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Pancreatic Neoplasms: HELP
Articles by Ralf Segersvard
Based on 31 articles published since 2010
(Why 31 articles?)
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Between 2010 and 2020, R. Segersvärd wrote the following 31 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
Pages: 1 · 2
1 Guideline European experts consensus statement on cystic tumours of the pancreas. 2013

Del Chiaro, Marco / Verbeke, Caroline / Salvia, Roberto / Klöppel, Gunter / Werner, Jens / McKay, Colin / Friess, Helmut / Manfredi, Riccardo / Van Cutsem, Eric / Löhr, Matthias / Segersvärd, Ralf / Anonymous3160750. ·Division of Surgery, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden. Electronic address: marco.del-chiaro@karolinska.se. ·Dig Liver Dis · Pubmed #23415799.

ABSTRACT: Cystic lesions of the pancreas are increasingly recognized. While some lesions show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). European expert pancreatologists provide updated recommendations: diagnostic computerized tomography and/or magnetic resonance imaging are indicated in all patients with cystic lesion of the pancreas. Endoscopic ultrasound with cyst fluid analysis may be used but there is no evidence to suggest this as a routine diagnostic method. The role of pancreatoscopy remains to be established. Resection should be considered in all symptomatic lesions, in mucinous cystic neoplasm, main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm as well as in branch duct intraductal papillary mucinous neoplasm with mural nodules, dilated main pancreatic duct >6mm and possibly if rapidly increasing in size. An oncological partial resection should be performed in main duct intraductal papillary mucinous neoplasm and in lesions with a suspicion of malignancy, otherwise organ preserving procedures may be considered. Frozen section of the transection margin in intraductal papillary mucinous neoplasm is suggested. Follow up after resection is recommended for intraductal papillary mucinous neoplasm, solid pseudo-papillary neoplasm and invasive cancer.

2 Review Are there still indications for total pancreatectomy? 2016

Del Chiaro, Marco / Rangelova, Elena / Segersvärd, Ralf / Arnelo, Urban. ·Pancreatic Surgery Unit-Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases-Karolinska University Hospital, K53-14186, Stockholm, Sweden. marco.del.chiaro@ki.se. · Pancreatic Surgery Unit-Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases-Karolinska University Hospital, K53-14186, Stockholm, Sweden. ·Updates Surg · Pubmed #27605208.

ABSTRACT: Total pancreatectomy is associated with short- and long-term high complication rate and without evidence of oncologic advantages. Several metabolic consequences are co-related with the apancreatic state. The unstable diabetes related to the total resection of the pancreas expose the patients to short- and long-term life-threatening complications. Severe hypoglycemia is a short-term dangerous complication that can also cause patients' death. Chronic complications of severe diabetes (cardiac and vascular diseases, neuropathy, nephropathy, and retinopathy) are also cause of morbidity, mortality and worsening of quality of life. For this reasons the number of total pancreatectomies performed has certainly decreased over time. However, today there are still some indications for this kind of procedures. Chronic pancreatitis untreatable with conventional treatments, surgical treatment of precancerous pancreatic lesions, surgical treatment of locally advanced pancreatic cancer and the management of patients with extraordinary high-risk pancreatic texture after pancreaticoduodenectomy represent possible indications for total pancreatectomy and are analyzed in the present paper.

3 Review Early detection and prevention of pancreatic cancer: is it really possible today? 2014

Del Chiaro, Marco / Segersvärd, Ralf / Lohr, Matthias / Verbeke, Caroline. ·Marco Del Chiaro, Ralf Segersvärd, Matthias Löhr, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, 141 86 Stockholm, Sweden. ·World J Gastroenterol · Pubmed #25232247.

ABSTRACT: Pancreatic cancer is the 4(th) leading cause of cancer-related death in Western countries. Considering the low incidence of pancreatic cancer, population-based screening is not feasible. However, the existence of a group of individuals with an increased risk to develop pancreatic cancer has been well established. In particular, individuals suffering from a somatic or genetic condition associated with an increased relative risk of more than 5- to 10-fold seem to be suitable for enrollment in a surveillance program for prevention or early detection of pancreatic cancer. The aim of such a program is to reduce pancreatic cancer mortality through early or preemptive surgery. Considering the risk associated with pancreatic surgery, the concept of preemptive surgery cannot consist of a prophylactic removal of the pancreas in high-risk healthy individuals, but must instead aim at treating precancerous lesions such as intraductal papillary mucinous neoplasms or pancreatic intraepithelial neoplasms, or early cancer. Currently, results from clinical trials do not convincingly demonstrate the efficacy of this approach in terms of identification of precancerous lesions, nor do they define the outcome of the surgical treatment of these lesions. For this reason, surveillance programs for individuals at risk of pancreatic cancer are thus far generally limited to the setting of a clinical trial. However, the acquisition of a deeper understanding of this complex area, together with the increasing request for screening and treatment by individuals at risk, will usher pancreatologists into a new era of preemptive pancreatic surgery. Along with the growing demand to treat individuals with precancerous lesions, the need for low-risk investigation, low-morbidity operation and a minimally invasive approach becomes increasingly pressing. All of these considerations are reasons for preemptive pancreatic surgery programs to be undertaken in specialized centers only.

4 Review The state of the art of robotic pancreatectomy. 2014

Del Chiaro, Marco / Segersvärd, Ralf. ·Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, K53, 14186 Stockholm, Sweden. ·Biomed Res Int · Pubmed #24982913.

ABSTRACT: During the last decades an increasing number of minimally invasive pancreatic resections have been reported in the literature. With the development of robotic surgery a new enthusiasm has not only increased the number of centers approaching minimally invasive pancreatic surgery in general but also enabled the use of this technique for major pancreatic procedures, in particular in minimally invasive pancreatoduodenectomy. The aim of this review was to define the state of the art of pancreatic robotic surgery. No prospective randomized trials have been performed comparing robotic, laparoscopic, and open pancreatic procedures. From the literature one may conclude that robotic pancreatectomies seem to be as feasible and safe as open procedures. The general idea that the overall perioperative costs of robotic surgery would be higher than traditional procedures is not supported. With the current lack of evidence of any oncologic advantages, the cosmetic benefits offered by robotic surgery are not enough to justify extensive use in cancer patients. In contrast, the safety of these procedure can justify the use of the robotic technique in patient with benign/low grade malignant tumors of the pancreas.

5 Clinical Trial Impact of pancreatic gland volume on fistula formation after pancreatic tail resection. 2010

Frozanpor, Farshad / Albiin, Nils / Linder, Stefan / Segersvärd, Ralf / Lundell, Lars / Arnelo, Urban. ·Division of Surgery, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden. farshad.frozanpor@ki.se ·JOP · Pubmed #20818111.

ABSTRACT: CONTEXT: Resection of the body and tail of the pancreas (distal pancreatectomy) is associated with high postoperative morbidity, most of which is due to leakage from the pancreatic transection surface. OBJECTIVE: The aim of the current study was to analyze factors which may affect the risk of pancreatic fistula formation. PATIENTS: All consecutive distal pancreatectomies prospectively registered in our hospital database from 1999 to 2007 were included. Clinically relevant pancreatic fistula grades B and C, defined according to the International Study Group on Pancreatic Fistula (ISGPF) definition were assessed. MAIN OUTCOME MEASURES: The impact of patient, tumor, surgery, and radiology-related factors on the risk of pancreatic fistula formation were assessed by univariate and multivariate analyses. RESULTS: A distal pancreatectomy was performed in 51 patients (median age: 59 years; range: 26-76 years), 22 of whom had malignant and 29 benign or premalignant disease. Pancreatic fistulas were diagnosed in 17 (33.3%) of the patients. An additional three patients had a local abscess without apparent but assumed pancreatic leakage. Multivariate analysis showed that pancreatic fistulas occurred more frequently after hand suturing of the transection area versus the use of a stapler (69.2% vs. 21.1%; OR: 40.4, 95% CI: 3.36-486; P=0.004) and a large volume of the pancreatic remnant (greater, or equal to, 34 cm3) increased the subsequent risk of pancreatic fistula (57.1% vs. 20.8%; OR: 6.14, 95% CI: 1.14-39.0; P=0.035). CONCLUSIONS: Development of pancreatic fistula after distal pancreatectomy remains a challenge. The volume of the remaining pancreas and the technique of closure of the transected pancreas were found to affect this risk, thus allowing future preventive measures to be explored and evaluated in clinical trials.

6 Article Decreased symptom burden following surgery due to support from an interactive app for symptom management for patients with pancreatic and periampullary cancer. 2019

Gustavell, Tina / Sundberg, Kay / Segersvärd, Ralf / Wengström, Yvonne / Langius-Eklöf, Ann. ·Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet , Stockholm , Sweden. · Department of Upper Abdominal Diseases, Cancer Theme, Karolinska University Hospital , Stockholm , Sweden. · Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet , Stockholm , Sweden. · Cancer Theme, Karolinska University Hospital , Stockholm , Sweden. ·Acta Oncol · Pubmed #31284797.

ABSTRACT:

7 Article Radiological assessment of local resectability status in patients with pancreatic cancer: Interreader agreement and reader performance in two different classification systems. 2018

Loizou, Louiza / Duran, Carlos Valls / Axelsson, Elisabet / Andersson, Mats / Keussen, Inger / Strinnholm, Jörgen / Bartholomä, Wolf / Del Chiaro, Marco / Segersvärd, Ralf / Lundell, Lars / Kartalis, Nikolaos. ·Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Abdominal Radiology, Karolinska University Hospital, 14186, Stockholm, Sweden. · Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Abdominal Radiology, Karolinska University Hospital, 14186, Stockholm, Sweden; Department of Radiology, Uppsala University Hospital, 75185, Uppsala, Sweden. · Department of Radiology, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, 41345, Gothenburg, Sweden. · Diagnostic Radiology, Department of Clinical Sciences and Center for Medical Imaging and Physiology, Skåne University Hospital, 22185, Lund, Sweden. · Diagnostic Radiology, Department of Radiation Sciences, Umeå University, 90187, Umeå, Sweden. · Department of Radiology and Department of Medical and Health Sciences, Linköping University Hospital, 58185, Linköping, Sweden. · Pancreatic Surgery Unit, Division of Surgery, CLINTEC, Karolinska Institutet, 14186, Stockholm, Sweden; Department of Upper GI diseases, Cancer Theme, Karolinska University Hospital, Stockholm, 14186 Sweden. · Pancreatic Surgery Unit, Division of Surgery, CLINTEC, Karolinska Institutet, 14186, Stockholm, Sweden. · Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Abdominal Radiology, Karolinska University Hospital, 14186, Stockholm, Sweden. Electronic address: nikolaos.kartalis@sll.se. ·Eur J Radiol · Pubmed #30150053.

ABSTRACT: OBJECTIVES: To assess the interreader agreement and reader performance in the evaluation of patients with pancreatic cancer (PC) in two classification systems of local resectability status prior to initiation of therapy, namely the National Comprehensive Cancer Network (NCCN) and Karolinska classification system (KCS). METHODS: In this ethics review board-approved retrospective study, six radiologists independently evaluated pancreatic CT-examinations of 30 patients randomly selected from a tertiary referral centre's multidisciplinary tumour board database. Based on well-defined criteria of tumour-vessel relationship, each patient was assigned to one of three NCCN and six KCS categories. We assessed the intraclass correlation coefficient (ICC) and compared the percentages of correct tumour classification of the six readers in both systems (Chi-square test; a P-value <0.05 was considered significant). The standard of reference was a consensus evaluation of CT-examinations by three readers not involved in the image analysis. RESULTS: The ICC for NCCN and KCS was 0.82 and 0.84, respectively (very strong agreement). The percentages of correct tumour classification at NCCN and KCS were 53-83% and 30-57%, respectively, with no statistically significant differences in the overall reader comparison per classification system. In pair-wise comparison between readers for NCCN/KCS, there were statistically significant differences between reader 5 vs. readers 4 (P = 0.012) and 3 (P = 0.045)/ reader 5 vs. reader 4 (P = 0.037). CONCLUSION: Interreader agreement in both PC classification systems is very strong. NCCN may be advantageous in terms of reader performance compared to KCS.

8 Article Pancreatectomies for pancreatic neoplasms in pediatric and adolescent age: A single institution experience. 2018

Scandavini, Chiara / Valente, Roberto / Rangelova, Elena / Segersvärd, Ralf / Arnelo, Urban / Permert, Johan / Svensson, Pär-Johan / Stenman, Jakob / Del Chiaro, Marco. ·Pancreatic Surgery Unit, Division of Surgery (KLINTEC) - Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden. · Pancreatic Surgery Unit, Division of Surgery (KLINTEC) - Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden; Digestive and Liver Diseases Unit - Sapienza University of Rome, Italy. · Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department for Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden. · Pancreatic Surgery Unit, Division of Surgery (KLINTEC) - Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden. Electronic address: marco.del.chiaro@ki.se. ·Pancreatology · Pubmed #29277262.

ABSTRACT: BACKGROUND: There are very few data in the current literature regarding the short- and long-term outcome of surgery for pediatric pancreatic tumors (PPT). No data are available on the impact of pancreatic surgery on the children's growth. METHODS: This is a retrospective cohort study on a consecutive series of pediatric/adolescent patients who underwent pediatric surgery at Karolinska University Hospital from January 2005 to July 2017. RESULTS: Overall 14 pancreatic operations were performed in 13 patients. The median age was 11.4 years (range 3-15). Six pancreaticoduodenectomies (42.8%), 5 distal pancreatectomies (35.7%), and 3 enucleations (21.5%) were performed. The final histology revealed a solid pseudopapillary tumor in 9 cases (69.2%), neuroblastoma in 1 (7.7%), ganglioneuroma in 1 (7.7%), pancreatoblastoma in 1 (7.7%), and insulinoma in 1 (7.7%). Overall, 3 patients developed post-operative complications (23%). There was no peri-operative mortality. All patients are alive after a median follow-up time of 80 months. Exocrine insufficiency was detected post-operatively in 4 patients (30.7%) Endocrine insufficiency requiring insulin treatment developed in one patient (7.7%). No significant impact on growth was detected in any of the patients after pancreatic resection. CONCLUSIONS: In our series, surgery performed for PPTs seems to be safe and effective. The effect of pancreatic surgery on children's growth does not seem to be significant.

9 Article Symptoms and self-care following pancreaticoduodenectomy: Perspectives from patients and healthcare professionals - Foundation for an interactive ICT application. 2017

Gustavell, Tina / Sundberg, Kay / Frank, Catharina / Wengström, Yvonne / Browall, Maria / Segersvärd, Ralf / Langius-Eklöf, Ann. ·Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Stockholm, Sweden; Karolinska University Hospital, Gastrocentrum, Stockholm, Sweden. Electronic address: tina.gustavell@ki.se. · Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Stockholm, Sweden. · Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Stockholm, Sweden; Karolinska University Hospital, Breast and Sarcoma Unit, Radiumhemmet, Stockholm, Sweden. · Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Stockholm, Sweden; University of Skövde, School of Health and Education, Skövde, Sweden. · Karolinska University Hospital, Gastrocentrum, Stockholm, Sweden; Karolinska Institutet, Department of Clinical Science, Intervention and Technology, Division of Surgery, Stockholm, Sweden. ·Eur J Oncol Nurs · Pubmed #28069150.

ABSTRACT: PURPOSE: Poor prognosis and a problematic recovery period after pancreaticoduodenectomy means that patients may benefit from early detection of symptoms and support for self-management. Interactive Information and Communication Technology tools can be used for this purpose, but the content needs to be relevant to patients as well as healthcare professionals. To facilitate development of the content of an application for this purpose, the aim of this study was to explore common symptoms and self-care in the first six months after pancreaticoduodenectomy, as identified by patients and healthcare professionals. METHOD: Data were collected through individual interviews with patients (n = 14), along with two focus group interviews and one individual interview with healthcare professionals (n = 10). Data were analysed using qualitative content analysis. RESULTS: Common symptoms after surgery were those related to eating, bowel function and emotional wellbeing, along with fatigue and pain. Some self-care activities and advice were mentioned in the interviews. The patients often experienced a lack of advice on self-care at discharge. CONCLUSIONS: The results render knowledge of the symptoms it is important to be aware of and to assess regularly after pancreaticoduodenectomy. The results also contribute to knowledge about specific self-care related to these symptoms, even though it was not extensively described, and further research is needed to define evidence-based self-care advice.

10 Article Survival Analysis and Risk for Progression of Intraductal Papillary Mucinous Neoplasia of the Pancreas (IPMN) Under Surveillance: A Single-Institution Experience. 2017

Del Chiaro, Marco / Ateeb, Zeeshan / Hansson, Marcus Reuterwall / Rangelova, Elena / Segersvärd, Ralf / Kartalis, Nikolaos / Ansorge, Christoph / Löhr, Matthias J / Arnelo, Urban / Verbeke, Caroline. ·Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden. marco.del.chiaro@ki.se. · Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden. · Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden. · Department of Pathology, Karolinska University Hospital, Stockholm, Sweden. ·Ann Surg Oncol · Pubmed #27822633.

ABSTRACT: PURPOSE: While surveillance of the majority of patients with IPMN is considered best practice, consensus regarding the duration of follow-up is lacking. This study assessed the survival rate and risk for progression of IPMN under surveillance. METHODS: All patients diagnosed with and surveyed for IPMN between January 2008 and December 2013 were identified and assigned to two groups: patients without indication for surgery (Group 1), and patients whose IPMN required surgery but were inoperable for general reasons (Group 2). Disease progression and survival data were compared between both groups. RESULTS: In total 503 patients were identified, of whom 444 (88.3%) were followed up. Group 1 included 395 patients, and Group 2 had 49. In Group 1, IPMN-specific 1-, 5-, and 10-year survival rates were 100, 100, and 94.2%, respectively. Four patients died of associated or concomitant pancreatic cancer, and 230 patients (58.2%) experienced disease progression. The 1-, 4-, 10-year cumulative risk for progression and for surgery was 11.2, 70.6, 97.5, and 2.9, 26.2, 72.1%, respectively. In Group 2, the 1-, 5-, 10-year IPMN-specific survival rate was 90.7, 74.8, and 74.8%, respectively. CONCLUSIONS: This study confirmed the safety of surveillance for patients with IPMN who do not require surgery. However, the risk for disease progression and for surgery increases significantly over time. The study results support International and European guidelines not to discontinue IPMN surveillance and validate the European recommendation to intensify follow-up after 5 years. The fairly good prognosis of patients whose IPMN requires surgery but cannot undergo resection suggests a relatively indolent disease biology.

11 Article Cattell-Braasch maneuver combined with local hypothermia during superior mesenteric artery resection in pancreatectomy. 2016

Westermark, Sofia / Rangelova, Elena / Ansorge, Christoph / Lundell, Lars / Segersvärd, Ralf / Del Chiaro, Marco. ·Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, K53, 14186, Stockholm, Sweden. · Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, K53, 14186, Stockholm, Sweden. marco.del.chiaro@ki.se. ·Langenbecks Arch Surg · Pubmed #27562317.

ABSTRACT: BACKGROUND: The recent development of new neo-adjuvant treatment regimens associated with a higher success rate of down-staging has increased the interest of pancreatic surgeons on the role of extended surgery for patients affected by locally advanced pancreatic cancer. Pancreatectomy together with resection of the portal/superior mesenteric vein is considered nowadays standard of care for patients affected by pancreatic cancer. However, the resection of major abdominal arteries is still debatable. In particular, the short- and long-term results after resection of the superior mesenteric artery (SMA) remain controversial and only few cases have been described in literature. The present paper describes a new, quick, and easy technique for resection of the SMA. CLINICAL CASE: A 71-year-old patient affected by IPMN cancer with infiltration of the SMA received FOLFIRINOX-based neo-adjuvant treatment. After 4 months of treatment, the patient underwent total pancreatectomy with en bloc resection of the SMA and direct end-to-end anastomosis. The vascular resection was performed combining a complete Cattell-Braasch maneuver with local bowel hypothermia in an attempt to avoid graft interposition by facilitating an end-to-end anastomosis and to reduce the warm ischemia time. The post-operative course was uneventful and the patient was discharged 8 days post-operatively.

12 Article Multidetector CT of pancreatic ductal adenocarcinoma: Effect of tube voltage and iodine load on tumour conspicuity and image quality. 2016

Loizou, L / Albiin, N / Leidner, B / Axelsson, E / Fischer, M A / Grigoriadis, A / Del Chiaro, M / Segersvärd, R / Verbeke, C / Sundin, A / Kartalis, N. ·Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 14186, Stockholm, Sweden. louiza.loizou@gmail.com. · Department of Radiology, C1-46 Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden. louiza.loizou@gmail.com. · Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 14186, Stockholm, Sweden. · Department of Radiology, Ersta Hospital, 11691, Stockholm, Sweden. · Department of Radiology, C1-46 Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden. · Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden. · Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet and Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden. · Department of Surgical Sciences, Division of Radiology, Uppsala University and Department of Radiology, Uppsala University Hospital, 751 85, Uppsala, Sweden. ·Eur Radiol · Pubmed #26965503.

ABSTRACT: OBJECTIVES: To compare a low-tube-voltage with or without high-iodine-load multidetector CT (MDCT) protocol with a normal-tube-voltage, normal-iodine-load (standard) protocol in patients with pancreatic ductal adenocarcinoma (PDAC) with respect to tumour conspicuity and image quality. METHODS: Thirty consecutive patients (mean age: 66 years, men/women: 14/16) preoperatively underwent triple-phase 64-channel MDCT examinations twice according to: (i) 120-kV standard protocol (PS; 0.75 g iodine (I)/kg body weight, n = 30) and (ii) 80-kV protocol A (PA; 0.75 g I/kg, n = 14) or protocol B (PB; 1 g I/kg, n = 16). Two independent readers evaluated tumour delineation and image quality blindly for all protocols. A third reader estimated the pancreas-to-tumour contrast-to-noise ratio (CNR). Statistical analysis was performed with the Chi-square test. RESULTS: Tumour delineation was significantly better in PB and PA compared with PS (P = 0.02). The evaluation of image quality was similar for the three protocols (all, P > 0.05). The highest CNR was observed with PB and was significantly better compared to PA (P = 0.02) and PS (P = 0.0002). CONCLUSION: In patients with PDAC, a low-tube-voltage, high-iodine-load protocol improves tumour delineation and CNR leading to higher tumour conspicuity compared to standard protocol MDCT. KEY POINTS: • Low-tube-voltage high-iodine-load MDCT improves pancreatic cancer conspicuity compared to a standard protocol. • The pancreas-to-tumour attenuation difference increases significantly by reducing the tube voltage. • The radiation exposure dose decreases by reducing the tube voltage.

13 Article Expansion of Tumor-reactive T Cells From Patients With Pancreatic Cancer. 2016

Meng, Qingda / Liu, Zhenjiang / Rangelova, Elena / Poiret, Thomas / Ambati, Aditya / Rane, Lalit / Xie, Shanshan / Verbeke, Caroline / Dodoo, Ernest / Del Chiaro, Marco / Löhr, Matthias / Segersvärd, Ralf / Maeurer, Markus J. ·Departments of *Laboratory Medicine, Division of Therapeutic Immunology ‡Microbiology, Tumor and Cell Biology, Karolinska Institute Departments of †Clinical Science, Intervention and Technology §Laboratory Medicine, Division of Pathology ∥Neurosurgery ¶CAST, Center for Allogeneic Stem Cell Transplantation, Karolinska Hospital, Stockholm, Sweden. ·J Immunother · Pubmed #26849077.

ABSTRACT: Generation of T lymphocytes with reactivity against cancer is a prerequisite for effective adoptive cellular therapies. We established a protocol for tumor-infiltrating lymphocytes (TILs) from patients with pancreatic ductal adenocarcinoma. Tumor samples from 17 pancreatic cancer specimens were cultured with cytokines (IL-2, IL-15, and IL-21) to expand TILs. After 10 days of culture, TILs were stimulated with an anti-CD3 antibody (OKT3) and irradiated allogeneic peripheral blood mononuclear cells. Reactivity of TILs against tumor-associated antigens (mesothelin, survivin, or NY-ESO-1) was detected by intracellular cytokine production by flow cytometry. Cytotoxicity was measured using a Chromium 51 release assay, and reactivity of TILs against autologous tumor cells was detected by INF-[gamma] production (ELISA). TIL composition was tested by CD45RA, CCR7, 4-1BB, LAG-3, PD-1, TIM3, and CTLA-4 marker analysis. TCR V[beta] was determined by flow cytometry and TCR clonality was gauged measuring the CDR3 region length by PCR analysis and subsequent sequencing. We could reliably obtain TILs from 17/17 patients with a majority of CD8(+) T cells. CD3(+)CD8(+), CD3(+)CD4(+), and CD3(+)CD4(-)CD8(-)[double-negative (DN) T cells] resided predominantly in central (CD45RA(-)CCR7(+)) and effector (CD45RA-CCR7-) memory subsets. CD8(+) TILs tested uniformly positive for LAG-3 (about 100%), whereas CD4(+) TILs showed only up to 12% LAG-3(+) staining and PD-1 showed a broad expression pattern in TILs from different patients. TILs from individual patients recognized strongly (up to 11.9% and 8.2% in CD8(+)) NY-ESO-1, determined by ICS, or mesothelin, determined respectively by TNF-[alpha] and IFN-[gamma] production. Twelve of 17 of CD8(+) TILs showed preferential expansion of certain TCR V[beta] families (eg, 99.2% V[beta]13.2 in CD8(+) TILs, 77% in the V[beta]1, 65.9% in the V[beta]22, and 63.3% in the V[beta]14 family). TCR CDR3 analysis exhibited monoclonal or oligoclonal TCRs, some of them (eg, CD8(+) V[beta]13.2) reacting strongly against autologous tumor defined by INF-[gamma] production or by cytotoxicity. We have optimized methods for generating pancreatic cancer–specific TILs that can be used for adoptive cellular therapy of patients with pancreatic cancer.

14 Article Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). 2016

Jais, B / Rebours, V / Malleo, G / Salvia, R / Fontana, M / Maggino, L / Bassi, C / Manfredi, R / Moran, R / Lennon, A M / Zaheer, A / Wolfgang, C / Hruban, R / Marchegiani, G / Fernández Del Castillo, C / Brugge, W / Ha, Y / Kim, M H / Oh, D / Hirai, I / Kimura, W / Jang, J Y / Kim, S W / Jung, W / Kang, H / Song, S Y / Kang, C M / Lee, W J / Crippa, S / Falconi, M / Gomatos, I / Neoptolemos, J / Milanetto, A C / Sperti, C / Ricci, C / Casadei, R / Bissolati, M / Balzano, G / Frigerio, I / Girelli, R / Delhaye, M / Bernier, B / Wang, H / Jang, K T / Song, D H / Huggett, M T / Oppong, K W / Pererva, L / Kopchak, K V / Del Chiaro, M / Segersvard, R / Lee, L S / Conwell, D / Osvaldt, A / Campos, V / Aguero Garcete, G / Napoleon, B / Matsumoto, I / Shinzeki, M / Bolado, F / Fernandez, J M Urman / Keane, M G / Pereira, S P / Acuna, I Araujo / Vaquero, E C / Angiolini, M R / Zerbi, A / Tang, J / Leong, R W / Faccinetto, A / Morana, G / Petrone, M C / Arcidiacono, P G / Moon, J H / Choi, H J / Gill, R S / Pavey, D / Ouaïssi, M / Sastre, B / Spandre, M / De Angelis, C G / Rios-Vives, M A / Concepcion-Martin, M / Ikeura, T / Okazaki, K / Frulloni, L / Messina, O / Lévy, P. ·Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France. · The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy. · Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. · Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. · Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. · First Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan. · Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. · Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea. · Department of Surgery, Yonsei University College of Medicine, Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea. · Pancreatic Surgery Unit, Department of Surgery, Polytechnic University of Marche Region, Ancona-Torrette, Italy. · NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK. · Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, Padua, Italy. · Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy. · Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. · Hepato-Pancreato-Biliary Unit, Pederzoli Hospital, Peschiera del Garda, Italy. · Department of Gastroenterology, Hepatopancreatology and GI Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium. · Institute of Hepatopancreatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China. · Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. · Department of Pathology, Gyeongsang National University School of Medicine, Jinju, Korea. · Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK. · National Institute of Surgery and Transplantology named after Shalimov, Kiev, Ukraine. · Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden. · Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA. · Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. · Hôpital Privé Mermoz, Gastroentérologie, Lyon, France. · Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan. · Gastroenterology Department, Hospital de Navarra, Pamplona, Spain. · Department of Gastroenterology and Hepatology, University College Hospital, London, UK. · Department of Gastroenterology, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Barcelona, Spain. · Department of Pancreatic Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy. · Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia. · Radiological Department, General Hospital Cá Foncello, Treviso, Italy. · Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute, Milan, Italy. · Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea. · Department of Gastroenterology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia. · Department of Digestive Surgery, Timone Hospital, Marseille, France. · Gastrohepatology Department, San Giovanni Battista Molinette Hospital, University of Turin, Turin, Italy. · Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca-IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain. · The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan. · Department of Medicine, Pancreas Center, University of Verona, Verona, Italy. ·Gut · Pubmed #26045140.

ABSTRACT: OBJECTIVES: Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality. DESIGN: Retrospective multinational study including SCN diagnosed between 1990 and 2014. RESULTS: 2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1). CONCLUSIONS: After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN. TRIAL REGISTRATION NUMBER: IRB 00006477.

15 Article Outcome of probe-based confocal laser endomicroscopy (pCLE) during endoscopic retrograde cholangiopancreatography: A single-center prospective study in 45 patients. 2015

Löhr, Johannes-Matthias / Lönnebro, Ragnar / Stigliano, Serena / Haas, Stephan L / Swahn, Fredrik / Enochsson, Lars / Noel, Rozh / Segersvärd, Ralf / Del Chiaro, Marco / Verbeke, Caroline S / Arnelo, Urban. ·Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden. · Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden ; Department of Gastroenterology, La Sapienza University, Rome, Italy. ·United European Gastroenterol J · Pubmed #26668748.

ABSTRACT: BACKGROUND: Diagnosis of pre-malignant and malignant lesions in the bile duct and the pancreas is sometimes cumbersome. This applies in particular to intraductal papillary mucinous neoplasia (IPMN) and bile duct strictures in primary sclerosing cholangitis (PSC). AIMS: To evaluate in a prospective cohort study the sensitivity and specificity of probe-based confocal laser microscopy (pCLE) during endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We performed pCLE together with mother-baby endoscopy (SpyGlass) during 50 ERCP sessions in 45 patients. The Miami and Paris criteria were applied. Clinical diagnosis via imaging was compared to pCLE and the final pathological diagnosis from surgically-resected, biopsy, or cytology specimens. Patients were followed up for at least 1 year. RESULTS: We were able to perform pCLE in all patients. Prior to endoscopy, the diagnosis was benign in 23 patients and undetermined (suspicious) in 16 patients, while six patients had an unequivocal diagnosis of malignancy. Sensitivity was 91% and specificity 52%. The positive (PPV) and negative predictive value (NPV) was 82% and 100%, respectively. Apart from mild post-ERCP pancreatitis in two patients, no complications occurred. CONCLUSIONS: Our study showed that pCLE is a safe, expert endoscopic method with high technical feasibility, high sensitivity and high NPV. It provided diagnostic information that can be helpful for decisions on patient management, especially in the case of IPMN and unclear pancreatic lesions, in individuals whom are at increased risk for pancreatic cancer.

16 Article Cattell-Braasch Maneuver Combined with Artery-First Approach for Superior Mesenteric-Portal Vein Resection During Pancreatectomy. 2015

Del Chiaro, Marco / Segersvärd, Ralf / Rangelova, Elena / Coppola, Alessandro / Scandavini, Chiara Maria / Ansorge, Christoph / Verbeke, Caroline / Blomberg, John. ·Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden. marco.del.chiaro@ki.se. · Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden. · Department of Pathology, Karolinska Institute, Stockholm, Sweden. ·J Gastrointest Surg · Pubmed #26423804.

ABSTRACT: Pancreatectomy associated with superior mesenteric-portal vein (SMPV) resection is currently considered the standard of care for patients with pancreatic tumors involving the major peripancreatic veins. However, a standard approach for resection and reconstruction is not defined yet. The aim of this study is to analyze the feasibility and short-term results of an original Cattell-Braasch artery-first approach (CBAF) for the resection of SMPV during pancreatectomy. Of 144 pancreatectomies with vascular resection undertaken from 2008 to 2013 at Karolinska University Hospital, 45 (31.2 %) were performed combining a Cattell-Braasch maneuver with an artery-first approach (from 2011 to 2013). The mean patient age was 65.2 years. Thirty-seven (82.2 %) patients underwent pancreatoduodenectomy and 8 (17.8 %) total pancreatectomy. Histology showed pancreatic ductal adenocarcinoma in 42 patients (93.3 %). The median length of the resected SMPV segment was 4.6 cm (range 3-7). In all patients, a direct end-to-end anastomosis was performed without graft interposition. In nine cases (20 %), an arterial resection was also performed. There was no mortality in this series, and the morbidity rate was 35.5 %. Combined CBAF for the resection of SMPV during pancreatectomy seems to be safe and effective. The reconstruction of the resected vessels is possible in many cases without graft interposition, even if the resected vein segment is of considerable length.

17 Article Variant Profiling of Candidate Genes in Pancreatic Ductal Adenocarcinoma. 2015

Huang, Jiaqi / Löhr, Johannes-Matthias / Nilsson, Magnus / Segersvärd, Ralf / Matsson, Hans / Verbeke, Caroline / Heuchel, Rainer / Kere, Juha / Iafrate, A John / Zheng, Zongli / Ye, Weimin. ·Department of Medical Epidemiology and Biostatistics and. · Center for Digestive Diseases, Division of Surgery, CLINTEC, and. · Department of Biosciences and Nutrition and Center for Innovative Medicine (CIMED), Karolinska Institutet, Huddinge, Sweden; · Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Clinical Pathology/Cytology, Karolinska University Hospital, Stockholm, Sweden; · Department of Pathology, Massachusetts General Hospital, Boston, MA; · Department of Medical Epidemiology and Biostatistics and Department of Pathology, Massachusetts General Hospital, Boston, MA; Current address: Department of Biomedical Sciences, City University of Hong Kong, Hong Kong. zhengzongli@gmail.com weimin.ye@ki.se. · Department of Medical Epidemiology and Biostatistics and zhengzongli@gmail.com weimin.ye@ki.se. ·Clin Chem · Pubmed #26378065.

ABSTRACT: BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis. Variant profiling is crucial for developing personalized treatment and elucidating the etiology of this disease. METHODS: Patients with PDAC undergoing surgery from 2007 to 2012 (n = 73) were followed from diagnosis until death or the end of the study. We applied an anchored multiplex PCR (AMP)-based next-generation sequencing (NGS) method to a panel of 65 selected genes and assessed analytical performance by sequencing a quantitative multiplex DNA reference standard. In clinical PDAC samples, detection of low-level KRAS (Kirsten rat sarcoma viral oncogene homolog) mutations was validated by allele-specific PCR and digital PCR. We compared overall survival of patients according to KRAS mutation status by log-rank test and applied logistic regression to evaluate the association between smoking and tumor variant types. RESULTS: The AMP-based NGS method could detect variants with allele frequencies as low as 1% given sufficient sequencing depth (>1500×). Low-frequency KRAS G12 mutations (allele frequency 1%-5%) were all confirmed by allele-specific PCR and digital PCR. The most prevalent genetic alterations were in KRAS (78% of patients), TP53 (tumor protein p53) (25%), and SMAD4 (SMAD family member 4) (8%). Overall survival in T3-stage PDAC patients differed among KRAS mutation subtypes (P = 0.019). Transversion variants were more common in ever-smokers than in never-smokers (odds ratio 5.7; 95% CI 1.2-27.8). CONCLUSIONS: The AMP-based NGS method is applicable for profiling tumor variants. Using this approach, we demonstrated that in PDAC patients, KRAS mutant subtype G12V is associated with poorer survival, and that transversion variants are more common among smokers.

18 Article Short-term Results of a Magnetic Resonance Imaging-Based Swedish Screening Program for Individuals at Risk for Pancreatic Cancer. 2015

Del Chiaro, Marco / Verbeke, Caroline S / Kartalis, Nikolaos / Pozzi Mucelli, Raffaella / Gustafsson, Peter / Hansson, Johan / Haas, Stephan L / Segersvärd, Ralf / Andren-Sandberg, Åke / Löhr, J-Matthias. ·Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden. · Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden. · Division of Radiology, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden. · Department of Clinical Genetics, Karolinska Institute, Stockholm, Sweden. · Department of Onco-Pathology, Karolinska Institute, Stockholm, Sweden. · Department of Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden. ·JAMA Surg · Pubmed #25853369.

ABSTRACT: IMPORTANCE: Pancreatic cancer is the fourth leading cause of cancer-related death in Western countries. In approximately 10% of all patients with pancreatic cancer, it is possible to define a positive family history for pancreatic cancer or for one of the other related genetic syndromes. A screening program for individuals at risk is recommended; however, surveillance modalities have not been defined yet. OBJECTIVE: To analyze the short-term results of a prospective clinical surveillance program for individuals at risk for pancreatic cancer using a noninvasive magnetic resonance imaging (MRI)-based screening protocol. DESIGN, SETTING AND PARTICIPANTS: A prospective observational study of all patients with a genetic risk for developing pancreatic cancer who were referred to Karolinska University Hospital between January 1, 2010, and January 31, 2013, using an MRI-based surveillance program. All patients were investigated for the most common genetic mutations associated with pancreatic cancer. EXPOSURE: A noninvasive MRI-based screening protocol. MAIN OUTCOMES AND MEASURES: The ability of MRI to identify potential precancerous or early cancers in individuals at risk for pancreatic cancer. RESULTS: Forty patients (24 women and 16 men) were enrolled. The mean age was 49.9 years. The mean length of follow-up was 12.9 months. The numbers of relatives affected by pancreatic cancer were 5 in 2 patients (5%), 4 in 5 patients (12.5%), 3 in 17 patients (42.5%), 2 in 14 patients (35%), and 1 in 2 patients (5%). In 4 patients (10%), a p16 mutation was found; in 3, a BRCA2 mutation (7.5%); and in 1, a BRCA1 mutation (2.5%). In 16 patients (40%), MRI revealed a pancreatic lesion: intraductal papillary mucinous neoplasia (14 patients, 35%) and pancreatic ductal adenocarcinoma (2 patients, 5%). One patient had a synchronous intraductal papillary mucinous neoplasia and pancreatic ductal adenocarcinoma. Five patients (12.5%) required surgery (3 for pancreatic ductal adenocarcinoma and 2 for intraductal papillary mucinous neoplasia), while the remaining 35 are under continued surveillance. CONCLUSIONS AND RELEVANCE: During a median follow-up of approximately 1 year, pancreatic lesions were detected in 40% of the patients, of whom 5 underwent surgery. Although the study time was relatively short, the surveillance program in individuals at risk seems to be effective.

19 Article Association between pancreatic intraductal papillary mucinous neoplasms and extrapancreatic malignancies. 2015

Marchegiani, Giovanni / Malleo, Giuseppe / D'Haese, Jan G / Wenzel, Patrick / Keskin, Muharrem / Pugliese, Luigi / Borin, Alex / Benning, Valentina / Nilsson, Linda / Oruc, Nevin / Segersvard, Ralf / Friess, Helmut / Schmid, Roland / Löhr, Matthias / Maisonneuve, Patrick / Bassi, Claudio / Ceyhan, Güralp O / Salvia, Roberto / Del Chiaro, Marco. ·Unit of Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. Electronic address: giovanni.marchegiani@ospedaleuniverona.it. · Unit of Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. · Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany. · Department of Gastroenterology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany. · Division of Gastroenterology, Department of Internal Medicine, Ege University, Izmir, Turkey. · Unit of General Surgery 2, Department of Surgery, IRCCS Policlinico San Matteo, Pavia, Italy. · Division of Surgery, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden. · Division of Gastroenterology, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden. · Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy. ·Clin Gastroenterol Hepatol · Pubmed #25478920.

ABSTRACT: BACKGROUND & AIMS: The association between pancreatic intraductal papillary mucinous neoplasms (IPMNs) and extrapancreatic neoplasms (EPNs) is controversial. We performed a multicenter observational study to assess the incidence of EPNs after an IPMN diagnosis. METHODS: 1340 patients with IPMNs were evaluated from 2000 through 2013 at 4 academic institutions in Europe for development of EPN. To estimate the actual incidence of EPN, we excluded patients with an EPN previous or synchronous to the IPMN, and patients who had been followed for less than 12 months, resulting in a study population of 816 patients. The incidence of EPN was compared with sex-specific, age-adjusted European cancer statistics; the standardized incidence ratio (SIR), and the 5- and 10-year cumulative incidence rates were calculated. RESULTS: A total of 290/1340 patients had a history of EPN (prevalence of 21.6%). In this subgroup of patients, the IPMN was discovered incidentally in 241. Among the 816 patients included in the incidence analysis, 50 developed an EPN after a median time of 46 months from study enrollment. The incidence of any EPN was not greater in patients with than without IPMN with a SIR of 1.48 (95% confidence interval, 0.94-2.22) in males and of 1.39 (95% CI 0.90-2.05) in females. The 5- and 10-year cumulative incidence rates for development of EPN in patients with IPMN were 7.9% and 16.6% in men, and 3.4% and 23.1% in women. CONCLUSIONS: Patients with IPMN do not have a significantly higher incidence of EPNs than the general European population. It might not be necessary to screen patients with IPMN for EPN.

20 Article Single-operator pancreatoscopy is helpful in the evaluation of suspected intraductal papillary mucinous neoplasms (IPMN). 2014

Arnelo, Urban / Siiki, Antti / Swahn, Fredrik / Segersvärd, Ralf / Enochsson, Lars / del Chiaro, Marco / Lundell, Lars / Verbeke, Caroline S / Löhr, J-Matthias. ·Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden. Electronic address: urban.arnelo@ki.se. · Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden; Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland. · Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden. · Division of Pathology, Dept. of Laboratory Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden. ·Pancreatology · Pubmed #25287157.

ABSTRACT: BACKGROUND AND OBJECTIVE: Even when advanced cross-sectional imaging modalities have been employed, endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMN) is often required in order to assess the final character and extent of lesions. The current study addresses the use of SpyGlass single-operator peroral pancreatoscopy in suspected IPMN. DESIGN: A prospective, non-randomized exploratory cohort study. SETTING: Single-center. PATIENTS AND INTERVENTION: A prospective study-cohort of 44 consecutive patients in a single tertiary referral center who underwent ERCP and peroral pancreatoscopy, was prospectively collected between July 2007 and March 2013 because of a radiological signs of IPMN. These IPMN-findings were discovered incidentally in 44% of the cases. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy (specificity & sensitivity) and complications. RESULTS: The targeted region of the pancreatic duct was reached with the SpyGlass system in 41 patients (median age 65 years, 41% female). Three patients were excluded from analysis because of failed deep cannulation of the pancreatic duct. Brush cytology was taken in 88% and direct biopsies in 41%. IPMN with intermediate or high-grade dysplasia was the main final diagnosis (76%) in 22 patients who had surgery. Out of the 17 patients with a final diagnosis of MD-IPMN, 76% were correctly identified by pancreatoscopy. Of the 9 patients with a final diagnosis of BD-IPMN, the pancreatoscopy identified 78% of the cases correctly.The incidence of post-ERCP pancreatitis was 17%. Pancreatoscopy was found to have provided additional diagnostic information in the vast majority of the cases and to affect clinical decision-making in 76%. LIMITATIONS: Single-center study. CONCLUSIONS: Single-operator peroral pancreatoscopy contributed to the clinical evaluation of IPMN lesions and influenced decision-making concerning their clinical management. The problem of post-procedural pancreatitis needs further attention.

21 Article Comparison of preoperative conference-based diagnosis with histology of cystic tumors of the pancreas. 2014

Del Chiaro, Marco / Segersvärd, Ralf / Pozzi Mucelli, Raffaella / Rangelova, Elena / Kartalis, Nikolaos / Ansorge, Christoph / Arnelo, Urban / Blomberg, John / Löhr, Matthias / Verbeke, Caroline. ·Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden, marco.del-chiaro@karolinska.se. ·Ann Surg Oncol · Pubmed #24385209.

ABSTRACT: BACKGROUND: Diagnostic errors in the evaluation of cystic neoplasms of the pancreas (PCNs) are quite common. Few data are available regarding the impact of these errors on clinical management. The aim of this study was to determine the accuracy of a pancreatic multidisciplinary conference in diagnosing PCNs, to assess the potential risk of misdiagnosis, and to evaluate the clinical impact of these errors. METHODS: A retrospective consecutive series of patients undergoing surgery for PCNs at Karolinska University Hospital between 2004 and 2012 was analyzed. RESULTS: During the study period, a total of 141 patients had undergone pancreatic resection for PCN. The overall accuracy of the preoperative diagnosis was 60.9 %. The rate of concordance between preoperative diagnosis and histology was similar for asymptomatic and symptomatic lesions (62.8 vs. 59.1 %; p = NS). The rate of correct diagnosis increased over time (54.5 % in 2004-2006, 61.7 % in 2007-2012, 63.5 % in 2010-2012). Univariate analysis identified the location of the lesion (diffuse pancreatic involvement) and a mucinous nature of the lesion as factors conducive to a correct diagnosis. Reevaluation of the original indication for surgery in light of the exact diagnosis showed that a surgical procedure should not have been performed in 12 patients (8.5 %). CONCLUSIONS: This study confirms that diagnostic errors are fairly common in the preoperative assessment of PCNs, but the errors are clinically relevant in <10 % of patients.

22 Article Is intraductal tubulopapillary neoplasia a new entity in the spectrum of familial pancreatic cancer syndrome? 2014

Del Chiaro, Marco / Mucelli, Raffaella Pozzi / Blomberg, John / Segersvärd, Ralf / Verbeke, Caroline. ·Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden, marco.del-chiaro@karolinska.se. ·Fam Cancer · Pubmed #24317685.

ABSTRACT: We report on a 78-year old male with a positive family history for pancreatic cancer, who underwent total pancreatectomy for a suspected intraductal papillary mucinous neoplasm with extensive involvement of the main pancreatic duct and multiple branch ducts. The post operative course was uneventful. Macroscopic examination of the specimen revealed multiple solid non-mucinous tumour nodules throughout the main pancreatic duct and within multiple branch ducts. The microscopic appearance of the tumour, in particular its tubulopapillary growth pattern and immunohistochemical mucin profile (MUC1, MUC6 positive; MUC2, MUC5AC negative) were consistent with intraductal tubulopapillary neoplasia (ITPN) showing high-grade dysplasia. No evidence of stromal invasion was identified. To the best of our knowledge, this is the first report on ITPN in a high-risk patient based on a history of familial pancreatic cancer (FPC). The potential association between this entity and the spectrum of neoplastic lesions in FPC should be investigated with particular consideration of the lower biological aggressiveness of ITPN.

23 Article Diagnostic value of abdominal drainage in individual risk assessment of pancreatic fistula following pancreaticoduodenectomy. 2014

Ansorge, C / Nordin, J Z / Lundell, L / Strömmer, L / Rangelova, E / Blomberg, J / Del Chiaro, M / Segersvärd, R. ·Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden. ·Br J Surg · Pubmed #24306817.

ABSTRACT: BACKGROUND: The use of prophylactic abdominal drainage following pancreaticoduodenectomy (PD) is controversial as its therapeutic value is uncertain. However, the diagnosis of postoperative pancreatic fistula (POPF), the main cause of PD-associated morbidity, is often based on drain pancreatic amylase (DPA) levels. The aim of this study was to assess the predictive value of DPA, plasma pancreatic amylase (PPA) and serum C-reactive protein (CRP) for diagnosing POPF after PD. METHODS: Patients undergoing PD with prophylactic drainage between 2008 and 2012 were studied prospectively. DPA, PPA and CRP levels were obtained daily. Differences between groups with clinically relevant POPF (International Study Group on Pancreatic Fistula (ISGPF) grade B/C) and without clinically relevant POPF (no POPF or ISGPF grade A) were evaluated. Receiver operating characteristic (ROC) analyses were performed to determine the value of DPA, PPA and CRP in prediction of POPF. Risk profiles for clinically relevant POPF were constructed and related to the intraoperative pancreatic risk assessment. RESULTS: Fifty-nine (18.7 per cent) of 315 patients developed clinically relevant POPF. DPA, PPA and CRP levels on postoperative day (POD) 1-3 differed significantly between the study groups. In predicting POPF, the DPA level on POD 1 (cut-off at 1322 units/l; odds ratio (OR) 24.61, 95 per cent confidence interval 11.55 to 52.42) and POD 2 (cut-off at 314 units/l; OR 35.45, 14.07 to 89.33) was superior to that of PPA on POD 1 (cut-off at 177 units/l; OR 13.67, 6.46 to 28.94) and POD 2 (cut-off at 98 units/l; OR 16.97, 8.33 to 34.59). When DPA was combined with CRP (cut-off on POD 3 at 202 mg/l; OR 16.98, 8.43 to 34.21), 90.3 per cent of postoperative courses could be predicted correctly (OR 44.14, 16.89 to 115.38). CONCLUSION: The combination of serum CRP and DPA adequately predicted the development of clinically relevant pancreatic fistula following PD.

24 Article Computed tomography staging of pancreatic cancer: a validation study addressing interobserver agreement. 2013

Loizou, L / Albiin, N / Ansorge, C / Andersson, M / Segersvärd, R / Leidner, B / Sundin, A / Lundell, L / Kartalis, N. ·Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, 14186 Stockholm, Sweden; Department of Radiology, Karolinska University Hospital, Huddinge, 14186 Stockholm, Sweden. ·Pancreatology · Pubmed #24280571.

ABSTRACT: BACKGROUND/OBJECTIVES: Ductal adenocarcinoma in the head of the pancreas (PDAC) is usually unresectable at the time of diagnosis due to the involvement of the peripancreatic vessels. Various preoperative classification algorithms have been developed to describe the relationship of the tumor to these vessels, but most of them lack a surgically based approach. We present a CT-based classification algorithm for PDAC based on surgical resectability principles with a focus on interobserver variability. METHODS: Thirty patients with PDAC undergoing pancreaticoduodenectomy were examined by using a standard CT protocol. Nine radiologists, representing three different levels of expertise, evaluated the CT examinations and the tumors were classified into four categories (A-D) according to the proposed system. For the interobserver agreement, the Intraclass Correlation Coefficient (ICC) was estimated. RESULTS: The overall ICC was 0.94 and the ICCs among the trainees, experienced radiologists, and experts were 0.85, 0.76, and 0.92, respectively. All tumors classified as category A1 showed no signs of vascular invasion at surgery. In category A2, 40% of the tumors had corresponding infiltration and required resection of the superior mesenteric vein/portal vein (SMV/PV). One of two tumors in category B2 and two of three in category C required SMV/PV resection. All six patients in category D had both arterial and venous involvement. CONCLUSION: There is almost perfect agreement among radiologists with different levels of expertise in regards to the local staging of PDAC. For tumors in a more advanced preoperative category, an increased risk for vascular involvement was noticed at surgery.

25 Article Enucleation of branch duct-IPMN in a transplant patient. 2013

Del Chiaro, Marco / Albiin, Nils / Segersvärd, Ralf. ·Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden. marco.del-chiaro@karolinska.se ·Pancreatology · Pubmed #23858563.

ABSTRACT: -- No abstract --

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