Thomas Seufferlein (Germany) presented updates from the German guidelines on pancreatic cancer, underscoring its transition to a "living" guideline, which allows for yearly revisions based on the latest evidence. The guideline outlines recommendations for managing risk factors, including obesity, alcohol intake, smoking, and diabetes. While there is no definitive dietary guideline to lower pancreatic cancer risk, lifestyle changes, specifically reducing alcohol, quitting smoking, and increasing physical activity, are strongly recommended.
A notable emphasis was placed on the genetic predisposition to pancreatic cancer. Individuals with a family history of pancreatic cancer, particularly those with two or more first-degree relatives affected, are encouraged to undergo genetic testing. Mutations in genes such as BRCA1, BRCA2, and CDKN2A are linked to increased risk, and those with confirmed mutations should begin screening at age 50, or 10 years younger than the youngest relative's age at diagnosis.
For patients diagnosed with pancreatic cancer, the guidelines advise surgery in specialized high-volume centers to reduce mortality rates. Evidence from German data shows significantly better outcomes in centers performing over 20 pancreatic resections per year. On the systemic treatment front, the addition of nanoliposomal irinotecan to FOLFIRINOX has shown promise in improving survival, particularly in advanced disease, though cost remains a challenge.
Pancreatic Exocrine Insufficiency (PEI) guidelines
Juan Enrique Dominguez-Munoz (Spain) reviewed the European guidelines on the diagnosis and management of pancreatic exocrine insufficiency (PEI), expanding its definition beyond traditional pancreatic diseases. PEI, characterized by the inadequate secretion of digestive enzymes, can occur in patients with conditions like celiac disease or post-gastrectomy.
The guideline stresses a comprehensive approach to diagnosis, combining clinical evaluation, nutritional markers, and pancreatic function tests. Fecal elastase remains the most accessible test, though it has limitations in specificity. The guideline suggests that for high-risk conditions like total pancreatectomy or pancreaticoduodenectomy, empirical treatment with pancreatic enzyme replacement therapy (PERT) may be initiated without waiting for test confirmation.
PERT remains the cornerstone of treatment, with enteric-coated preparations being the preferred choice. Dosage should be tailored to the severity of the insufficiency and the nutritional demands of the patient, with higher doses required in conditions like pancreatic cancer. Proton Pump Inhibitors (PPIs) are recommended as adjunctive therapy when PERT alone does not adequately control symptoms.
Dietary management is also essential. Patients should aim for a normal, healthy diet, with enzyme doses adjusted accordingly. Reducing dietary fiber may be necessary for patients with high-fiber diets, as fiber can inhibit lipase activity. The guideline underscores the importance of individualized nutritional care, ideally managed by a dietitian.
Global guidelines for pancreatic cysts
Giovanni Marchegiani (Italy) addressed the pressing need for harmonized global guidelines on the management of pancreatic cystic lesions. Current guidelines from different regions and organizations offer conflicting recommendations, particularly in the surveillance and management of asymptomatic cysts. This lack of consensus leads to variability in clinical practice, with significant differences in the frequency and modality of follow-up imaging, as well as the criteria for surgical intervention.
Marchegiani highlighted that many of the existing guidelines rely on low-level evidence, often based on expert opinion or retrospective surgical series. He advocated for global collaboration to create evidence-based guidelines that can be uniformly applied, improving patient outcomes and reducing unnecessary interventions. In particular, the development of biomarkers and AI-driven tools could help clinicians better stratify patients based on risk.
The importance of standardizing the reporting of pancreatic cysts, particularly in radiological assessments, was also emphasized. Clear, uniform criteria are needed to guide decisions on when to intervene surgically or continue surveillance. With up to 49% of individuals over 70 having pancreatic cysts, the challenge lies in identifying those at real risk of malignancy.
NASH and MASH: current challenges
Jörn Schattenberg (Germany) presented the latest developments in non-alcoholic steatohepatitis (NASH) and metabolic-associated steatohepatitis (MASH). The new European guidelines consolidate these conditions under the broader term "metabolic dysfunction-associated steatotic liver disease" (MASLD). Schattenberg emphasized that while lifestyle modifications remain the cornerstone of treatment, including weight loss and dietary changes, recent pharmacological advances offer hope for patients with advanced fibrosis.
Schattenberg discussed the pivotal role of cardiovascular risk management in patients with MASLD, as these patients often have multiple comorbidities, including type 2 diabetes and obesity. Cardiovascular mortality remains a leading cause of death in this population, and clinicians must address this in parallel with liver disease management. He also noted the importance of using non-invasive tools, such as the Fibrosis-4 (FIB-4) index, to stratify patients by fibrosis risk. Although FIB-4 is not perfect, its simplicity and cost-effectiveness make it a valuable tool in routine practice.
Looking ahead, Schattenberg highlighted the impending approval of resmetirom, a thyroid hormone receptor beta agonist, as the first pharmacotherapy specifically for NASH in Europe. This drug, which has already been approved in the United States, has shown promising results in improving fibrosis in patients with metabolic liver disease, marking a significant step forward in treatment.
- Thomas Seufferlein. Novel aspects of the updated german pancreatic cancer guideline. UEG WEEK 2024 - From guidelines to clinical practice: HPB. 13.10.2024
- Juan Enrique Dominguez-Munoz. European guideline on the diagnosis and therapy of pancreatic exocrine insufficiency. UEG WEEK 2024 - From guidelines to clinical practice: HPB. 13.10.2024
- Giovanni Marchegiani. Pancreatic cystic lesions: Why we need a harmonised global guideline. UEG WEEK 2024 - From guidelines to clinical practice: HPB. 13.10.2024
- Giovanni Marchegiani. Pancreatic cystic lesions: Why we need a harmonised global guideline. UEG WEEK 2024 - From guidelines to clinical practice: HPB. 13.10.2024
- Jörn Schattenberg. NASH, MASH: Recent developments that challenge current guidelines. UEG WEEK 2024 - From guidelines to clinical practice: HPB. 13.10.2024