Objectives: To determine the reproducibility of the National Comprehensive Cancer Network (NCCN) resectability status classification for pancreatic cancer. Background: The NCCN classification defines 3 resectability classes (resectable, borderline resectable, locally advanced), according to vascular invasion. It is used to recommend different approaches and stratify patients during clinical trials. Methods: Prospective, multicenter, observational study (trial ID: NCT03673423). Main outcome measure was the interobserver agreement of tumor assignment to different resectability classes and quantification of vascular invasion degrees. Agreement was measured by Fleiss’ k (k = 1 perfect agreement; k = 0 agreement by chance). Sixty-nine computed tomography (CT) scans of pathologically confirmed pancreatic adenocarcinoma were independently reviewed in a blinded fashion by 22 observers from 11 hospitals (11 surgeons and 11 radiologists). Rating differences between surgeons or radiologists and between hospitals with different volumes (≥60 or <60 resections/year) were assessed. Results: Complete agreement among 22 observers was recorded in 5 CT scans (7.2%), whereas 25 CT scans (36.2%) were variously assigned to all 3 resectability classes. Interobserver agreement varied from fair to moderate (Fleiss’ k range: 0.282–0.555), with the lowest agreement for borderline resectable tumors. Assessing vascular contact ≤180° had the lowest agreement for all vessels (k range: 0.196–0.362). The highest concordance was recorded for venous invasion >180° (k range: 0.619–0.756). Neither reviewers’ specialty nor hospital volume influenced the agreement. Conclusions: There is high variability in the assignment to resectability categories, which may compromise the reliability of treatments recommendations and the evidence of trials stratifying patients in resectability classes. Criteria should be revised to allow a reproducible classification.

Mucormycosis is a life threatening condition caused by invasion of fungi of the order Mucorales. Gastrointestinal invasion is very rare and often lethal, particularly in disseminated mucormycosis. We present the case of a 26-year-old woman from North Africa with type 2 diabetes who, after a cholecystectomy, developed unexplained septic shock and haematemesis due to gastric necrosis. Computed tomography (CT) revealed a disseminated fungal invasion of the lungs, kidney and paranasal sinuses. A gastrectomy and subsequent amphotericin B treatment resolved her condition. The number of patients with mucormycosis is increasing. Early diagnosis of high risk patients with CT and biopsies from which fungi are directly isolated must be followed by surgery and systemic amphotericin B infusion. Mucormycosis is a life threatening infection caused by fungi of the subphylum Mucoromycotina, order Mucorales. Mucoromycotina are characterised by large, ribbon-like hyphae with only occasional septa (aseptate fungi). These fungi cause mucormycosis, which leads to severe and potentially life threatening infections. Patients at risk of invasive mucormycosis include those with type 2 diabetes or autoimmune disorders, solid organ and hematopoietic stem cell transplant recipients, neonates, users of illicit intravenous drugs and patients with burns, trauma or surgical wounds.1 The symptoms of mucormycosis are varied and depend on the site affected; however, no specific blood test is available. Case HistoryIn the summer of 2010, a 26-year-old woman of North African ethnicity was admitted to our emergency department for abdominal pain, which had developed three days previously, and fever. She complained of upper right quadrant pain with a positive Murphy's sign, tachypnoea and tachycardia. Her blood tests showed increased leucocytes, C-reactive protein and transaminases. Her past medical history revealed type 2 diabetes mellitus. Abdominal ultrasonography identified distended, abnormal gallbladder with lithiasis. She underwent a laparoscopic cholecystectomy for suspected acute cholecystitis.In the early postoperative period, she developed rapid and progressive respiratory failure, and was admitted to the intensive care unit with a diagnosis of severe sepsis. She deteriorated rapidly, developing multiple organ failure with kidney, lung and cardiovascular involvement despite treatment. She required vasoactive support with norepinephrine and dopamine. Blood samples from central and peripheral lines were obtained for culture, and urine was collected for analysis. She was treated with broad spectrum antibiotics and antifungal therapy.On the third postoperative day, her blood results were: white blood cells 33,000/mm 3 , haemoglobin 8g/dl, haematocrit 27.1%, platelets 95,000/mm 3 , creatinine 9.6mg/dl, glucose 151mg/dl, pH 7.22, C-reactive protein 34mg/l and procalcitonin 15ng/ml. She underwent continuous venovenous haemofiltration. On the same day, she had an episode of haematemesis and an oesophagogastroduodenoscopy revealed gastric nec...

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Background The Oncology Network of Piedmont and Aosta Valley (North-West Italy) was started in 2000 and fully established in 2010 as a regional organisational model offering multidisciplinary care by experienced reference centres for cancer diagnosis and surgical treatment. In particular, the San Giovanni Bosco Hospital in Turin is the regional reference centre for pancreatic cancer since 2015 (50-70 oncologic surgery operations performed annually). The aim of study is to assess the effectiveness of this model for pancreatic cancer surgery by comparing survival outcomes before and after the adoption of the Oncology Network model. Methods The study included 178 patients, aged 37-84, who underwent duodenocephalo- or total pancreatectomy for ductal cancer in the years 2007-2019. Clinical data were retrieved from surgical records, whereas the vital status was ascertained through an application connected to the Regional Registry Office. The Kaplan-Meier method was used to estimate survival and the log-rank test was then used to compare survival rates between the two groups (before vs. after 2015). Cox's regression was employed to assess the difference between the groups, also adjusting for age, sex and ASA score. Results The median survival for included patients was 19 months. No significant differences were found between patients of the two groups (before vs. after 2015), neither considering all patients (p = 0.4) nor for any single ASA or age category (p-values ranging from 0.1 to 0.6). The multivariate Cox model accounting for ASA, age and sex confirmed absence of significant survival differences between the two groups. Conclusions Despite increased case complexity, due to the extension of surgery indication to more critical patients, the Oncology Network model allowed achieving an overall survival in pancreatic cancer surgery that is consistent with international literature and not inferior to survival outcomes previously reached in patients more strictly selected. Key messages This study found survival after pancreatic cancer surgery was similar before and after the center entered an Oncological Network, which led to include patients with an increased severity in case-mix. Promoting the implementation of Oncology Networks should be a public health priority as it allows to improve health outcomes and quality of care.

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