European evidence-based guidelines on pancreatic cystic neoplasms

Background Screening individuals at increased risk for pancreatic cancer (PC) detects early, potentially curable, pancreatic neoplasia. Objective To develop consortium statements on screening, surveillance and management of high-risk individuals with an inherited predisposition to PC. Methods A 49-expert multidisciplinary international consortium met to discuss pancreatic screening and vote on statements. Consensus was considered reached if ≥75% agreed or disagreed. Results There was excellent agreement that, to be successful, a screening programme should detect and treat T1N0M0 margin-negative PC and high-grade dysplastic precursor lesions (pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasm). It was agreed that the following were candidates for screening: first-degree relatives (FDRs) of patients with PC from a familial PC kindred with at least two affected FDRs; patients with Peutz–Jeghers syndrome; and p16, BRCA2 and hereditary non-polyposis colorectal cancer (HNPCC) mutation carriers with ≥1 affected FDR. Consensus was not reached for the age to initiate screening or stop surveillance. It was agreed that initial screening should include endoscopic ultrasonography (EUS) and/or MRI/magnetic resonance cholangiopancreatography not CT or endoscopic retrograde cholangiopancreatography. There was no consensus on the need for EUS fine-needle aspiration to evaluate cysts. There was disagreement on optimal screening modalities and intervals for follow-up imaging. When surgery is recommended it should be performed at a high-volume centre. There was great disagreement as to which screening abnormalities were of sufficient concern to for surgery to be recommended. Conclusions Screening is recommended for high-risk individuals, but more evidence is needed, particularly for how to manage patients with detected lesions. Screening and subsequent management should take place at high-volume centres with multidisciplinary teams, preferably within research protocols.

To estimate cumulative radiation exposure and lifetime attributable risk (LAR) of radiation-induced cancer from computed tomographic (CT) scanning of adult patients at a tertiary care academic medical center. This HIPAA-compliant study was approved by the institutional review board with waiver of informed consent. The cohort comprised 31,462 patients who underwent diagnostic CT in 2007 and had undergone 190,712 CT examinations over the prior 22 years. Each patient's cumulative CT radiation exposure was estimated by summing typical CT effective doses, and the Biological Effects of Ionizing Radiation (BEIR) VII methodology was used to estimate LAR on the basis of sex and age at each exposure. Billing ICD9 codes and electronic order entry information were used to stratify patients with LAR greater than 1%. Thirty-three percent of patients underwent five or more lifetime CT examinations, and 5% underwent between 22 and 132 examinations. Fifteen percent received estimated cumulative effective doses of more than 100 mSv, and 4% received between 250 and 1375 mSv. Associated LAR had mean and maximum values of 0.3% and 12% for cancer incidence and 0.2% and 6.8% for cancer mortality, respectively. CT exposures were estimated to produce 0.7% of total expected baseline cancer incidence and 1% of total cancer mortality. Seven percent of the cohort had estimated LAR greater than 1%, of which 40% had either no malignancy history or a cancer history without evidence of residual disease. Cumulative CT radiation exposure added incrementally to baseline cancer risk in the cohort. While most patients accrue low radiation-induced cancer risks, a subgroup is potentially at higher risk due to recurrent CT imaging.

The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy.