Antwi, Stella K Adjei

BACKGROUND: The first total pancreatectomy (TP) resulting in survival past the immediate postoperative period was performed at Mayo Clinic in 1944. Although still uncommonly performed, indications have recently fluctuated. We aimed to evaluate trends in TP use and outcomes over four decades. STUDY DESIGN: Patients who underwent single-stage TP at Mayo Clinic Rochester from 1988 to 2024 were analyzed in two cohorts: early era (EE, 1988 to 2009) and modern era (ME, 2010 to 2024). RESULTS: In total, 437 patients were identified: 118 during EE (mean 8 per year) and 319 during ME (mean 21 per year). Primary indications were adenocarcinoma (42% EE vs 60% ME), intraductal papillary mucinous neoplasm (31% EE vs 17% ME), and chronic pancreatitis (11% EE vs 13% ME; p < 0.001). Concurrent vascular resection was performed in 9.3% (EE; all venous only) vs 53% (ME; venous alone in 20% and arterial with or without venous in 33%; p < 0.001). Multivisceral resection was performed in <1% (EE) vs 24% (ME; p < 0.001). Major complications occurred in 13% (EE) vs 27% (ME; p = 0.018), and 90-day mortality was 3.4% (EE) vs 6.3% (ME; p = 0.35). For adenocarcinoma, 5-year median overall survival from both surgery and diagnosis was significantly improved in ME (p = 0.009 and p < 0.001, respectively). Median last HbA1c was 7.7 (EE) vs 7.3 (ME; p < 0.001). Among patients surviving more than 1 year, insulin pumps were used in 12% (EE) vs 49% (ME; p < 0.001). Conclusions: The use of TP has dramatically increased in recent years, primarily for adenocarcinoma alongside increased use of neoadjuvant therapy and ever-expanding criteria for anatomic resectability. Operative complexity has significantly increased with resultant increased perioperative morbidity. TP remains a higher-risk procedure, specifically with en bloc vascular resections, emphasizing the importance of appropriate patient selection, preoperative patient education, and thoughtful postoperative and long-term management.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive and lethal malignancy. Surgical resection is the only curative modality combined with neoadjuvant chemotherapy to improve survival. Given the limitations of traditional responses such as cross-sectional imaging (CT/MRI) or tumor markers, carbohydrate antigen 19-9 (CA19-9), the 2023 National Comprehensive Cancer Network guidelines included 18F-fluorodeoxyglucose (FDG)-PET as an adjunct to assess response to neoadjuvant chemotherapy. There are common misconceptions on the metabolic activity (tumor avidity) in PDAC so we aimed to describe the baseline characteristics and use of FDG-PET in a cohort of treatment-naive patients with PDAC. STUDY DESIGN: A single-center retrospective study was conducted capturing all biopsy-proven, treatment-naive patients with PDAC who underwent either baseline FDG-PET/CT or FDG-PET/MRI imaging between 2008 and 2023. Baseline FDG-PET characteristics were collected, including primary tumors’ maximum standardized uptake value defined as metabolic activity (FDG uptake) of tumor compared with surrounding pancreatic parenchymal background, and the identification of extrapancreatic metastatic disease. RESULTS: We identified 1,095 treatment-naive patients with PDAC who underwent baseline FDG-PET imaging at diagnosis. CA19-9 was elevated in 76% of patients. Overall, 96.3% (1,054) of patients had FDG-avid tumors with a median maximum standardized uptake value of 6.4. FDG-PET also identified suspicious extrapancreatic metastatic lesions in 50% of patients, with a higher proportion (p < 0.001) in PET/MRI (59.9%) vs PET/CT (44.3%). After controlling for CA19-9 elevation, PET/MRI was superior in detection of extrapancreatic lesions compared with PET/CT. CONCLUSIONS: FDG-PET has significant use in PDAC as a baseline imaging modality earlier neoadjuvant therapy given the majority of tumors are FDG-avid. FDG-PET can identify additional extrapancreatic suspicious lesions allowing for optimal initial staging, with PET/MRI having increased sensitivity over PET/CT.