2018 Caper Pancreas Academy and PancreasFest

July 25, 2018 – July 27, 2018

Day One Caper Academy

Primer: Anatomy, Physiology, and Function of the Pancreas, Aatur Singhi, MD, PhD, University of Pittsburgh, Medical Center

Effective Primer. Comprehensive evolution to acute pancreatitis in his explanation and pictures. Differences of chronic versus acute also meaningful. The emerging of pancreatic cancer and adenocarcinomas well presented. Endocrine carcinomas also a good explanation of the differences between the tumor type. Take Home Points also an excellent restating of key points. Comprehensive for an experience patient.

Overview of Acute Pancreatitis: presentation, Diagnosis, Severity and Course, Peter Lee, MD, Fellow

Interesting comments on the overuse of CT scan in diagnosis. Also interesting differentiation of labs to determine pancreatitis etiologies. ER, GI, and hospitalist docs need uniform education on these topics across the country. Dr. Lee said that when there is not an alcoholic etiology, then genetic sources must be examined. This is so important for doctors to know so that they are not prolonging diagnosis and monitoring pseudocyst as something actionable versus just monitoring.  The nuances of studies and labs that differentiate the acuity of what the patient is dealing with is specialized knowledge that all doctors need to know.

Overview of Chronic Pancreatitis: Presentation, Diagnosis, Course, Anna Evans Phillips, MD, Instructor of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center

Effective imaging slides and explanation. Panel of tests routinely done for potential genetic etiologies are so purposeful and important. The specificity of these tests and their relation to chronic pancreatitis need to be parlayed to physicians throughout the country. Early chronic pancreatitis offers great opportunity for intervention but with the inconsistent testing/diagnostics at the non-tertiary care facilities – the clinicians just don’t know what to look for and what it means. Pancreatic endocrine dysfunction is known as type 3c Diagnoses with a prevalence of 25-80%. A lot of physicians have never heard of type 3c diabetes. The intervention section addressed drinkers and smokers – I am not sure where that leaves the rest of us. Excellent presentation overall.

Overview of Pancreatic Cysts: Diagnosis and Management, Walter Park, MD, Stanford University Medical Center

MRI reports higher prevalence of cysts due to its higher detection acuity than a CT scan. Three types of cysts have a high potential to convert to malignant disease. Serous cystic, mucinous cystic, and intraductal papillary mucinous neoplasms. He’s netting out important facts that could make a life difference for a patient if the doctor’s knew to look for and respond to these things. As a personal aside, I marvel that it took doctors two years of following me to send me to a tertiary care facility to have my pseudocyst biopsied only to find a mucinous neoplasm just as Dr. Park is presenting. His statement of operating on too many people that did not need surgery is alarming, especially given what the operations are. Resecting less and abandoning tumor size determination as criteria for immediate resection is interesting. The summary of guidelines and efforts to standardize cyst assessment and treatment seemed chaotic at best. It seems to me, someone should be able to quantify comprehensive guidelines to be followed throughout the medical community. Hope in cyst biomarkers perhaps?

Overview of Pancreatic Cancer, Randy Brand, MD, University of Pittsburgh Medical Center

Encouraged to hear there is effort with NIH for funding. Validating to hear of the diagnosis of new onset diabetes. Type 3c, how do we treat. 1.6 % lifetime risk of developing pancan. Adenocarcinomas the most prevalent. 55000 people will develop pancan this year and most of them will die. It takes 10 years for a cyst grow with precursor types discussed in Dr. Park’s talk. Pancreatic cancer will be the second leading cause of cancer deaths, passing up colon cancer, by 2020. Tumor spreads early when tumor is small, makes it challenging, one of the reasons it spreads so quickly. Symptoms are nondescript and difficult to source. 1% of all pancreatic cancer patients present as acute pancreatitis. That is how I presented. New onset diabetics with weight lose increase their risk for pancreatic cancer by double. Interesting information overall; important to understand the relationship with DM and Pancan. CA 19-9 – not sensitive for picking up pancan with specificities. Not reliable for screening due to too many false workups with 19-9. Staging is so complex. Localized tumor 21.5% 5 year survival with resection and treatment. Love the ‘what we need to do’ section in closing – it seems imperative that therapies and diagnostics become universal.

Management of Acute Pancreatitis and its Complications, Venkata Akshintala, MD, Johns Hopkins Hospital

Cambridge classifications around the ERCP is informative. Complications specifically all of the pancreatic related side effects makes invasive diagnostics so risky. Can we not do better? Interesting that endoscopic interventions help to relieve symptoms for chronic pancreatitis. 4-5 ercps to successfully treat a stricture, has to be hard on the patient – would be interested in hearing how a pt endures that. Great results with the stenting per Dr. Akshintala’s metrics – 50-60 % pain improvement. Lithotripsy used to shock the obstructing stones via ultra sound. Good results. Seems like good testing with good results. Pseudocysts can be drained if they are symptomatic. It is important to understand the underlying etiology. Of 100 patients, 5 had pancreatic cancer – we need to be sure that its not being missed. Great graphics on understanding how they access the pancreatic ducts to stent. Wow there is a lot of stuff that can go wrong with the pancreas.

Pancreatic Enzyme Replacement Therapy for Pancreatic Diseases: Current Treatment, Gaps, and Opportunities, Andres Gelrud, MD, Miami Cancer Institute

Important to check Vitamin D and bone density in patients. Imaging and good history critical in diagnosing. Suspect EPI (Exocrine Pancreatic Insufficiency) with low albumin, pre albumin, elevated HgA1c, Vit A, D, E, K; fecal collections are important not done often enough. All of the enzymes on the market work. Recommended: 72,000 lipase units per meal, 36,000 lipase units per snack. Best ways to take enzymes: consume enzymes throughout the meal, 2nd highest, just after meals, lowest efficacy before meal. Enzyme needs to meet with the food for their action to incur. Insightful to discuss to discuss the social issues for patients to take meds publically at a meal. Effective summary, good take away stressing right dosing. Nice reference to NPFs cartoon education comprehension on the pancreasfoundation.org website.

Management of Pancreatic Cancer: Perspectives from a Multidisciplinary Clinic, Nathan Bahary, MD, PhD, University of Pittsburgh Medical Center

Very comprehensive. Tells a true story of the complexity of arriving at a diagnosis. CA 19-9 not a good predictor, can be normal with cancer present. Discussed his multidisciplinary team and their collaboration, and their diagnostic and treatment approach. Surgery is the only cure, all treatment should lead to surgery. I really appreciate that psychosocial aspects of managing this disease is part of the multi-disciplinary team’s scope. Anatomic slides comprehensive. Life span improvement still not good enough. FOLFIRINOX has shown improvement. Hydroxychloquin helps the chemo into the cell. How does the ca19-9 – if it remains elevated patient will die. Targeted therapy: braca pathway, parp pathway. Love the positive outcome in the case study.

Where does Surgery fit in the Modern Management of Pancreatic Diseases? Kenneth Lee, MD, University of Pittsburgh Medical Center

Consider a posterior view of the pancreas anatomically to begin to understand the complexity of access the pancreas given the vasculature around the pancreas. Resections, drainage, and debridement are types of pancreatic surgeries. Retroperitoneal margin is prone to end up as a positive margin. The surgery is not worth pursuing if the surgeon cannot achieve clean margins – makes sense. Modified Whipple preserves the pyloris sphincter. Pseudocyst drainage is not done so much now, handled more with an EUS. Large hernias can result with the large abdominal incision. I ended up with a large ventral hernia that had to be repaired. Side effects of draining, fluid leakage, fistula development are all concerning. Leading secretions from anastomoses sites is complex to resolve with bad incomes. Delayed gastric emptying is another challenge requiring surgical intervention – can mostly provide palliative care. Wow, this is stuff with no good solution. Interestingly, developing diabetes is a potential side effect from surgery. Of course with all of the surgery options, most of the complications come with the Whipple. Interesting to learn that the same nerve pathways that carry pain also carry N/V/D. I did not find a lot of hope in this talk. It was well presented and the facts are what they are, but there existed no real hopeful statements or plans of care. May very well be a theme unfortunately?

Precision Medicine in Pancreatic Disease: Where are we now and where are we going? David Whitcomb, MD, PhD, University of Pittsburgh Medical Center

Interesting that a CT scan with a lot of fibrosis has no correlation with pain. Have to have end stage disease before a diagnosis can be made because it is chronic. Precision medicine can occur in pancreas patients. The cells of the pancreas are only three major types, not so complex. Family genetics, cystic fibrosis gene, which dwells most richly in the pancreas, play a big part in the development of pancreas disease. The disease can progress over many years. Feeding babies cow pigs didn’t work, but pig pancreas did not – this is crazy. But the same treatment exists today it is just more refined having capsuled s elements for the baby to ingest. Some hope – we can target the therapy for genetic problems based on from where the molecules are derived. This is true for CF but also true for pancreatitis. You have to know the underlying problem and if a CFTR mutation is present. The vision for communicating in the cloud is clever – it just seems like all of the problems still exist.

Day 2 PancreasFest

I am writing both as a patient and a caregiver given the number of patients I work with through my support group and take care of in the hospital. Also, I am a pancreatic cancer survivor. It is both difficult and encouraging to listen to the many knowledgeable physicians presenting on various relevant topics related to pancreas disease and pancreatic cancer. It is exciting to see such enthusiasm, knowledge, and dedication. Progress seems slow. It seems as though these physicians are doing their part and then some with research, innovation, and inspiring young physicians. It is the disease that continues to prove challenging as the statistics for survival have not budged for 20 years. However, I heard several inroads that serve as cracks of light beaming through the harsh exterior of the pancreatic tumor cell. That brings hope. Incorporating genetics into customizing treatment for pancreas patients seems the way of the future. Ascertaining pertinent genetics once far reaching was presented as routine and attainable. That brings hope. Hearing the many physicians at PancreasFest present caring about what patients go through with pain management and harsh judgement from the medical community at the Emergency Department and hospitalist level brings hope. Because these pancreas doctors see the problem, they are working on improving the problem. Better therapies for pain management brings hope.

Additionally, it is moving to see doctors from all around the country gathered in one place to share their knowledge and enlighten one another. There was a vast presentation of knowledge and research findings broken down into a comprehensive delivery system so that all present could gain the benefit of listening to the varied topics. The whole experience was extremely educational and encouraging. I spoke with several physicians, all accessible and excited about sharing their knowledge and answer questions. PancreasFest was well organized, effective in all that it taught, and meaningful to patients as well as physicians. I am grateful I was invited to attend.

Finally, the exhibitors provided a wealth of knowledge, innovation, and made themselves accessible. Each that I spoke with was happy to share how they fit in with PancreasFest. I was able to make some great contacts to help patients back home and to network with for future central PA events

Day 3 PancreasFest

Sitting in on a lecture describing in detail the cyst that was found in my body and the propensity for it to turn malignant, less than 0.1%, was eye opening. There exists yet no effective biomarker to detect such cysts, but these doctors are certainly working the problem with their research, and that brings hope. There were many pediatric sessions on this last day and several pediatric specialists researching different aspects of pancreas disease. I could see that brought hope. Overall the assembly of so many experts, and the vast depth of the work that is to be done regarding the pancreas is remarkable.

What a lovely, robust, meaningful, educational, and uplifting festival of the pancreas. Thank you again for the privilege of participating.