .019), and there was one (1.2%) amylase-rich abscess in neo-CRT group, compared with eight (12%) in the conventional group. In addition, two patients in the conventional group died of leak-associated sepsis, compared with none in the neo-CRT group. Multivariate analysis revealed that neoadjuvant chemoradiation (odds ratio, .15) was the most significant factor associated with a reduced risk of pancreatic leak., Conclusions: Neo-CRT does not increase the mortality or morbidity of PD. In contrast, neo-CRT was associated with a marked reduction in the incidence of pancreatic leak, as well as leak-associated morbidity and mortality.

Background: Neoadjuvant (preoperative) chemoradiotherapy (CRT) for pancreatic cancer offers theoretical advantages over the standard approach of surgery followed by adjuvant CRT. We hypothesized that histological responses to CRT would be significant prognostic factors in patients undergoing neoadjuvant CRT followed by resection., Methods: Since 1994, 193 patients with biopsy-proven pancreatic adenocarcinoma have completed neoadjuvant CRT, and 70 patients have undergone resection. Specimens were retrospectively examined by an individual pathologist for histological responses (tumor necrosis, tumor fibrosis, and residual tumor load) and immunohistochemical staining for p53 and epidermal growth factor receptor. Factors influencing overall survival were analyzed with the Kaplan-Meier (univariate) and Cox proportional hazards (multivariate) methods., Results: The estimated overall survival (median +/- SE) in the entire group of patients undergoing resection was 23 +/- 4.2 months, with an estimated 3-year survival of 37% +/- 6.6% and a median follow-up of 28 months. Complete histological responses occurred in 6% of patients. Overexpression of p53 was more common in patients with large residual tumor loads. Tumor necrosis was an independent negative prognostic factor, as were positive lymph nodes, a large residual tumor load, and poor tumor differentiation., Conclusions: Histological response to neoadjuvant CRT--as measured by residual tumor load--may be useful as a surrogate marker for treatment efficacy. Characterization of the tumor cells that survive neoadjuvant CRT may help us to identify new or more appropriate targets for systemic therapy.

Background: This study aimed to define PDS characteristics that predict malignancy and would thus invoke further diagnostic evaluation or aggressive treatment., Methods: 355 cases of PDS were diagnosed by ERCP during a 7-year period at a single institution. A retrospective review identified clinical/demographic patient data and ERCP results., Results: 218 (61%) patients with a PDS were found to have an isolated PDS. Twelve percent of isolated PDS and 79% of CBD stricture-associated PDS were malignant. The sensitivity and specificity for the double duct sign for malignancy were 77% and 80% respectively, and the positive predictive value was 65%. Predictors of malignancy were statistically similar for both isolated PDS and those associated with a CBD stricture. Univariate predictors of malignancy included stricture location in the pancreatic head/neck, jaundice, and patient age. Predictors of benign disease included a history of pancreatitis, the presence of multiple strictures, pancreatic duct stones, pseudocyst, pancreas divisum anatomy, irregular side branches, and irregular pancreatic duct morphology. Less than 1% of patients with either pancreas divisum anatomy, pancreatic duct stones, or pancreatic pseudocyst had malignancy. Using malignancy as the dependent variable, multivariate factors included in the final prognostic equation were history of pancreatitis (odds ratio 0.009 with history of pancreatitis), stricture location in the head or neck (odds ratio 42) and irregular pancreatic duct side branches (odds ratio 0.05 with irregular branches)., Conclusions: This study demonstrates that certain characteristics of PDS can predict the subset of patients who have an increased risk of cancer.

Background: This study examined the effect that 18-fluorodeoxyglucose positron emission tomography ((18)FDG-PET) imaging had on the clinical management of patients with suspected periampullary malignancy., Methods: Fifty-four patients with suspected pancreatic neoplasms underwent both whole-body (18)FDG-PET and abdominal computed tomography (CT). Malignant or benign disease was confirmed pathologically in 47 patients., Results: Of the 41 patients with malignancy, (18)FDG-PET failed to identify the primary tumor in 5 patients. (18)FDG-PET demonstrated increased uptake suggesting primary malignancy in 37 patients. Malignant pathology was confirmed in 36 cases. (18)FDG-PET identified malignant locoregional lymph node metastases in six of ten patients. All nodes identified before surgery by (18)FDG-PET were also seen on preoperative CT. Six patients who were thought to have resectable disease by CT were found to have distant metastasis at laparotomy. (18)FDG-PET did not detect metastasis in any of these cases. Before surgery, (18)FDG-PET identified distant metastases that were not detected by CT in one patient., Conclusions: Despite high sensitivity and specificity in diagnosing periampullary malignancy, (18)FDG-PET did not change clinical management in the vast majority of patients previously evaluated by CT. In addition, (18)FDG-PET missed >10% of periampullary malignancies and did not provide the anatomical detail necessary to define unresectabilty.