The peritoneum is the second most common site of metastasis in patients with pancreatic ductal adenocarcinoma (PDAC). Up to half of all patients that undergo curative-intent resection eventually develop peritoneal metastasis (PM), which accounts for significant morbidity and drives mortality. Despite recent advances in management, PM is associated with very poor prognosis, which is often measured in weeks to months. Clinical manifestations including bowel obstruction, ascites, and urinary obstruction have profound impact on quality of life. Even with relatively advanced disease, PM often remains occult on imaging and thus tend to be underdiagnosed and understudied. Many patients with peritoneal-only PM are excluded from clinical trials because response cannot be measured by standard radiographic criteria. Furthermore, as patients with PM are not eligible for surgical resection and low-volume peritoneal disease is often not amenable to percutaneous biopsy, tissue samples for peritoneal-specific translational studies are limited. Intraperitoneal therapeutics have been proposed as an attractive option for PM, as better penetration of tumor tissue can be achieved with less systemic toxicity compared with intravenous chemotherapy. Heated intraperitoneal chemotherapy (HIPEC), typically combined with cytoreductive surgery (CRS), is an option for select patients with PM from gynecologic or gastrointestinal primary, and for patients with primary peritoneal mesothelioma. However, the incorporation of locoregional therapy for PM in patients with PDAC has been poorly studied given the aggressive nature of pancreatic cancer and overall poor prognosis. With recent advances in existing treatment options, there may be a subset of patients who may derive benefits from locoregional control with cytoreduction and/or intraperitoneal chemotherapy. Critically, additional work is needed to determine PM-favorable clinical and tumoral predictive biomarkers to identify patients who may benefit from a more aggressive approach. We describe the current state of management of patients with peritoneal metastasis from PDAC and review the available data exploring peritoneal-directed therapy with cytoreductive surgery and/or intraperitoneal chemotherapy.

Liver metastases (LMs) pose a significant burden of morbidity and mortality, resulting in a worse prognosis for many primary malignancies. Despite advancements in cancer treatment, such as immunotherapy, molecular therapies, additional lines of chemotherapy and optimisation of surgical resection, effective therapy against hepatic metastases remains elusive. Recent studies in immuno-oncology have implicated distinct tumour microenvironment (TME) signatures in the hepatic metastatic niche, which interplay with the intrinsic microenvironmental features specific to each primary tumour or organ of origin. Regulatory T cells (Tregs) have been implicated in the immunosuppressive nature of the hepatic TME, yet the exact mechanisms of interaction have not been fully elucidated. Discrepancies in number, function and proportion of Tregs to other tumour-infiltrating lymphocytes have been documented, with conflicting findings in the LMs from different primary tumours. These results may be attributable to the underlying biology of each organ-specific tumour and the unique hepatic TME that forms during the stepwise progression of the metastatic cascade. In this review, we explore the often-contradicting findings of intrahepatic Tregs in LMs from different originating tumours and offer insight into potential mechanisms for these observed differences with implications for future therapeutic strategies.

Background/Objectives: Treatment options for advanced HCC are limited. Immunotherapy, a promising new therapeutic, has recently been incorporated as a first-line systemic treatment. This study evaluates immunotherapy uptake and disparities in its adoption prior to first-line approval, which are currently unknown. Methods: Patients diagnosed with stage IV HCC between 2014 and 2019 were identified in the National Cancer Database (NCDB). Multivariable logistic regression analysis was performed for demographic and clinical variables to determine their association with the receipt of immunotherapy. Results: A total of 18,248 patients were diagnosed with stage IV HCC, of which 977 (5.35%) received immunotherapy. From 2014 to 2019, the rate of immunotherapy uptake increased each year, with an approximate 25-fold increase overall. On multivariable analysis, patients with a more recent period of diagnosis (OR: 30.19, 95% CI: 16.47–55.33), with private insurance (OR: 2.56, 95% CI: 1.62–4.04), with treatment at an academic or research center (OR: 1.97, 95% CI: 1.37–2.82), or with an income ≥ USD 63,333 (OR: 1.27, 95% CI: 1.01–1.59) were more likely to receive immunotherapy. Conclusions: Various demographic factors impact the receipt of immunotherapy in the pre-approval setting, such as income, insurance status, and treatment center. As immunotherapy use will likely further expand and these disparities may potentially persist following first-line approval, strategies to mitigate them are especially important.

Objectives: Recently, 40 comprehensive quality indicators in various management domains were created. The aim was to determine if these indicators could be used to audit the management of acute pancreatitis. Methods: A retrospective study of consecutive patients admitted with acute pancreatitis in 2018 was conducted. Adherence rates with the individual quality indicators were calculated and compared between services. Results: A total of 320 patients were included in this study. Twenty-eight of the 40 quality indicators (70%) could be used to audit management retrospectively. The medical service was found to have lower adherence rates for quality indicators 12 (initial assessment and risk stratification domain; 11% vs 22%, P = 0.009), 14 (initial management domain; 72% vs 88%, P = 0.003), and 33 (surgery domain; 83% vs 100%, P = 0.006). The surgical service was noted to have statistically significant lower adherence rates for quality indicators 4, 5, and 6 of the etiology domain (54% vs 72%, P = 0.002; 86% vs 96%, P = 0.004; and 45% vs 71%, P < 0.0001, respectively), and 21 of the nutrition domain (76% vs 93%, P < 0.0001). Conclusions: We show that these quality indicators can be used to audit the management of acute pancreatitis in specific management domains.