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Pancreatic cystic neoplasm (PCN) is characterized by cystic degeneration with a low incidence. With the development of imaging technology and the popularization of screening, the detection rate of this disease has been increasing in recent years, especially in the elderly population. Due to the multiple subtypes of PCN, difficult differential diagnosis, and the potential risk of malig-nant transformation, the formulation of reasonable diagnosis and treatment strategy is the key to treat PCN. Although many clinical guidelines have been released, the diagnosis and treatment strategies of PCN are still controversial. Elderly patients are generally weak, some with serious comorbidities, and have poor tolerance to surgery. In the process of diagnosis and treatment, clinicians need to pay special attention, carefully evaluate and weigh the advantages and disadvantages, so as to make the best plan for treatment. Based on the current guidelines and clinical experience, the authors summarize the diagnosis, surgical indications, and the whole-course management strategies of elderly patients with PCN, in order to provide suggestions for the diagnosis and treatment of this disease.
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Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare low-grade malignant tumor. In recent years, with the improvement of national health check-up awareness and the advancement of imaging diagnostic technology, the detection rate of SPN has continued to rise. With the release of guidelines for many pancreatic cystic tumors at home and abroad, the diagnosis and treatment of SPN has gradually become standardized. However, its diagnostic and treatment strategies are still difficult and controversial. Therefore, the author summarizes the current status of diagnosis and treatment of SPN by referring to the literature and combining clinical experience, in order to deepen the understanding of rare pancreatic tumor by clinicians and further promote the standardized diagnosis and treatment of SPN in China.
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Objective:To investigate the effects of mitochondrial arginyl-tRNA synthase (RARS2) on cell proliferation, invasion, migration and chemotherapy resistance of pancreatic cancer.Methods:Human pancreatic cancer cell lines AsPC-1 and PANC-1 were divided into negative control group, RARS2 interference group-1, RARS2 interference group-2, RARS2 overexpression control group and RARS2 overexpression group. Cell proliferation and sensitivity to gemcitabine were detected by CCK-8 assay, and cell invasion and migration were detected by Transwell assay. Western blot was used to detect the expression of RARS2 under different concentrations and different times of gemcitabine treatment. Western blot and PCR were used to detect the expression of RARS2 in gemcitabine-resistant AsPC cell.Results:Inhibition of RARS2 expression in AsPC-1 and PANC-1 cells significantly inhibited cell proliferation and enhanced sensitivity of gemcitabine to chemotherapy. Overexpression of RARS2 enhanced cell proliferation and decreased sensitivity to gemcitabine. In AsPC-1 cells, the number of migrated cells (100×) in negative control group, RARS2 interference group-1, RARS2 interference group-2, RARS2 overexpression control group and RARS2 overexpression group were (586.7±37.4) cells/field, (195.7±18.6) cells/field, (237.0±17.1) cells/field, (157.7±19.1) cells/field, (456.0±23.1) cells/field, the number of invasive cells were (87.7±13.2) cells/field, (24.7±6.5) cells/field, (31.7±6.1) cells/field, (29.3±4.5) cells/field, (94.3±9.3) cells/field, respectively. The migration and invasion ability of cells were decreased after the expression of RARS2 was decreased, and the migration and invasion ability of cells were enhanced after the expression of RARS2 was increased. PCR and Western blot assay showed that RARS2 expression in the gemcitabine-resistant AsPC-1 was higher than that in the common cell line. In AsPC-1 cells, the expression of RARS2 increased with increasing gemcitabine concentration and treatment time.Conclusion:RARS2 promotes cell proliferation, invasion, migration and chemoresistance of pancreatic cancer, and expression of RARS2 is positively correlated with gemcitabine concentration and treatment time.
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With the development of neoadjuvant therapy, the treatment of pancreatic cancer has entered the era of comprehensive diagnosis and treatment consisting of surgery, chemo-therapy and radiotherapy. In recent years, the concept of 'total neoadjuvant therapy' has become one of the important treatment methods for locally advanced rectal cancer. The authors focus on pancrea-tic cancer, introduce the development status of total neoadjuvant therapy in pancreatic cancer and summarize the current controversies and challenges in the application of total neoadjuvant therapy in pancreatic cancer, in order to further standardize the diagnosis and treatment of pancreatic cancer and improve the overall level of pancreatic cancer treatment in China.
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Peking Union Medical College Hospital, as one of the most stressful medical institutions in China, is facing the problem of emergency department overcrowding. In order to effectively alleviate the emergency overcrowding, improve the medical quality and patients′ medical experience, the hospital firmly grasped the two incremental links of " throughput" and " output" factors, established a multidisciplinary and multi-department cooperation team, constructed a close medical alliance cooperation mode, and innovated and explored a harmonious emergency overcrowding relief mode with the goal of unblocking the " exit" of patients. The practice showed that the comprehensive measures could effectively alleviate the problem of emergency overcrowding, and improve the medical environment and medical quality.
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Artificial intelligence is a branch of computer science. As a new science and technology, it is more and more extensive used in the medical and health field recent years and shows outstanding ability in the diagnosis and treatment of complex diseases. Pancreatic cancer has the characteristics of high degree of malignancy, high concealment, difficult diagnosis and treatment, poor prognosis and so on. Therefore, clear diagnosis and early treatment are significant to improve patient prognosis. This paper summarizes the development and application of artificial intelligence and radiomics in the field of pancreatic cancer.
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Objective:To summarize the atypical manifestations and treatment strategies of serous microcystic neoplasm of the pancreas.Methods:Review the case data of 11 cases of pancreatic serous microcystic adenoma with atypical preoperative clinical imaging findings admitted to Peking Union Medical College Hospital from July 2008 to October 2019, and summarize their clinical manifestations, CT/MRI features, and preoperative clinical diagnosis, surgical methods, postoperative conditions.Results:The median age of the 11 patients was 50 (46-66) years old, 7 females, and 4 males. There were 8 cases with back pain and 6 cases with weight loss. The preoperative imaging examination found that the lesion was located in the head and neck in 8 cases, with pancreaticobiliary duct dilatation in 7 cases, suspected vascular invasion in 3 cases, and pancreatic parenchymal atrophy in 2 cases, 3 cases showed rich blood supply and solid space, and 2 cases were connected to the pancreatic duct. Preoperative diagnosis of pancreatic malignant tumors accounted for 4 cases, neuroendocrine tumors in 3 cases, solid pseudopapillary tumors in 3 cases, and intraductal papillary mucinous tumors in 1 case. All patients underwent surgical treatment, 3 cases of distal pancreatectomy (2 cases of using Kimura method to protect the spleen), 3 cases of pancreaticoduodenectomy, 1 case of total pancreatectomy, 2 cases of pancreatic head resection with duodenum preservation, 2 cases of local resection. All patients had no early postoperative deaths. There were 2 cases of grade B pancreatic fistula, 2 cases of biochemical leakage, 1 case of postoperative abdominal hemorrhage, and 2 cases of delayed gastric emptying, all of which were cured after active treatment. The median postoperative hospital stay was 18 (7-63) days.Conclusions:Pancreatic serous microcystic neoplasm could be accompanied by atypical features such as pancreatic/bile duct dilation, parenchyma atrophy, or even present vessel invasion. Understanding the atypical clinic and image features would help improving differential diagnosis and treatment. For those with invasive features, surgical exploration should be recommended.
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Pancreatic ductal adenocarcinoma (PDAC) has poor prognosis due to limited therapeutic options. This study examines the roles of genome-wide association study identified PDAC-associated genes as therapeutic targets. We have identified HNF4G gene whose silencing most effectively repressed PDAC cell invasiveness. HNF4G overexpression is induced by the deficiency of transcriptional factor and tumor suppressor SMAD4. Increased HNF4G are correlated with SMAD4 deficiency in PDAC tumor samples and associated with metastasis and poor survival time in xenograft animal model and in patients with PDAC (log-rank P = 0.036; HR = 1.60, 95% CI = 1.03-2.47). We have found that Metformin suppresses HNF4G activity via AMPK-mediated phosphorylation-coupled ubiquitination degradation and inhibits in vitro invasion and in vivo metastasis of PDAC cells with SMAD4 deficiency. Furthermore, Metformin treatment significantly improve clinical outcomes and survival in patients with SMAD4-deficient PDAC (log-rank P = 0.022; HR = 0.31, 95% CI = 0.14-0.68) but not in patients with SMAD4-normal PDAC. Pathway analysis shows that HNF4G may act in PDAC through the cell-cell junction pathway. These results indicate that SMAD4 deficiency-induced overexpression of HNF4G plays a critical oncogenic role in PDAC progression and metastasis but may form a druggable target for Metformin treatment.
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With the development of modern imaging technology and improvement of physical examination consciousness of people, the incidence of pancreatic cystic neoplasm (PCN) has increased significantly. The overall prognosis of PCN is good, and great progress in surgical techniques and multidisciplinary teamwork has been made in pancreatic surgery. Although many guidelines have been released at home and abroad, there are controversies in the differential diagnosis, operative indications, surgical procedure, and the follow-up strategies toward patients with PCN. There are also significant differences in the level of diagnosis and treatment of medical centers, which brings certain challenges to the standardized diagnosis and treatment of PCN. Based on the latest clinical guidelines and new developments in clinical researches, the authors summarize the controversies of different guidelines in the diagnosis, treatment and follow-up of PCN in order to further improve the standardization of the diagnosis and treatment.
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Pancreatectomy is difficult and has various complications. Pancreatic fistula is one of the most serious postoperative complications after pancreatectomy. It will corrode the surrounding tissues of pancreas, which will cause abdominal infection, if the drainage of pancreatic fistula is not complete. Pancreatic fistula combined with abdominal infection may lead to systemic inflammatory response syndrome. Patients at the severe stage often die of multiple organ dysfunction and septic shock. Up to now, the treatment of pancreatic fistula with abdominal infection has not been well determined. This paper reviewed the relevant studies of pancreatic fistula combined with abdominal infection, analyzed the diagnostic criteria and common pathogenic bacteria of pancreatic fistula with abdominal infection, discussed the indications and systematic treatment plan of the surgical intervention, in order to provide direction for the treatment of pancreatic fistula combined with abdominal infection.
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Pancreatic cancer is a highly aggressive tumor in the digestive system, and the progress in surgical technique hasn’t improved patients’ prognosis significantly for many years. As the popularization of multidisciplinary team, the role of neoadjuvant therapy has been highlighted in pancreatic cancer. The aim of neoadjuvant therapy is to reduce the tumor size and eliminate micro-metastasis, so as to increase the R 0 resection rate and decrease recurrence and metastasis. Due to the unique tumor microenvironment, pancreatic cancer is not sensitive to chemotherapy and radiotherapy. So neoadjuvant therapy is not effective for all patients, and controversy still exists regarding the patients selection, therapeutic regimen, re-evaluation after neoadjuvant therapy, etc. The application of neoadjuvant therapy is not very mature. At present, we should pay more attention to the role of neoadjuvant therapy in pancreatic cancer. More high-quality clinical researches are urgently needed, and multidisciplinary team should be applied to make personalized treatment strategy in order to improve the prognosis of patients with pancreatic cancer.
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Pancreatic cancer is extremely malignant and has poor prognosis. Surgery is the only way for the therapy. In recent years, minimally invasive surgery has been developed rapidly in pancreatic surgery. However, pancreatic cancer is often accompanied with vascular aggression and inflammation, which greatly increasing the difficulty of minimally invasive surgery procedure. Its feasibility, safety and radical tumor cure are still controversial. In this article, combined with the existing guidelines and the latest clinical researches, we compared the application of minimally invasive and open surgery in pancreatic cancer and summarized the development status and controversy of minimally invasive treatment of pancreatic cancer. Surgeons should strictly grasp the minimally invasive surgical adaptation certificate, and further carry out clinical research on minimally invasive treatment of pancreatic cancer, so as to standardize and enhance the development of minimally invasive pancreatic surgery in China.
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Objectives@#To examine the expression of the long coding RNA GSTM3TV2 in pancreatic cancer tissues and to examine its role and mechanism in chemoresistance of pancreatic cancer cells.@*Methods@#The expression of lncRNA GSTM3TV2 in 15 pancreatic cancer specimens and corresponding adjacent to cancer tissue samples diagnosed by Department of Pathology, Peking Union Medical College Hospital was detected by real-time PCR.And the expressions of GSTM3TV2 in pancreatic cancer cell AsPC-1, BxPC-3, MIAPaCa-2, PanC-1, SU86.86, T3M4, and chemoresistant cells AsPC-1/GR and MIAPaCa-2/GR, and human pancreatic nestin-expressing cells hTERT-HPNE were detected. Pancreatic cancer cell lines were transfected with GSTM3TV2-pcDNA3.1(+)in order to get cells with GSTM3TV2 overexpression.GSTM3TV2-siRNA was transfected into pancreatic cancer cells to knock down GSTM3TV2. The cell chemoresistance was measured by CCK-8 and flow cytometry assay when incubated with nab-paclitaxel. At the same time, subcutaneous xenograft tumor models were established in nude mice to observe the effect of GSTM3TV2 on chemoresistance of tumor growth in nude mice.Western blot assay was also performed to detect the molecular mechanism of chemoresistance of GSTM3TV2.@*Results@#Comparing toadjacent tissues(0.084±0.019), GSTM3TV2 expression was significantly upregulated in the pancreatic cancer tissues(0.493±0.084) (t=5.146, P<0.05). GSTM3TV2 expression were higher in the chemotherapy resistance pancreatic cancer cells AsPC-1/GR(210.799±19.788) and MIAPaCa-2/GR(122.408±23.419) than that in the AsPC-1(3.793±0.615) and the MIAPaCa-2(5.179±1.095)(t=21.800,P<0.05;t=-18.490,P<0.05). The results of in vivo experiments showed that the volume of subcutaneously transplanted tumors in the overexpressing GSTM3TV2 group ((1 059.609±102.498)mm3) was significantly larger than that in the control group((566.414±81.087) mm3) by treated with nab-paclitaxel(t=4.230,P<0.05).Meanwhile, GSTM3TV2 could promote the expression of Cyclin D1, CDK6, Cyclin E1, Vimentin, N-cadherin, ZEB1, Snail and Slug; but decrease cleaved caspase-3, cleaved PARP in pancreatic cancer cells.@*Conclusions@#The expression level of GSTM3TV2 in pancreatic canceris higher than that in paired adjacent tissues. GSTM3TV2 may act as an oncogene to promote chemoresistance in pancreatic cancer through regulation of cell proliferation, apoptosis, and epithelial-mesenchymal transition.
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Clinical decision-making has been perceived as a primary cognitive activity for clinicians in daily practice,which based on the process of choosing between alternatives or options for patients.A single clinical decision might affect one patient's health outcomes,while the sum of clinical decisions made by all clinicians would play a decisive role in the allocation and utilization of health resources.Several dimensions should be taken into consideration when making clinical decisions,such as scientificity,clinical experience,economical status,medical humanities and government administration.In addition,clinical decision-making behavior should be administrated and guided by government,from the following seven aspects,so as to avoid "scientism" or " commercial alienation" phenomenon:national guidelines and standards development,academic standardization,expertise offering,medical training with human factors as well as legal punishment,medical knowledge accessibility,reimbursement restriction,and application of artificial intelligence.
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Pancreaticoduodenectomy is cumbersome and difficult to operate,with a long operative time and high risk of postoperative complications,thus it is one of the most complicated operations among general surgery.With the popularization and progress of minimally invasive techniques,minimally invasive pancreaticoduodenectomy (MIPD) has obtained a well developing.It has been confirmed that MIPD is noninferior or even superior to the traditional open pancreaticoduodenectomy in term of the feasibility,safety and effects of radical cure.However,the relevant conclusions are mostly from single-center retrospective studies,without high-quality evidence support.The authors has reviewed the recent research progress of MIPD in the indications and contraindications,safety,feasibility and tumor curative effect,and illustrated the current status and prospects of MIPD with clinical experience and related literature,contributing to the standardization of MIPD in China.
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Objective To investigate the imaging anatomy and clinical significance of the inferior pancreaticoduodenal veins (IPDVs).Methods The retrospective and descriptive study was conducted.The clinicopathological data of 42 patients with pancreatic head ductal adenocarcinoma who were admitted to Peking Union Medical College Hospital from January to June 2018 were collected.There were 24 males and 18 females,aged from 41 to 78 years,with an average age of 61 years.Patients received preoperative contrast-enhanced computed tomography (CT) examination with 1 mm slice thickness,and underwent corresponding surgery according to the preoperative evaluation.Observation indicators:(1) results of preoperative CT examination;(2) surgical situations.Normality of measurement data was analyzed using Shapiro-Wilk test.Measurement data with skewed distribution were described as M (QR) or M (range),and comparison between groups was analyzed by the Mann-Whitney U test.Count data were described as absolute number or percentage,and comparison between groups was analyzed by the chi-square test.Results (1) Results of preoperative CT examination:42 patients received preoperative contrast-enhanced CT examination with 1 mm slice thickness.① The first jejunal venous trunk was identified in all the 42 patients.The first jejunal venous trunk crossed dorsal to the superior mesenteric artery (SMA) in 34 patients and ventral to the SMA in 8 patients.② Of 42 patients,2 showed no IPDV,and 40 showed IPDV including 23 with 1 IPDV,13 with 2 IPDVs,3 with 3 IPDVs,and 1 with 4 IPDVs.A total of 62 IPDVs were identified in the 42 patients,with an average IPDV number of 1 (range,0-4).There were 43 IPDVs drained into first or second jejunal venous trunks and 19 IPDVs drained into superior mesenteric vein (SMV).③ Of 42 patients,type Ⅰ IPDV was identified in 32 patients including 20 with 1 IPDV drained into jejunal venous trunk at dorsal side of SMA,7 with 2 IPDVs drained into jejunal venous trunk at dorsal side of SMA,2 with 3 IPDVs drained into jejunal venous trunk at dorsal side of SMA,and 3 with 1 IPDV drained into jejunal venous trunk at ventral side of SMA,and non-type Ⅰ IPDV was identified in 10 patients;type Ⅱ IPDV was identified in 18 patients including 17 with 1 IPDV drained into SMV and 1 with 2 IPDVs drained into SMV,and non-type Ⅱ IPDV was identified in 24 patients.Some patients can simultaneously had type Ⅰ and type Ⅱ IPDV.(2) Surgical situations:42 patients underwent pancreatoduodenectomy,14 of which underwent laparoscopic surgery and 28 underwent open surgery.There were 5 cases with SMV or portal vein reconstruction,and 18 with intraoperative blood transfusion.All the 42 patients were diagnosed as pancreatic ductal adenocarcinoma by postoperative pathological examination,including 30 of R0 resection and 12 of R1 resection.The volume of intraoperative blood loss,cases with intraoperative blood transfusion,cases with R0 and R1 resection (situation of surgical margin),cases with SMV or portal vein reconstruction were 650 mL(853 mL),15,20,12,4 in the 32 patients with type Ⅰ IPDV,aod 475 mL (480 mL),3,10,0,1 in the 10 patients with non-type Ⅰ IPDV;there were significant differences in the volume of intraoperative blood loss and situation of surgical margin (Z=94.000,x2=5.250,P＜ 0.05).There was no significant difference in the cases with intraoperative blood transfusion,cases with SMV or portal vein reconstruction between patients with type Ⅰ and non-type Ⅰ IPDV (x2 =0.045,0.886,P＞0.05).Conclusions IPDVs can be distinguished on the contrast-enhanced CT with slice thickness,and classified as IPDVs drained into SMV or jejunal venous trunk.It is necessary to carefully deal with IPDVs drained into jejunal venous trunk in the pancreaticoduodenectomy due to its more volume of intraoperative blood loss and lower R0 resection rate.
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Pancreatic cancer is a highly malignant tumor in the digestive system and has a low rate of surgical resection and poor prognosis. Since pancreatic cancer has unique biological behaviors, surgical resection alone cannot meet the need of clinical treatment. With the popularization of the concept of multimodality therapy, multidisciplinary collaboration can integrate the superior resources of disciplines and develop standardized and individualized diagnosis and treatment process based on patients′ conditions. It can help clinicians to observe the indications for neoadjuvant therapy in patients with pancreatic cancer and develop individualized surgical and adjuvant treatment regimens and has achieved a good effect in the treatment of pancreatic cancer. This article summarizes the advances and challenges in the multidisciplinary diagnosis and treatment of pancreatic cancer, in order to improve the level of multidisciplinary diagnosis and treatment of pancreatic cancer in China and the prognosis of patients with pancreatic cancer.
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Objective@#To explore the accuracy in localizing occult insulinomas with Glucagon-like peptide-1 receptor(GLP-1R) PET-CT with 68Ga-exendin-4.@*Methods@#In this prospective cohort study, patients with biochemically proven endogenous hyperinsulinemic hypoglycemia and negative contrast-enhanced CT with pancreatic perfusion scans were enrolled consecutively at Department of Nuclear Medicine, Peking Union Medical College Hospital from February 2014 to June 2018.There were 37 males and 32 females, with age of (43.2±17.9)years. 68Ga-exendin-4 PET-CT, MRI and endoscopic ultrasound(EUS) were done before elective surgery. Sensitivity, specificity, accuracy, positive predictive value(PPV) and negative predictive value(NPV) of the above imaging modalities were calculated.@*Results@#A total of 69 patients were recruited. Thirty-two patients were diagnosed with insulinomas at histology. Four patients with positive 68Ga-exendin-4 PET-CT findings did not undergo surgery so far. Twenty-eight patients were proven to be noninsulinoma induced hyperinsulinemic hypoglycemia. Five patients were unknown of etiology of hypoglycemia. The sensitivity, specificity, accuracy, PPV and NPV of 68Ga-exendin-4 in localizing occult insulinomas were 96.9%(31/32), 100%(30/30), 98.3%(59/60), 100%(29/29), 96.8%(30/31), respectively.The sensitivity, specificity, accuracy, PPV and NPV of MRI were 74.1%(20/27), 9/11, 76.3%(29/38), 90.9%(20/22), 9/16, respectively. The sensitivity, specificity, accuracy, PPV and NPV of EUS were 75.0% (15/20), 2/2, 77.3%(17/22), 15/15, and 2/7.@*Conclusion@#68Ga-exendin-4 PET-CT has a high sensitivity, specificity and accuracy for detection of occult insulinoma, which shows superiority to MRI and EUS.
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The insulinoma, which is the most common pancreatic neuroendocrine tumor, can be misdiagnosed and mistreated easily.Recently, the misdiagnosis rate has decreased significantly owing to the establishment of diagnosis and treatment system.However, the misconception about its diagnosis and treatment still exists because the diagnosis and treatment level varies greatly among different centers.This article aims to summarize the experience in the diagnosis and treatment of insulinoma in Peking Union Medical College Hospital, and introduce the qualitative and localization diagnosis, surgical and interventional treatment and perioperative management about insulinoma, so as to standardize the diagnosis and treatment procedure in China.
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Objective@#To investigate the expression of KLK7 in pancreatic cancer and its clinical significance.@*Methods@#Immunohistochemistry was used to detect the expression of KLK7 protein in pancreatic cancer tissue microarray with 92 samples. Statistical analysis of the relationship between KLK7 and clinicopathological characteristics was finished. Pancreatic cancer cell lines were infected with lentiviuses in order to get cells with KLK7 stable overexpression.KLK7-siRNA was transfected into pancreatic cancer cells to knock down KLK7.Cell proliferation and chemosensitivity were detected by CCK-8 assay; Cell invasion and migration abilities were detected by Transwell assay. At the same time, subcutaneous xenograft tumor models were established in nude mice to observe the effect of KLK7 on tumor growth in nude mice. Data were statistically analyzed by rank sum test, χ2 test and Logistic regression analysis.@*Results@#The expression level of KLK7 in pancreatic cancer tissues was higher than that in paired adjacent tissues (P<0.05). KLK7 expression was correlated with vascular invasion(χ2=7.535, P<0.05). Further univariate and multivariate analysis showed that KLK7 expression was an independent risk factor for vascular invasion of pancreatic cancer(χ2=7.535, P<0.05). The overexpression of KLK7 in pancreatic cancer cell lines BxPC-3 and CFPAC can increase their proliferation abilities, reduce the chemosensitivity and promote their migration and invasion behaviour; The results of in vivo experiments showed that the volume of subcutaneously transplanted tumors in the overexpressing KLK7 group was significantly larger than that in the control group (t=4.479, P<0.05). The group of overexpressing KLK7 showed greater tumor weight than the control group(t=2.831, P<0.05).@*Conclusions@#The expression level of KLK7 in pancreatic ductal adenocarcinoma was higher than that in paired adjacent tissues and it is an independent risk factor for vascular invasion of pancreatic cancer.KLK7 can promote the proliferation of pancreatic cancer cells, reduce the chemosensitivity and increase the invasion and migration of pancreatic cancer cells.