Pancreatic neuroendocrine tumors (PNETs) are relatively uncommon malignancies, characterized as either functional or nonfunctional secondary to their secretion of biologically active hormones. A wide range of clinical behavior can be seen, with the primary prognostic indicator being tumor grade as defined by the Ki67 proliferation index and mitotic index. Surgery is the primary treatment modality for PNETs. While functional PNETs should undergo resection for symptom control as well as potential curative intent, nonfunctional PNETs are increasingly managed nonoperatively. There is increasing data to suggest small, nonfunctional PNETs (less than 2 cm) are appropriate follow with nonoperative active surveillance. Evidence supports surgical management of metastatic disease if possible, and occasionally even surgical management of the primary tumor in the setting of widespread metastases. In this review, we highlight the evolving surgical management of local and metastatic PNETs.

Pancreatic ductal adenocarcinoma (PDAC) remains one of the deadliest malignancies in the United States. Improvements in imaging have permitted the categorization of patients according to radiologic involvement of surrounding vasculature, i.e., upfront resectable, borderline resectable, and locally advanced disease, and this, in turn, has influenced the sequence of chemotherapy, surgery, and radiation therapy. Though surgical resection remains the only curative treatment option, recent studies have shown improved overall survival with neoadjuvant chemotherapy, especially among patients with borderline resectable/locally advanced disease. The role of radiologic imaging after neoadjuvant therapy and the potential benefit of adjuvant therapy for borderline resectable and locally advanced disease remain areas of ongoing investigation. The advances made in the treatment of patients with borderline resectable/locally advanced disease are promising, yet disparities in access to cancer care persist. This review highlights the significant advances that have been made in the treatment of borderline resectable and locally advanced PDAC, while also calling attention to the remaining challenges.

Background Complete pathologic response following neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) is rare; alternative markers associated with survival are needed. The aim of this study was to evaluate the impact of tumor response to NAT on overall survival (OS) in PDAC patients who received NAT and curative-intent surgery. Methods A retrospective study utilizing the 2006-2018 National Cancer Database identified 6,960 adult patients with PDAC who received NAT. As a comparator group, 15,799 patients who underwent upfront surgical resection were separately analyzed. Primary outcome among patients who received NAT was OS according to changes in pathologic T and N staging compared to clinical T and N staging following NAT, defined as favorable response (downstaging) and non-favorable response (no change and upstaging). Results After NAT, 35.1%, 43.4%, and 21.5% of patients had T downstaging, no change, and upstaging, respectively. Comparatively, 3.5%, 53.4%, and 43.1% of patients who underwent upfront surgical resection were over-staged, accurately staged, and under-staged, respectively, in reference to the T stage. Adjusting for patient, hospital, treatment, tumor, and margin status covarities, a favorable response to NAT, or T downstaging, was significantly associated with higher OS (HR 0.80, 95% CI 0.75-0.86; median OS 34.4 months, 95% CI 32.6-36.5) compared with a non-favorable response to NAT as the reference group (median OS 27.9 months, 95% CI 26.9-28.8). Similarly, a favorable response to NAT in the N stage was associated with a higher OS (HR 0.87, 95% CI 0.79-0.95; median OS 33.7 months, 95% CI 31.4-36.5) compared with a non-favorable response (median OS 29.3 months, 95% CI 28.6-30.3). Conclusion A favorable response to NAT is associated with higher OS among PDAC patients who underwent curative intent surgery.

Introduction: ON-Q pumps, or surgically placed wound catheters, provide analgesia without the side effects of epidural catheters. This study aimed to evaluate perioperative outcomes, including total postoperative oral morphine milligram equivalents (MMEs), perioperative intravenous (IV) fluid volume, and maximum patient-reported pain scale values, in pancreatic or hepatic resection patients on an Enhanced Recovery After Surgery (ERAS) pathway with ON-Q pumps versus other perioperative pain modalities.