OverviewPancreatic cancer is one of the most common causes of cancer-related death among men and women in the United States. Abstract Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection. J Natl Compr Canc Netw 2017;15(8):1028-1061 doi: 10.6004/jnccn.2017 NCCN Categories of Evidence and Consensus Please NoteThe These guidelines are also available on the Internet. For the latest update, visit NCCN.org.

The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.

Background The use of antibiotics in the primary prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is controversial. Purpose To determine the beneficial effect of fluoroquinolones as compared to placebo in primary prophylaxis of SBP in high-risk patients with cirrhosis using meta-analysis. Data Sources Medline, Embase, Cochrane, and Web of Science databases were searched in all languages until August 2008. Study Selection Randomized-placebo controlled studies evaluating the role of fluoroquinolones in primary prevention of SBP in patients with low protein ascites (total ascitic protein <1.5 g/dL) and without prior history of SBP. Data Extraction Two investigators independently performed literature search and data extraction, and then another investigator independently reviewed whether the studies met pre-specified criteria and rechecked data extraction. Odds ratios (Peto method) for the risk reduction with fluoroquinolones were calculated for each study and combined using a random-effects model. Results Four randomized-controlled studies met predefined criteria. The odds ratios for developing first episode of SBP, serious infections and mortality with fluoroquinolone prophylaxis (n=194) vs. placebo (n=190) were 0.18 (95% CI, 0.09–0.35), 0.18 (95% CI, 0.10–0.32) and 0.60 (95% CI, 0.37–0.97), respectively. All studies were unidirectional in showing the beneficial effect of fluoroquinolone prophylaxis. Limitations Few studies with relatively small sample sizes. Conclusions Daily oral fluoroquinolone prophylaxis reduces the risk of development of first episode of SBP and mortality in cirrhotic patients with low total protein in the ascitic fluid. Fluoroquinolones may be advisable for the primary prophylaxis of SBP in selected high-risk patients with cirrhosis.

Immune checkpoint inhibitors (ICIs) can result in immune-related adverse events which require rapid identification and treatment. Gastrointestinal immune-related adverse events are among the most frequent and severe of these events. ICI colitis can be refractory to current therapies such as corticosteroids and biologic therapy. Fecal microbiota transplantation (FMT) is currently used in cases of recurrent Clostridioides difficile colitis. Many investigations are underway to test the utility of FMT for additional indications, including inflammatory bowel disease (IBD). We present a 71-year-old man with ICI colitis that was nonresponsive to currently defined management options and treated with benefit from FMT.

Primary pancreatic leiomyosarcomas are rare tumors of the pancreas that are usually diagnosed after resection or by biopsy. One case in the literature has utilized endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology. We report a second case of a primary pancreatic leiomyosarcoma that yielded diagnostic material on EUS-FNA cytology. A 72-year-old female presented with 3-4 months of abdominal pain. A CT scan showed a large heterogeneous, lobulated pancreatic head and uncinate mass and multiple hypoattenuating liver lesions. An EUS-FNA was performed on one of the liver lesions with a 25-gauge needle, yielding an adequate sample with lesional cells. The initial read was a spindle cell neoplasm. A subsequent endoscopic ultrasound-guided fine needle biopsy with a 22-gauge needle was performed on the pancreatic head mass to rule out two primaries and to provide tissue for a mitotic index in the case of gastrointestinal tumor. Both the cell block of the EUS-FNA and the core biopsy were equally cellular and showed interlacing spindle cells that stained positive for SMA and negative for DOG-1, CD 117, and CD34. In addition, the core biopsy of the pancreas stained positive for Desmin. A diagnosis of a primary pancreatic leiomyosarcoma was made and the patient was started on systemic chemotherapy. Primary pancreatic leiomyosarcomas are rare pancreatic tumors that may yield diagnostic material by EUS-FNA with a 25-gauge needle. Diagn. Cytopathol. 2016;44:1070-1073. © 2016 Wiley Periodicals, Inc.