J Gastrointest Surg (2017) 21:749–754 DOI 10.1007/s11605-017-3374-5
PANCREAS CLUB
Proceedings of the 50th Annual Pancreas Club Meeting Marshall S. Baker 1,2 & Nicholas J. Zyromski 3,4
Received: 25 November 2016 / Accepted: 18 January 2017 / Published online: 15 February 2017 # 2017 The Society for Surgery of the Alimentary Tract
Abstract The 50th Annual Pancreas Club meeting was held on May 20 and 21, 2016, at the Hyatt Regency Mission Bay in San Diego, CA. Three hundred and three attendees included pancreatologists from 15 countries; one hundred attendees were international. Two hundred ninety-three abstracts were submitted; from these submissions, 64 oral presentations and 194 posters were selected for presentation. The table documents oral abstract titles with institutional affiliation. Full abstracts for all oral presentations and posters are available at the Pancreas Club website, http://pancreasclub.com. Representative abstracts from each of the seven sessions are summarized below.
Keywords Pancreas Club . Pancreatitis . Pancreatic adenocarcinoma . Neuroendocrine tumor . Pancreatic fistula
Scientific Session I: Drains/Pancreatic Fistula/Complications of Pancreatic Surgery Several papers in this session highlighted active work defining patients at risk to develop pancreatic fistula after pancreatoduodenectomy. Kantor used data from the pancreas demonstration project of the National Surgical Quality Improvement Project (NSQIP) to develop an easily applicable and reproducible clinically relevant fistula risk predictor (S005 Using the
* Nicholas J. Zyromski
[email protected] 1
Department of Surgery, NorthShore University Health Systems, Evanston, IN, USA
2
Department of Surgery, University of Chicago, Chicago, IL, USA
3
Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
4
545 Barnhill Dr. EH 519, Indianapolis, IN 46202, USA
pancreatic demonstration project to derive a fistula risk score for preoperative risk stratification in patients undergoing pancreaticoduodenectomy). Vollmer presented data from a multi-institutional study suggesting that based on a preoperative risk score, drain placement may not be necessary and that in those patients with drains, drain amylase values may direct early drain removal (S002 A multicenter risk-stratified prospective trial of drain management for pancreatoduodenectomy). The direct challenge from experienced pancreatic surgeons was to identify how to specifically improve morbidity—as opposed to simply identifying patients at high risk of morbidity. A second topic in this session related to frailty and sarcopenia in pancreatic surgery patients. The Wake Forest group presented their data regarding a modified frailty index that identified at-risk patients (S008 Modified frailty index predicts morbidity and mortality after pancreatoduodenectomy). The University Bio-medica group from Rome presented their analysis of the effect of sarcopenia on operative outcomes, concluding that a 14- to 20-day preoperative window focusing on Bpre-habilitation^ (including aggressive nutritional support) may improve tolerance of pancreatectomy (S009 Impact of sarcopenia on surgical outcomes in patients undergoing pancreatoduodenectomy by using enhanced recovery after surgery [ERAS] protocol).
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Scientific Session II: Surgical Techniques and Innovations
Scientific Session IV: Basic Science Studies/Rare Pancreatic Tumors
The second scientific session focused on surgical technique. Two papers focused on training curriculum. The Pittsburgh group presented their sophisticated ex vivo fellow training protocol for robotic pancreatoduodenectomy anastomosis (S010 Robotic Whipple biotissue curriculum improves technical performance for fellows and has construct validity). Repeated performance clearly correlated with decreased time and fewer errors in specific task analysis. At a national level, the Dutch group presented results from a training program in laparoscopic distal pancreatectomy implemented in the Netherlands (S014 Impact of a nationwide training program in laparoscopic distal pancreatectomy). This aggressive and thorough training program resulted in increased utilization of laparoscopy for distal pancreatectomy nationally. These data are currently in press in the Annals of Surgery.
The second afternoon session was dedicated to basic investigations on the pathophysiology of pancreatic cancer and mechanisms of metastasis. Two papers in this session examined the role of mRNA-binding protein HuR in the pathogenesis of pancreatic cancer. The first evaluated tissue from resected pancreatic cancer patients and identified an INDEL DNA sequence in a thymidine-enriched region of the HuR binding site within a noncoding region of the WEE1 gene. Expressed WEE1 arrests cell cycle to allow DNA repair. Patients with this mutation demonstrated increased rates of pancreatic, hepatobiliary, melanoma, gastric, ovarian, and endometrial cancer in other members of their families. This finding was correlated with basic evaluation of transfected PDA cell lines that demonstrated an impaired ability of HuR to upregulate WEE1 expression in cell lines with these mutations. A second paper from this group examined tissue samples from pancreatic cancer patients treated within the ESPAC-3 trial. This trial was a randomized controlled trial comparing the use of 5-FU to gemcitabine monotherapy in an adjuvant setting following resection. The authors examined cytoplasmic HuR expression in tissue samples from these patients and correlated that expression to response to chemotherapy with 5-FU and gemcitabine. They found that patients with resected pancreatic cancer and treated with adjuvant 5-FU had better disease-free survival if they had high rates of cHuR. Patients with high cHuR treated with 5-FU demonstrated disease-free survival of 20.1 months compared to 12.8 months for those with low cHuR treated with 5-FU. There was no detectable difference in the survival probabilities of patients with low and high cHuR treated with gemcitabine (12.9 vs 10.9 months). These findings support a personalized approach to choice of chemotherapy in patients with pancreatic cancer. Patients with high cHuR levels in their resection pathology may be better treated by 5-FU-based protocols including FOLFIRINOX.
Scientific Session III: Borderline Resectable Pancreatic Cancer/Neo-adjuvant Therapy The first afternoon session was dedicated to neo-adjuvant and adjuvant chemoradiotherapy in pancreatic cancer treatment. The majority of papers in this session were retrospective clinical registry studies. Notable was a study examining the impact of neo-adjuvant chemotherapy in early stage (clinical stages I and II) pancreatic cancer using National Cancer Database data (S016 Neo-adjuvant chemotherapy is associated with a survival advantage in early-stage pancreatic head cancer). The authors identified an overall survival benefit of 5 months in patients receiving perioperative chemotherapy (i.e., chemotherapy both prior to and after resection). This advantage was demonstrated in Cox modeling adjusted for demographic factors including patient age, comorbid disease characteristics, and tumor grade. The authors questioned the role of radiation in these patients, noting that on subset analysis, no overall survival benefit was provided by adjuvant radiation treatment. Another notable paper from this session came from the MD Anderson group and examined the impact of the dose of neoadjuvant radiation on rates of local disease control (S017 Preoperative therapy for patients with pancreatic ductal adenocarcinoma undergoing pancreatoduodenectomy: impact of radiation dose on outcomes). This retrospective, single institution found no difference in rates of local control and no difference in disease-specific survival when comparing patients receiving 30 Gy to those receiving 50 Gy.
Scientific Session V: Acute and Chronic Pancreatitis/Disconnected Duct Syndrome/TPIAT The first session on Saturday morning included papers on autoimmune pancreatitis, total pancreatectomy with islet cell autotransplantation (TP-IAT), and management of walled off pancreatic necrosis (WON). The Medical University of South Carolina group presented data documenting deficiencies in vitamins A, D, E, and B12 and iron/ferretin in TP-IAT patients. These deficiencies were observed across the spectrum from shortly post-operative up to 3 years. Future research will focus on concurrent existing pancreatic exocrine insufficiency.
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Bang presented data from the University of Alabama Birmingham and the Florida Hospital documenting aggressive endoscopic treatment of patients with WON (S045 Impact of disconnected pancreatic duct syndrome [DPDS] on endoscopic treatment outcomes in pancreatic fluid collections).
Scientific Session VI: Centralization/Nomogram/Genetics of Cancer The afternoon session included papers dedicated to better understanding the effect of centralization of care on the costs and effectiveness of care in patients with resectable pancreatic cancer. This session included one paper examining the effect of centralization of pancreatic cancer care in Finland between 2002 and 2008. This paper compared outcomes from the two largest pancreatic surgical centers in Finland (performing more than 20 resections per year during the study period) to 6 medium-volume centers (performing between 6 and 20 resections per year) and to 8 low-volume centers (performing less than 6 resections per year). The authors found that although no formal effort to centralize care existed, the percent of total cases being performed at the high-volume centers increased from 36% in 2002 to 52% in 2008. The authors identified improved long-term survival in patients that had R0 resections at high-volume hospitals and also identified high rates of lymph node assessment and lower 30-day mortality rates. Questions regarding the reason for the improved outcomes at these centers suggested that the observed effect may be due as much to the impact of advanced multidisciplinary care in medical oncology and interventional radiology as to surgical performance.
Scientific Session VII: IPMN The highlighted paper from this session was a multiinstitutional Italian study led by the Milan group (S064 Non-operative management of low-risk branch-duct IPMN is safe in the long-term [>5 years] follow-up). These investigators followed 144 patients with low-risk, small (mean 15.5 mm) branch-duct IPMN for 68– 277 months. They found changes in 48% of patients, which led to resection in 7 (5%). Five patients (3.5%) developed malignancy. Clinically significant changes (worrisome features and/or high-risk stigmata) developed in 17% of patients and, importantly, were observed at a median time of 67 and 78 months after diagnosis. These data suggest that continued long-term follow-up of IPMN patients—even those at lowest risk—is warranted.
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Awards Five sponsored awards were presented this year: The PanCan awards sponsored by the Pancreatic Cancer Action Network were given to Christopher R. Shubert (Mayo Clinic; paper 21), Nigel B. Jamieson (Glasgow Royal Infirmary, paper 24), and John R. Bergquest (Mayo Clinic, paper 22). The Kenneth K. Warren award was presented to Ji Young Bang (Florida Hospital). The John M. Howard Award was presented to Stefano Crippa (San Raffaele Scientific Institute, Milan, Italy) The meeting concluded with an invitation to attend the 51st Pancreas Club meeting on May 5–6, 2017, in Chicago, IL. Table: Oral papers presented at the 50th Annual Pancreas Club meeting
Paper Title # Scientific session I:
Primary institution
Topic: drains/pancreatic fistula/complications of pancreatic surgery 1 Incidence of hepaticojejunostomy University of Texas Medical Branch stricture following Galveston hepaticojejunostomy University of Pennsylvania 2 A multicenter, risk-stratified, School of Medicine prospective trial of drain management for pancreatoduodenectomy University of Verona 3 The evolution of Verona’s experience: looking for a new drain amylase value cut-off to predict pancreatic fistula. Results of a prospective study University of Pittsburgh 4 Grading of surgeon technical performance predicts post-operative pancreatic fistula for the pancreaticoduodenectomy independent of patient related variables 5 Using the pancreatic demonstration University of Chicago/NorthShore project to derive a fistula risk score for preoperative risk stratification in patients undergoing pancreaticoduodenectomy Wakayama Medical 6 Identification of risk factors of University pancreatic exocrine insufficiency after pancreaticoduodenectomy using 13C-labeled mixed triglyceride breath test 7 Stent associated infectious Universitatsklinikum complications after Freiburg pancreatoduodenectomies can be prevented by perioperative antibiotic therapy 8 Modified frailty index predicts Wake Forest Baptist Health morbidity and mortality after pancreaticoduodenectomy
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Impact of sarcopenia on surgical Campus Bio-Medico outcomes in patients undergoing University, Rome pancreaticoduodenectomy by using enhanced recovery after surgery (ERAS) protocol Scientific session II: Topic: surgical techniques and innovations 10 Robotic Whipple biotissue curriculum improves technical performance for fellows and has construct validity 11 Robotic versus open pancreatoduodenectomy: a propensity score-matched analysis of pancreatic fistula 12 Robot-assisted versus open pancreaticoduodenectomy: a case-matched study based on clinical risk score for pancreatic fistula 13 Modified Appleby procedure for pancreatic tumors: the Johns Hopkins experience 14 Impact of a nationwide training program in laparoscopic distal pancreatectomy (LAELAPS) 15 Laparoscopic versus open distal pancreatectomy: the outcomes of Japanese multicenter comparative study using propensity score-matching Scientific session III:
University of Pittsburgh Medical Center
University of Pennsylvania
University of Pisa
The Johns Hopkins Hospital St Antonius Hospital, Netherlands Kyushu University, Fukuoka, Japan
Topic: borderline resectable pancreatic cancer/neo-adjuvant therapy NorthShore University 16 Neo-adjuvant chemotherapy is Health System associated with a survival advantage in early stage pancreatic head cancer MD Anderson Cancer 17 Preoperative therapy for patients Center with pancreatic ductal adenocarcinoma undergoing pancreatoduodenectomy: impact of radiation dose on outcomes 18 Does radiologic response correlate University of Cincinnati to pathologic response in patients undergoing neo-adjuvant therapy for pancreatic malignancy? 19 Survival after neo-adjuvant therapy University of Texas Southwestern and resection versus resection alone for early stage pancreatic cancer: a propensity score matched analysis in a national cohort of patients 20 Ability of TNM staging to predict Johns Hopkins overall survival after resection of pancreatic adenocarcinoma in patients undergoing neo-adjuvant chemotherapy Mayo Clinic 21 Overall survival is increased among stage III pancreatic adenocarcinoma patients receiving neo-adjuvant chemotherapy compared to surgery first and adjuvant
chemotherapy: an intention to treat analysis of the National Cancer Database 22 Carbohydrate antigen 19-9 In ana- Mayo Clinic tomically resectable, early stage pancreatic cancer is independently associated with decreased overall survival and an indication for neo-adjuvant therapy: a National Cancer Database study 23 Pattern of Ca19-9 response to Virginia Mason Medical neo-adjuvant chemotherapy in Center locally advanced, borderline resectable pancreatic cancer predicts progression 24 Neo-adjuvant treatment with Royal Glasgow Infirmary FOLFIRINOX for resectable and borderline resectable pancreatic ductal adenocarcinoma: feasibility and clinicopathological implications 25 Down staging of liver metastases San Raffaele Scientific from pancreatic cancer Institute, Milan, Italy following primary chemotherapy: is surgical resection worthwhile? 26 Prognostic relevance of the timing Seoul National University of initiating and the completion Bundang Hospital of adjuvant therapy in patients with resected pancreatic ductal adenocarcinoma 27 University of Pittsburgh Adjuvant radiotherapy does not improve outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma: a margin-stratified analysis 28 External radiation is associated University of with improved survival in Chicago/NorthShore University resected margin-negative stage IIB pancreatic adenocarcinoma Mayo Clinic 29 Extended long-course induction systemic chemotherapy, consolidative chemoradiation, and aggressive resection of Bat-risk^ anatomy is associated with significant survival benefit in stage Iii (Br/La) pancreatic adenocarcinoma: the Mayo Clinic experience Scientific session IV: Topic: basic science studies/rare pancreatic tumors Massachusetts General 30 Tumor establishment and rate of Hospital growth in patient-derived pancreatic ductal adenocarcinoma xenograft models are associated with adverse clinicopathological features and poor survival/outcomes 31 S031 Hyperglycemia impacts Thomas Jefferson tumor biology and University chemotherapy response in pre-clinical cancer models and patients with pancreatic cancer 32 An indel DNA Sequence Thomas Jefferson embedded in the WEE1 University
J Gastrointest Surg (2017) 21:749–754 regulatory binding site correlates with increased cancer risk in family members of pancreatic cancer patients 33 Restitution of tumor suppressor University of Tennessee MIR-145 using magnetic nanoHealth Science Center particles inhibits pancreatic cancer Memphis 34 A personalized approach to adjuvant Thomas Jefferson University therapy: cytoplasmic HuR status predicts disease free survival after resection for pancreatic ductal adenocarcinoma 35 T-cell infiltrate as a simple tool to University of Maryland predict intermediate term survival in pancreatic ductal adenocarcinoma 36 Analysis of 337 patients with solid Providence Portland Cancer Center pseudopapillary tumors of the pancreas—role for surgery in metastatic disease UCLA 37 Periampullary cancers: histopathologic subtype is a stronger determinant of patient survival than anatomic location 38 Pancreaticoduodenectomy for Brigham and Women’s metastatic pancreatic Hospital neuroendocrine tumor Johns Hopkins 39 Surgical outcomes of resected functional pancreatic neuroendocrine tumors: a single institution experience Scientific session V: Topic: acute and chronic pancreatitis/disconnected duct syndrome/TPIAT 40 Variations of oral and fecal Ospedale San Raffaele, microbiota are associated with Milan, Italy autoimmune pancreatitis 41 Clinical significance of B Ehime University, To-on, cell-activating factor in autoimJapan mune pancreatitis Medical University of 42 Outcomes after salvage total South Carolina pancreatectomy for refractory chronic pancreatitis Dartmouth Medical School 43 Comparable rate of long term insulin independence between adult patients undergoing remote and local TPIAT 44 Vitamin and iron deficiencies are Medical University of common in patients who South Carolina undergo total pancreatectomy with islet auto transplantation for chronic pancreatitis 45 Impact of disconnected pancreatic Florida Hospital duct syndrome (DPDS) on endoscopic treatment outcomes in pancreatic fluid collections (PFCS) 46 EUS-based step-up treatment ap- Florida Hospital proach is associated with better systemic inflammatory response in walled-off necrosis (WON) 47 Transgastric necrosectomy for the Indiana University School management of walled-off panof Medicine creatic necrosis: long-term outcomes at a high-volume pancreatic center
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Novel method of direct endoscopic University of Washington necrosectomy in the treatment of walled-off pancreatic necrosis Scientific session VI: Topic: centralization/nomogram/genetics of cancer Academic Medical Center, 49 Continuous wound infiltration Amsterdam versus epidural analgesia after open pancreatic and hepato-biliary surgery (POP-UP): a multicenter, randomized controlled, open-label, non-inferiority trial University of Cincinnati 50 Pancreatic surgery at safety net hospitals: should it be abandoned? Johns Hopkins 51 Assessing the financial toxicity associated with treatment options for resectable pancreatic cancer 52 Physiologic pancreatic cancer Oregon Health and Science imaging using dynamic University contrast-enhanced magnetic resonance imaging (DCE-MRI) Tampere University 53 The effect of centralization on Hospital, Finland prognosis: operated pancreatic ductal adenocarcinoma (PDA) patients in Finland 2002–2008 Massachusetts General 54 Effect of angiotensin system Hospital inhibitors on overall survival in pancreatic ductal adenocarcinoma patients Johns Hopkins 55 A new nomogram better stratifies patients with resected pancreatic ductal adenocarcinoma than does the AJCC staging: an analysis of 3,473 patients from the pancreas surgery consortium The University of 65 Genomic analyses identify Queensland, Australia molecular subtypes of pancreatic cancer Scientific session VII: IPMN 56 Biomarkers for detection of high Johns Hopkins grade dysplasia and carcinoma-in-situ in IPMN 57 Low progression of intraductal San Raffaele Scientific papillary mucinous neoplasms Institute, Milan, Italy with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis Johns Hopkins 58 Circulating epithelial cells in intraductal papillary mucinous neoplasms and cystic pancreatic lesions 59 Multi-institutional study on the Indiana University School natural history of large-sized of Medicine (>3 cm) branch-duct intraductal papillary mucinous neoplasm Moffitt Cancer Center 60 Patterns of recurrence and long-term outcomes in patients who underwent pancreatectomy for intraductal papillary
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J Gastrointest Surg (2017) 21:749–754 mucinous neoplasms with high grade dysplasia: implications for surveillance Massachusetts General Elevated serum Ca19-9 in Hospital branch-duct IPMN is a highly-specific predictor of invasive cancer Local progression in the pancreatic Johns Hopkins remnant following resection of intraductal papillary mucinous neoplasm (IPMN of the
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pancreas occurs by one of three distinct mechanisms Johns Hopkins The pattern of recurrence of invasive-IPMN is different than conventional PDAC Non-operative management of San Raffaele Scientific low-risk branch-duct intraductal Institute Milan, Italy papillary mucinous neoplasms is safe in the long-term (>5 years) follow-up
