Clinical Case Summary

A 70-year-old patient with diabetes mellitus and cholecystectomy performed six months earlier was admitted to the emergency department for generalized abdominal pain, hyporexia and weight loss.
An abdominal CT scan showed a solid-cystic pancreatic lesion suggestive of mucinous neoplasia, together with peritoneal nodules in the right paracolic gout. In view of the suspicion of malignancy, an echoendoscopy with fine needle aspiration puncture (EUS-FNA) was performed, identifying an irregular lesion with heterogeneous and hypovascular ultrastructure in the pancreatic neck-body and a discrete dilatation of the main pancreatic duct. Finally, the histological study didn´t show neoplastic cells.
Suddenly the patient experienced a clinical worsening with severe pain and high fever. Laboratory tests showed a progressive increase in C-reactive protein and leukocytosis with left shift. In a control CT scan, a reduction in the size of the pancreatic lesion is observed, together with an increase in the peritoneal lesions which present a polyglobulated contour, hypercapillary margins and rarefaction of the surrounding fat. These finding suggesting the presence of peritoneal abscesses secondary to dropped gallstones. After broad-spectrum antibiotic therapy, the intra-abdominal abscesses improved radiologically, but the collection persisted in the right posterior pararenal space which was drained under ultrasound control with subsequent disappearance of fever and normalization of analytical parameters.
Dropped gallstones occur in approximately 7% of cholecystectomies. The secondary granulomatous reaction in paucisymptomatic patients can simulate peritoneal tumor processes in imaging tests, being one of the adverse effects described in relation to this pathology. In our case, the concomitant presence of peritoneal lesions together the pancreatic lesion oriented the initial case as a malignant process; however, the patient's evolution were key to the final diagnosis.

Introduction

Pancreatic cancer (PC) screening can improve survival in high-risk patients by detecting preneoplastic lesions or early-stage tumors.
Surveillances is mainly based on annual magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS). However, little has been described regarding the possibility of finding other morphological changes that may be also important.

Aims & Methods

The aim of the study is to evaluate all the findings described in screening test and to analyze the correlation between these two screening techniques.
Descriptive observational single-center study that includes high-risk PC patients either due to family history (familial pancreatic cancer) or because they belong to hereditary syndromes, who have been undergone pancreatic cancer screening at our center from 2015 to 2023. Demographic variables and findings described in the EUS or MRI were collected.

Results

Thirty-five patients were included, with a mean age of 57.3 ± 8.2 years and a predominance of females (65.7%). Four patients (11.4%) were smokers, two were diabetic (5.7%), and one had a history of chronic pancreatitis (2.9%). The median follow-up time was 23 months (interquartile range 8-59 months).
The most frequent hereditary syndrome was hereditary breast and ovarian cancer syndrome (n=19, 54.3%), followed by familial atypical multiple mole melanoma syndrome (n=4; 11.4%). The BRCA2 mutation was the most common identifiable genetic factor (34.8%).
Regarding screening test findings, solid tumors were detected in three patients (8.6%) (Two stage I and IV adenocarcinomas and one stage I neuroendocrine tumor). In two individuals (5.7%) branch-duct intraductal papillary mucinous neoplasm were observed. Other pancreatic abnormalities were detected in 18 patients (51.4%) that include chronic pancreatitis-like parenchymal changes (34.3%), peripancreatic lymph nodes and fatty pancreas (5.7%). Finally, in 12 patients (34.3%) the screening tests were normal.
In relation to the concordance between MRI and EUS, in ten patients (28.6%) there was no agreement between these two techniques. EUS detected more parenchymal changes (n=5), pancreatic steatosis (n=2) and one neuroendocrine tumor that were not described on MRI. In contrast, MRI detected a cystic lesion and a pseudonodular enhancement that were not found on EUS.

Conclusion

Pancreatic cancer screening in high-risk individuals, detects neoplastic and preneoplastic lesions at a high rate.
Other findings, such as chronic pancreatitis-like parenchymal changes, peripancreatic lymph nodes or fatty pancreas, were also common in these patients
MRI and EUS have a good correlation, but EUS detects more parenchymal changes.

References

1. Goggins M, Overbeek KA, Brand R et al. Management of patients with increased risk for familial pancreatic cancer: updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium. Gut 2020; 69 (1): 7-17
2. Bogdanski AM, van Hooft JE, Boekestijn B, Bonsing BA, Wasser MNJM, Klatte DCF, van Leerdam ME. Aspects and outcomes of surveillance for individuals at high‑risk of pancreatic cancer. Fam Cancer 2024; 23(3):323-339.
3. Blackford AL, Canto MI, Dbouk M, Hruban RH, Katona BW, Chak A et al. Pancreatic Cancer Surveillance and Survival of High-Risk Individuals. JAMA Oncol. 2024;10(8):1087-1096.
4. Maurer E, Lehman B, Matthäi E, Denzer U, Figiel J, Jseinghaus M et al. Pancreatic cancer screening is effective in individuals at risk with predisposing germline gene variants, but not in gene variant‐negative familial pancreatic cancer families. United European Gastroenterol J 2024; 12 (9): 1211-1221

Introduction

Intestinal ultrasound (IUS) is an increasingly valuable, non-invasive imaging tool for assessing inflammatory bowel diseases (IBD). IUS training remains a significant challenge due to the need for hands-on experience and expert supervision. Traditional training programs offer limited hands-on training, restricting the competency level of trainees. To address this gap, we developed the IUS MindsView system, an innovative tele-ultrasound and augmented reality (AR) platform designed to provide real-time remote supervision and extend hands-on IUS training.

Aims & Methods

This study aimed to evaluate the feasibility and effectiveness of the system in improving trainee competency. The IUS MindsView system integrates AR glasses, real-time ultrasound streaming, and remote annotation capabilities to facilitate interactive, long-distance training. The system was deployed in two hospitals, where one trainee at each site performed IUS examinations under remote expert guidance. Over five supervised training sessions, each lasting up to two hours, trainees scanned 3-4 patients per session. The remote expert provided live feedback on probe positioning and ultrasound image interpretation through the MindsView ARNet platform, ensuring accurate imaging and anatomical identification.

Results

Both trainees completed the full 10-hour training program and reported high satisfaction with the system. They particularly appreciated the real-time expert annotations, the interactive nature of the training, and improved precision in probe handling. By the end of the study, both trainees demonstrated significant improvement in identifying bowel wall thickness, vascularity, and other key IUS parameters. They also expressed confidence in applying their newly acquired skills independently in clinical practice.

Conclusion

The system presents a scalable and accessible solution to address current limitations in IUS education, potentially reducing the need for prolonged on-site training at specialized centers. Additionally, its potential applications in telemedicine could enhance IBD patient care, particularly in remote or resource-limited settings.

Disclosure

AbbVie sponsored the project; contributed to the ideation, characterization, adaptation and the design; in writing, reviewing, and approval of the final version. No honoraria or payments were made for authorship.
Prof. Dan Carter has served as a consultant to AbbVie and has received research funding and speaker fees from AbbVie.
Dr. Tamar Thurm has received consulting and speaker fees from AbbVie.
Dr. Bernardo Melamud has received consulting and speaker fees from AbbVie.
Gabriel Dan has no conflict of interest.
Dr. Assaf Halperin and Dr. Shiran Naftelberg Blonder are employees of AbbVie and may own AbbVie stock.

Introduction

The rising number of patients with intraductal papillary mucinous neoplasms (IPMNs) in countries with aging populations in the near future is predictable considering that the incidence of pancreatic cystic tumors is positively correlated with patient age and that IPMNs occur most frequently among multifocal pancreatic cystic tumors. Although the majority of IPMNs detected incidentally through various imaging tests have a tumor diameter ≤10 mm and are thus deemed low-risk for carcinogenesis, the possibility of malignant transformation persists. Thus, such IPMNs are subject to periodic follow-up diagnostic imaging. Therefore, an appropriate surveillance system must be established to effectively and efficiently identify cases of IPMN-related malignant transformation, which develops only in few IPMN cases, under the constraints of limited national healthcare funding.

Aims & Methods

In the current study, we analyzed the clinical background observed at initial patient presentation that affect long-term prognosis and tried to narrow the population for whom continued evaluation is inevitable. The study included 1645 patients with IPMNs (776 men and 869 women) treated at our hospital since 2010. We examined the types and timing of medical intervention (surgical resection or pancreatic carcinogenesis) selected mainly in terms of worrisome features (WF) as advocated by the international guidelines (Pancreatology, 2024:24;255–70) for IPMN treatment. Statistical analysis was performed using the chi-square test, log-rank test, and Cox proportional hazards model, with statistical significance set at α = 0.05.

Results

During the entire observation period, 123 patients (7.5%) had IPMN-derived carcinoma (IPMN-DC), whereas 41 patients (2.5%) had concomitant pancreatic ductal adenocarcinoma (PDAC), which required medical intervention. The proportion of cases with c-Stage I, II, III, and IV (UICC 8th edition) at the time of diagnosis were 52.0%, 43.9%, 0.8%, and 3.3%, respectively, for IPMN-DC and 39.0%, 31.7%, 9.8%, and 19.5%, respectively for PDAC. A significantly higher proportion of PDAC cases were diagnosed with an advanced disease stage that developed earlier in time. Factors with significantly shorter time for IPMN-DC medical intervention were: maximum cyst diameter ≥30 mm, non-branched type, main pancreatic duct diameter ≥5 mm, and septal nodal structure for IPMN-DC. For PDAC, these factors were maximum cyst diameter ≥30 mm, main duct type, main pancreatic duct diameter ≥5 mm, septal nodal structure, cyst enlargement (≥2.5 mm/year), and abnormally high levels of CA19-9. Both groups could be significantly stratified by the number of WFs. However, the difference was more distinct in IPMN-DC, whereas <1% (9/1190) medical intervention from the group with 0 WFs was noted in PDAC. Relative risk (hazard ratio, HR) analysis of WF in which proportional hazard was maintained revealed that the presence of septal nodular structure (HR 5.2), maximum cyst diameter ≥30 mm (HR 3.3), and main pancreatic duct diameter ≥5 mm (HR 2.6) were significant factors for IPMN-DC, whereas abnormally high CA19-9 levels (HR 5.0) and septal nodular structure (HR 4.8) were significant for PDAC. Conversely, a significantly higher percentage of patients who exhibited these factors at initial presentation also later developed IPMN-DC or PDAC.

Conclusion

Ten percent of IPMN cases will develop IPMN-DC or PDAC, thereby requiring careful follow-up, especially in cases with septal nodules, abnormally high CA19-9 levels, and cysts with a maximum diameter of ≥30 mm.

Introduction

Gastric cancer remains one of the leading causes of death internationally and a major health concern in the United States (US). To develop better prevention strategies, this study quantifies trends in gastric cancer related mortality, stratified by age, sex, region, urbanity, and race over two decades.

Aims & Methods

Our study used the CDC WONDER database to analyze death certificates from 1999 to 2022 across the U.S. ICD codes C16.0-C16.9 were used to identify the relevant cases. Demographic variables such as sex, race, age, urban-rural classification, and census regions were analyzed. Trends in AAMR were assessed using the Joint Point Regression Program to determine annual percentage changes (APC).

Results

Overall mortality related to malignant stomach neoplasms in the US declined significantly (Table 1) from 79.26 (1999) to 44.81 (2022), with notable periods of steep decrease between 1999–2006 (APC -3.51, 95% CI: -5.16 to -2.78) and 2006–2018 (APC -2.27, 95% CI: -3.55 to -1.83). Men consistently exhibited higher mortality rates than women (overall men: 81.14 vs women: 42.10). Men experienced an initial significant drop from 113.45 to 78.68 (1999–2009, APC -3.55), followed by a slower decrease till 2022 (APC -2.22). Women's mortality showed an initial sharp decline (1999–2008, APC -3.11), then a modest reduction from 2008–2018 (APC -1.96), plateauing thereafter.

Racially, Non-Hispanic (NH) Black individuals exhibited the highest mortality (109.37), followed by NH Asians/Pacific Islanders (102.47), Hispanic/Latino (91.93), NH American Indian/Alaskan Natives (78.21), and NH White (44.85). NH Blacks demonstrated a marked initial decrease (159.46 to 119.13 by 2017) then plateaued. NH Whites showed a continuous decline (1999–2018), slowing post-2018. Hispanics had two significant declining periods (1999–2011, APC -2.82; 2011–2022, APC -1.56), whereas NH Asians and NH American Indians steadily declined throughout.

Mortality by age was highest among older adults (202.46), followed by middle-aged (60.58) and young adults (40.55). Older adults had two notable decreasing phases (1999–2009, APC -3.56; 2009–2018, APC -2.89), with slower decline afterward. Middle-aged adults showed an initial steep decline (1999–2005, APC -3.65), followed by gradual reduction (2005–2022, APC -0.79). Young adults exhibited minimal, non-significant declines throughout.

Regionally, the Northeast showed highest mortality (64.78), followed by West, South, and Midwest. Both metropolitan and non-metropolitan areas saw significant mortality reductions, with non-metropolitan areas consistently having higher rates overall.

Table 1. Annual Percent Change (APC) in mortality rates by selected demographics, 1999–2022.
APC values are presented with 95% confidence intervals (CI). Asterisk (*) indicates statistically significant APC values (p < 0.05).

Conclusion

Gastric carcinoma has poor prognosis, and although the general trend is decreasing across all socio-demographic areas, further research is required for targeted interventions and health policies for populations at high risk of dying.

References

1. Stahl KA, Olecki EJ, Dixon ME, et al. Gastric cancer treatments and survival trends in the United States. Current Oncology. 2020;28(1):138-151. doi:10.3390/curroncol28010017
2. Kumar RK, Raj SS, Shankar EM, Ganapathy E, Ebrahim AS, Farooq SM. Gastric carcinoma: a review on epidemiology, current surgical and chemotherapeutic options. Gastric Carcinoma-New Insights into Current Management. 2013/1/13 2013;12doi:10.5772/52138
3. Li C, Chen D, Yang H. Trends in incidence, survival and mortality of gastric cancer in the United States: a population-based study, 2001-2015. Asian Pacific Journal of Cancer Prevention: APJCP. 2023;24(6):2011-2020. doi:10.31557/APJCP.2023.24.6.2011
4. Hudler P, Komel R. Clinical Implications of Molecular Heterogeneity of Gastric Cancer. Gastric Cancer. 2017/9/20 2017;doi:10.5772/intechopen.69775
5. Ali H, Ishtiaq R, Tedder B, et al. Trends in mortality from gastrointestinal, hepatic, and pancreatic cancers in the United States: A comprehensive analysis (1999–2020). JGH Open. 2024;8(4):e13064. doi: 10.1002/jgh3.13064

Disclosure

No conflicts of interest to disclose.

Introduction

The PAN-PROMISE symptom score is the first patient-reported outcome (PROM) in acute pancreatitis (AP), and it was developed and validated in a prospective cohort of patients to be used as an endpoint in research. The aim of this study was to assess the performance of the score in a large randomized controlled trial (RCT) and its association with well-established AP endpoints.

Aims & Methods

This is an ancillary study of the WATERFALL trial, where PAN-PROMISE was evaluated at baseline, 24, 48 and 72 hours. The study examined the association between PAN-PROMISE with stablished endpoints in AP: severity, pancreatic and/or peripancreatic fat necrosis (necrosis), infected necrosis, intensive care unit (ICU) admission, persistent organ failure (POF), prolonged hospital stay and mortality. Areas under the ROC curve (AUC) were calculated and used to compare baseline PAN-PROMISE and baseline Bedside Index for Severity in AP (BISAP) for the prediction of these endpoints.

Results

248 patients from the WATERFALL trial were included. A statistically significant association was found between PAN-PROMISE and severity, necrosis, POF, ICU admission, and prolonged hospital stay at all checkpoints (p<0.05). Higher scores were also significantly associated with infected pancreatic necrosis at 24, 48, and 72h and death at baseline and 24 hours. PAN-PROMISE baseline score had a higher AUC than BISAP for severity and necrosis, but the results were not statistically significant.

Conclusion

In the context of a RCT, the PAN-PROMISE score, a patient-centered measure, has been validated with established AP outcomes and as an endpoint for future clinical trials.