In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.

Introduction Aggressive management of hepatic neuroendocrine (NE) metastases improves symptoms and prolongs survival. Because of the rarity of these tumors, however, the best method for hepatic artery embolization has not been established. We hypothesized that in patients with hepatic NE metastases, hepatic artery chemoembolization (HACE) would result in better symptom improvement and survival compared to bland embolization (HAE). Methods Retrospective review identified all patients with NE hepatic metastases managed by HACE or HAE at three institutions from January 1996 through December 2007. Results We identified 100 patients managed by HACE (n=49) or HAE (n=51) that were similar with respect to age, gender, and primary tumor type. The percentage of patients experiencing morbidity, 30-day mortality, and symptom improvement were similar between the two groups (HACE vs. HAE: 2.4% vs. 6.6%; 0.8% vs. 1.8%; and 88% vs. 83%, respectively.) No differences in the median overall survival were observed between HACE and HAE from the time of the first embolization procedure (25.5 vs. 25.7 months, p=0.79). Multivariate analysis revealed that resection of the primary tumor predicted survival (73.8 vs. 19.4 months, p<0.04). Conclusions These data suggest that morbidity, mortality, symptom improvement, and overall survival are similar in patients with hepatic neuroendocrine metastases managed by chemo- or bland hepatic artery embolization.

Introduction Oxidative stress plays an important role in the pathogenesis of many liver diseases. Investigators often measure markers of oxidative stress in peripheral veins as a reflection of hepatic oxidative stress as it is not always feasible to measure oxidative stress in liver tissue. However, it is unknown whether markers of oxidative stress measured from peripheral sites accurately reflect hepatic tissue oxidative stress. The aim of this study is to examine the relationship of oxidative stress marker among hepatic tissue, hepatic and peripheral veins and urine. Methods Malondialdehyde (MDA), a marker of oxidative stress was measured in hepatic vein, peripheral vein and urine samples from 26 consecutive patients undergoing transjugular liver procedures. In 19 patients undergoing liver biopsies, we measured MDA by immunohistochemical staining of paraffin-embedded liver tissue. Results Peripheral venous MDA levels showed significant correlation with hepatic venous MDA levels (r = 0.62, P = 0.02), but they did not correlate with hepatic tissue MDA content (r = 0.22, P = 0.4). Hepatic venous MDA levels did not correlate with hepatic tissue MDA content (r = −0.01, P = 0.9). Subgroup analysis of patients without portal hypertension showed a positive correlation between hepatic venous and hepatic tissue MDA levels, but this was not statistically significant (r = 0.45, P = 0.22). Urinary MDA did not correlate with MDA from any other sampling location. Conclusion Oxidative stress measured from the peripheral venous samples is poorly reflective of hepatic tissue oxidative stress. Hepatic venous sampling might be suitable for assessing hepatic tissue oxidative stress in patients without portal hypertension, but a larger study is needed to examine this possibility.

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SUMMARY BackgroundTranscatheter arterial chemoembolization (TACE) has been shown to improve survival in patients with unresectable hepatocellular carcinoma (HCC).