Pancreatic Cancer - St. John Providence

Pancreatic Cancer: What is

My Risk and What Can I Do?

Roberto M. Gamarra, MD, FACG, FACP

Director of Endoscopic Ultrasonography

Providence Hospital

St. John-Providence Health System

Advances in Hepatobiliary and Pancreatic Diseases Conference

Saturday, February 28, 205

Disclosures

• Speaker bureau for Boston Scientific

What Everyone Always Pictures

What Everyone Should Know

• There is always hope!

• A multi-disciplinary team approach is fundamental

(gastroenterology, surgery, medical oncology, radiation oncology, radiology, pain medicine, dietitians, palliative care experts, and specialty nursing)

• Experience matters!

Introduction to

Pancreatic Cancer

Pancreatic Cancer Statistics

• Prevalence = 43,538 living with pancreatic cancer in US

• # new cases = 12.3 per 100,000

• # deaths = 10.9 per 100,000

• Lifetime risk of developing pancreatic cancer = 1.5%


9

10

-

6

7

8

1

2

3

4

5

12

COMMON CANCERS

PROSTATE

BREAST CANCER (FEM)

LUNG

COLORECTAL

MELANOMA

BLADDER

NON-HODGKIN

KIDNEY/RENAL PELVIS

THYROID

ENDOMETRIAL

-

PANCREATIC

ESTIMATED NEW

CASES IN 2014

233,000

232,670

224,210

136,830

76,100

74,690

70,800

63,920

62,980

52,630

-

46,420

ESTIMATED DEATHS

IN 2014

29,480

40,000

159,260

50,310

9,710

15,580

18,990

13,860

1,890

8,590

-

39,590

•


4th leading cause of cancer death

• No single reliable screening test for early detection


Cases and Death Rates

Rates of new cases have not changed

Death rates have been increasing about 0.4% per year between 2004-2011


5-Year Survival Rates: All Cancer & Pancreatic Cancer

Death rates have been increasing about 0.4% per year between 2004-2011


Survival by Stage


Who Gets of Pancreatic Cancer?

98%

90%

70%

What is My Real Risk?

1-year risk Lifetime risk

What Causes Pancreatic

Cancer?

What Causes Pancreatic Cancer?

• Damage to DNA of pancreatic ductal or acinar cells

• Can be inherited or acquired

• Chance mutations

What Causes Pancreatic Cancer?

What Risk Factors Lead to

Pancreatic Cancer?

Risk Factors

<5% LIFETIME RISK 5-10% LIFETIME RISK >10% LIFETIME RISK

Male gender

Black race

Ashkenazi Jew

Familial adenomatous polyposis (FAP)

BRCA1

Non-O blood type?

2 FDRs with PC

Cystic fibrosis

BRCA2

PALB2

Li-Fraumeni syndrome

Ataxia telangiectasia

3 FDRs

Peutz-Jeghers syndrome

Hereditary pancreatitis

FAMMM

Smoking (3.7x)

Diabetes mellitus (2x)

Obesity (1.7x)

Heavy alcohol use

H. pylori and Hep B

Exposure to chemicals

Chronic pancreatitis

Adapted from Brand R, et al. Gut 2007

How Much Does My Family

History Affect My Risk?

CATEGORY

Overall

3+ FDRs

2 FDRs

1 FDR

Young onset kindred

Late onset kindred

SIR

6.79 (4.54-9.75)*

17.02 (7.34-33.5)*

3.97 (1.59-8.2)*

6.86 (3.75-11.04)%

9.31 (3.42-20.2)*

6.34 (4.02-9.51)*

Brune, et al. NJCI 2010

Risk Factors

INDIVIDUAL

No history

1 FDR

2 FDRs

3 FDRs

Breast-Ovarian CA

FAMMM

Hereditary panc

Peutz-Jeghers

Lynch syndrome

GENE

None

?

?

?

BRCA1

BRCA2 p16/CDKN2A

PRSS1

STK11/LKB1

MLH1,MSH2

RR

1

2.3

6.4

32

2

5-10

20-34

50-80

132

10

RR 5-10%

RR >10%

RISK BY AGE 70

0.5%

1.15%

8-12%

16-32%

1%

5%

10-17%

25-40%

30-60% (36%)

5%

Pancreatic Cancer

5-Year Survival Correlates with T Stage

Carcinoma in situ

Minute

<1 cm

T1

<2 cm

Large

Resectable

Unresectable

100%

85%

20-40%

5-Year Survival 10-20%

0-2%

Chari, et al. Sem Oncol 2007

Compton CC, Mulvihill SJ. Prognostic factors in pancreatic carcinoma. Surg Oncol Clin N Am 1997; 6:533-54

Paradigm Shift is Needed

• No change in mortality over decades

- Unlike breast lung, breast, and colon cancer!

• No major advances in pancreatic cancer treatments

- Modest advances in chemotherapy and surgical techniques

- Little impact on survival

Should We Screen?

• Rare cancer (1:10,000 cases per year)

• 90% are sporadic

• Testing is difficult

• Testing is invasive and can cause harm

• Testing not cheap

• No proof it reduced mortality

Screening May Be Cost Effective

• Decision analysis study using 1-time screening using EUS in

100 familial pancreatic cancer kindred patients

• Cost effective if prevalence is >16% and sensitivity of EUS is

>84%

• Almost $17,000 per life-year saved

Rulyak SJ, et al. Cost-effectiveness of pancreatic cancer screening in familial pancreatic cancer kindreds. GIE 2003; 57:23-9

Renewed Interest in Screening for Pancreatic Cancer

• Better understanding of pathogenesis and natural history

• Estimated accumulations of mutations

- 11.7 years until overt cancer

- Another 6.8 years until overt metastases

• Improved resolution of EUS, CT, and MRI

• Improved EUS-FNA and cytology processing techniques

• Advances in molecular testing and cytogenetics

Yachida S, Jones S, Bozic I, et al. Distant metastasis occurs late during the genetic evolution of pancreatic cancer. Nature

2010; 467:1114-7

Precursor Lesions

Precursor Lesions

IPMN

Easily visible

MUCINOUS CYSTIC

NEOPLASM (MCN)

Easily visible

PANIN

Microscopic

15%

Most common lesion diagnosed!

0-5%

99% women

80-85%

Difficult to find!

PanIN Lesions

Text

PanIN Lesions

PanIN Lesions

Pancreatic Cancer Screening:

The Data

Clinical Studies

• To date, 13 published studies on pancreatic cancer screening limited to high-risk individuals

• All studies used EUS as test of choice

• Screening is safe

• Most clinically important lesions found at index study

• Limited by benign lesions with malignant potential requiring work up

MRI-based

Clinical Studies

EUS-based

STUDY INSTITUTION #HRI GROUPS IMAGING

BRENTNALL 1999 U of Washington 14

KIMMEY 2002 U of Washington 46

FPC

FPC

EUS+ERCP+C

T

EUS+ERCP

CANTO 2004

CANTO 2006

Johns Hopkins

Johns Hopkins

38

78

FPC, PJS

FPC, PJS

EUS, ERCP,

CT

EUS, ERCP,

CT

POLEY 2009 Rotterdam 44

FPC, BRCA, PJS, p16, p53, HP

EUS, CT, MRI

LANGER 2009 Marburg 76 FPC, BRCA

EUS+MRI, EUS-

FNA

VERNA 2010

LUDWIG 2011

VASEN 2011

Columbia

Sloan Kettering

Leiden U

51 FPC, BRCA, p16 EUS+/-MRCP

109

77

FPC, BRCA p16

MRCP+/-EUS+/-

FNA

MRI/MRCP

AL-SUKHNI 2011 U of Toronto 262

FPC, BRCA 1/2,

PJS, p16, HP

SCHNEIDER 2011 German Nat’l

CANTO 2012

DELCHIARO 2013

72 FPC

Johns Hopkins

Sweden

216

FPC, PJS,

BRCA

40 FPC,BRCA1/2,p16

MRI, CT, EUS,

ERCP

EUS+MRCP

CT, MRI/MRCP,

EUS, ERCP

MRI

#PREMALIG # MALIG YIELD

7

12

1

6

7

1

4

7

9

16

2

92

14

0

0

1

1

3

0

2

1

7

3

1

0

2

50%

26%

5.3%

10.3%

23%

1.3%

12%

8.3%

20%

7.3%

4%

43%

40%

CAPS2 Study

Johns Hopkins University

• 2 high risk groups: PJS (group 1) and familial pancreatic cancer kindreds (group 2)

• Baseline:

- Baseline screening evaluation and at least 1 follow up clinical and radiologic (EUS and CT) within 1 year

- Genetic counseling

- If abnormal EUS, then CT and possibly ERCP

• Surgery offered for mass, large cysts, mural nodules, or severe dysplasia on FNA

Canto MI, et al. Screening for early pancreatic neoplasia in high risk individuals: a prospective controlled study. Clin

Gastroenterol Hepatic 2006; 4:766-81

•

CAPS2 Study


8 of 78 (10.2%) patients had pancreatic neoplasia

- 1 PJS with IPMN with carcinoma in situ resected

- 1 FPC with 3FDRs with IPMN x 2 and multifocal PanIN3 resected

- 1 FPC with 3 relatives with multifocal PanIN1/2 resected

- 1 FPC with 4 relatives with chronic pancreatitis and panIN1/2 resected

- 1 FPC with 3 relatives/BRCA2 with chronic pancreatitis and IPMNs x 2

- 1 FPC with 3 relatives with IPMN and PanIN1

- 1 FPC with 5 relatives/BRCA2 IPMN advised for surgery

- 1 FPC with 4 relatives with IPMN and PanIN1-3



•

CAPS2 Study


6 PJS and 72 familial pancreatic cancer vs. 149 controls

• 3 extra-pancreatic cancers

• 1 patient with IPMN refused surgery and developed metastatic pancreatic cancer

• Proof: Premalignant lesions can be identified

• Proof: At-risk patients can be identified

• Proof: Intervention can prevent malignancy



Columbia University

Patients & Protocol

• Prospective study of 51 patients [FPC, BRCA 1/2, PJS,

FAMMM, Lynch, hereditary pancreatitis]

• All patients with family history and interest in risk of disease offered enrollment

• H&P, family history by genetic counselor, results of all imaging and blood testing, storage of frozen serum and any surgically resected tissue

• Blood processed for DNA extraction and EBV immortalization

Verna EC, et al. Pancreatic cancer screening in a prospective cohort of high-risk patients: a comprehensive strategy of imaging and genetics. Clint Cancer Res 2010; 16(2): 5028-37


H&P, PE, family history, genetic testing

Avg Risk:

1 relative >55yo

Moderate Risk:

>=2 FDR, SDR or TDR

1FDR <55yo

High Risk:

>=3 FDR, SDR, TDR

>=2 FDR

1FDR+1SDR w/ 1<55yo

Genetic syndrome

Basic labs,

Additional testing if indicated

EUS or MRI

CA 19-9 & OGTT

EUS or MRI

CA 19-9 & OGTT

No malignant or premalignant disease identified

Any abnormal testing:

EUS

(if not already done)

(+/- FNA and ERCP)

Malignant or premalignant disease diagnosed or suspected

Surveillance Consider surgery



Genetics Testing

• 24 (47%) had genetic testing: 7 positive for BRCA 1/2

- BRCA 1 and 2

- MMR testing

- CDKN2A/p16

• Counseling before and after testing by genetics counselor

• Prophylactic mastectomy, oophorectomy, chemoprevention and enhanced screening discussed



Follow Up

• Weekly multidisciplinary meeting

• Screening started 10 years before youngest affected family member

• Follow up:

- High risk: Every 6 months with alternating EUS and MRI

- Moderate risk: Every 1 yr with alternating EUS and MRI

- Average risk: No imaging. Annual visits and further testing if they developed symptoms or new onset DM



Results

• 51 patients from 43 families

- 90% non-Hispanic whites, 35% male, 35% tobacco hx

- 29% personal history of cancer other than pancreatic

• Family history: 15 (29%) >2 FDRs; 35 (69%) >2 relatives

• Categories: 32 (69%) high risk, 14 (27%) moderate risk, 5

(10%) avg risk

• 61% had EUS and 65% had MRI/MRCP



Results

OVERALL (51) AVG RISK (5)

MODERATE

RISK (14)

EUS: CHRONIC PANC

CHANGES

6/31 (19%) 1/2 (50%) 0/5 (0%)

5/31 (16%) 0/2 (0%) 2/5 (40%) EUS: IPMN

EUS: SOLID MASS

ERCP: PD IRREG

ERCP: IPMN

MRI/MRCP: PD IRREG

MRI/MRCP: IPMN

MRI/MRCP: SOLID MASS

5/24 (21%)

2/31 (6%) 0/2 (0%) 0/5 (0%)

2/7 (29%) 1/1 (100%) 0/1 (0%)

4/7 (57%) 0/1 (100%) 1/1 (100%)

1/33 (3%) 0/3 (0%) 0/7 (0%)

1/33 (3%)

3/33 (9%)

5/51 (10%)

0/3 (0%)

1/3 (33%)

0/5 (0%)

1/7 (14%)

0/7 (0%)

3/24 (13%)

2/24 (8%)

1/5 (20%)

3/5 (60%)

1/23 (4%)

0/23 (0%)

2/23 (9%)

2/14 (14%) 3/32 (10%) PANCREAS SURGERY

HIGH RISK

(32)



• Results:

- 2 (4%) pancreatic CA (FPC and BRCA2), 5 (10%)

IPMNs, 7 cysts

- 4 extrapancreatic tumors: 2 ovarian CA, 1 carcinoid, 1 papillary thyroid carcinoma

• 12% diagnosed with malignant/premalignant disease of pancreas

• 18% diagnosed with malignant/premalignant disease of any organ


•

CAPS4


Prospective observational cohort study

• Study the diagnosis and long-term outcomes of screening patients with increased risk for pancreatic cancer

HIGH RISK GROUPS

Group 1: Peutz-Jeghers Syndrome

(PJS)

Group 2: Familial pancreatic cancer

Group 3: Germline mutations:

BRCA1, BRCA2, PALB2, PRSS1, p16

Group 4: Young-onset pancreatic cancer relative

Group 5: Both parents affected

Not yet completed

CONTROLS

Group 1: Negative controls

Group 2: Chronic pancreatitis

Group 3: Pancreatic cancer

Group 4: IPMN

CAPS Consensus Summit

50 experts from 10 different countries

• What to start? 40 or 10 years prior to youngest relative?

• How to screen? EUS? MRI/MRCP? CT? ERCP?

• How often to follow? Once only? Yearly? Every other year?

• When to resect? How much to resect?

• >75% agreement considered consensus

Canto MI, Harnick F, Hruban RH, et al. International cancer of the pancreas screening (CAP) consortium summit on the management of patients with increased risk for familial pancreatic cancer. Gut 2013; 62:339-47


Who Should Be Screened?

HIGH RISK GROUP > 75% CONSENSUS

2+ relatives with/without FDR

Peutz-Jeghers syndrome

BRCA2 with >1 FDR p16 with >1 FDR

Lynch syndrome with >1 FDR

PALB2 with >1 FDR

BRCA2 without family history

BRCA1

Young onset pancreatic cancer

New-onset DM

92%/78%

96%

86%

88%

88%

78%

51.1%

69.4%

No

No

Canto MI, Harinck F, Hruban RH, et al. International cancer of the pancreas screening (CAP) consortium summit on the management of patients with increased risk for familial pancreatic cancer. Gut 2013; 62:339-47


How Should Patients Be Screened?

SCREENING MODALITY > 75% CONSENSUS

Initial screen with EUS (MRI/MRCP)

F/u of normal with EUS (MRI/MRCP)

In normal tests, f/u should be every 1 year

84% (74%)

79% (70%)

73%

Benign cysts followed every 6-12 mo

Indeterminate lesions followed at 3 mo

ERCP should NOT be performed as an additional test for solid/cystic lesions

CT should be performed for EUS abnormalities

Initial screen with US, CT, or ERCP

84%

86%

77.5%/77.%

Yes

No

FNA of cysts should be performed No



When Should Surgery Be Offered?

• Screening should only be offered to patients who are candidates for surgery (75.5%)

• Most lesions found are IPMNs

• Resection for:

- Symptomatic lesions

- >3 cm

- Mural nodules

• Surgery should be considered for suspected IPMNs >2 cm



When Should Surgery Be Offered?

SCREENING MODALITY

Screen only if surgical candidate

Surgery only at high-volume centers

Continue surgery until R0 resection

Stop resection in unifocal PanIN2

Stop resection if <HGD

Repeat surgery if PanIN3 at margin post-op

> 75% CONSENSUS

76%

100%

76%

78%

78%

No



When is Screening Considered a Success?

SCREENING MODALITY

T1N0M0 at baseline/follow-up

Any stage pancreatic cancer at baseline

Multifocal PanIN-3

Unifocal PanIN-3

IPMNs with HGD

IPMNs without HGD

Pancreatic NETs

> 75% CONSENSUS

90%/78%

90%

84%

74%

96%

No

No


What Can I Do to Reduce My

Risk?


Risk of Pancreatic Cancer?

• Avoid all tobacco

• Lose weight with diet and exercise



• Diets high meat, cholesterol, fried foods, nitrosamines vs. diets high in fruits/vegetables



• Avoid all tobacco

• Lose weight with diet and exercise

• Do not drink alcohol in excess

• Control my diabetes

• Know my family history: breast, colon, skin cancer

• Eradicate H. pylori & vaccinate for hepatitis B

• Avoid occupational chemicals



Screening is NOT Recommended for…

• Common medical conditions: obesity, diabetes, smokers, chronic pancreatitis

• Family history: 1 FDR with pancreatic cancer >50 years old,

2 SDRs with pancreatic cancer

• Genetic syndromes: hereditary pancreatitis, cystic fibrosis,

FAP, Li-Fraumeni syndrome, ataxia-telangiectasia



Consider Enrolling in Screening Program if…

• Family history: 2+ FDRs or 2 relatives with 1 FDR or 1 FDR

<50 years old

• Common genetic syndromes: BRCA2, PALB2, BRCA1 w/ family history, Lynch syndrome

• Rare genetic syndromes: Peutz-Jeghers and FAMMM

Summary

• Pancreatic cancer is rare and the risk for most people is low

• All people can reduce their risk with lifestyle modifications

• There are pancreatic cancer precursors that are difficult but not impossible to discover with current imaging

• Pancreatic cancer screening in high risk individuals is recommended

• EUS and MRI/MRCP are the preferred imaging modalities for looking for pancreatic cancer precursors and early pancreatic cancer


• There is always hope!

• A multi-disciplinary team approach is fundamental

(gastroenterology, surgery, medical oncology, radiation oncology, radiology, pain medicine, dietitians, palliative care experts, and specialty nursing)

• Experience matters!

Thank You!

University of Washington

• 14 patient from 3 kindreds with a history of pancreatic cancer

• CT, CA 19-9, CEA, EUS, ERCP on all patients

• 7 of 14 thought to have dysplasia and referred to pancreatectomy

• CT had low sensitivity; EUS findings similar to chronic pancreatitis

• All 7 of 14 had widespread dysplasia

Brentnall T, et al. Early diagnosis and treatment of pancreatic dysplasia in patients with family history of pancreatic cancer.

Ann Intern Med 1999;131:147-55

University of Washington 2

• 46 patients from 1 kindred with history of pancreatic cancer

• Observational study

• CT, MRI, PET, EUS, and ERCP

- EUS: 24 of 46 (%) abnormal

- ERCP: 13 of 28 (%) abnormal

• 12 of 12 (100%) of surgery had widespread dysplasia

Kimmey, MB, et al. Screening and surveillance for hereditary pancreatic cancer. Gastronintest Endosc 2002; 56(4)(suppl):

S82-86

CAPS1 Study


• 38 asymptomatic patients: 31 (>3 relatives), 6 (2 relatives),

1 PJS underwent screening with EUS and ERCP

• 6 masses: 1 invasive cancer (FPC), 1 IPMN (PJS), 2 serous cystadenomas, 2 non-neoplastic masses

• Yield = 2 of 38 (5.3%)

• 1 cancer patient treated and was alive at >5 years

• 2 of 24 (8.3%) had post-ERCP pancreatitis

Canto MI, et al. Screening for pancreatic neoplasia in high risk individuals: an EUS-based approach. Clin Gastroenterol

Hepatic 2004; 2:606-21

Dutch Study

Erasmus Medical Center, Rotterdam, Netherlands

• 44 patients: 21 FDRs, 3 BRCA 1, 2 BRCA2, 2 hereditary pancreatitis, 2 PJS, 13 FAMMM, 1 p53

• Screening EUS, CT, MRI

• 3 (6.8%) masses: 3 cancers (1 BRCA2 and 2 FAMMM)

• 7 (15.9%) branched duct IPMNs

Poley JW, et al. The yield of first-time endoscopic ultrasonography in screening individuals at high risk of developing pancreatic cancer. Am J Gastroenterol 2009; 104:2175-81

German Study

Philipps University, Marburg, Germany

• 76 HRIs in families with FPC in FaPaCa Registry

• Clinical exam, labs, EUS, MRI/MRCP and MRA

• Abnormal in 28 of 76 (37%): 25 EUS and 12 MRI/MRCP

• 7 had FNAs, 7 had surgery with 6 limited resections

• All 6 lesion benign: 3 SCAs, 1 PanIN1, 1 PanIN2, 1 IPMN

• Screening is not justified

Langer P, et al. Five yers of prospective screening of high risk individuals from families with familial pancreatic cancer. Gut

2009; 58:1410-18

Sloan Kettering Study

Text

• 309 at risk relatives form Familial Pancreatic Tumor Registry

- Early pancreatic cancer, 2+ relatives, 3+ SDRs, BRCA 1/2 with family history

• MRI/MRCP yearly followed by EUS if abnormal

- 18/109 (16.5%) abnormal; 15 underwent EUS

• Diagnostic yield: 9/109 (8.3%), 6 resected

- 1 T3N0 pancreatic cancer, 2 IPMNs, 1 PanIN3, 1 PanIN2,

1 serous cystadenoma), 3 suspected IPMNs not resected

Ludwig E, et al. Feasibility and yield of screening in relatives from familial pancreatic cancer families. Am J Gastroenterol

2011; 106:946-54

Dutch Study 2

Leiden University Medical Center, Netherlands

• p16 = CDKN2A leads to FAMMM

• 77 patients underwent annual MRI/MRCP

- If abnormal, offered surgery or intensive follow up

• Pancreatic cancer 7 of 77 (9%) (3 prevalent and 4 incident) all resectable

- 9 more patients had possible precursor lesions

Vasen HFA, et al. magnetic resonance imaging surveillance detects early stage pancreatic cancer in carriers of p16 Leiden mutation. Gastroenterol 2011; 140:850-6

Canadian Study

University of Toronto

• Prospective cohort study

• 262 FPC, FAMMM, PJS, BRCA 1 w/ FHx, BRCA2

• MRI/MRCP annually; consider EUS, ERCP, CT, or rpt MRI

- 3 advanced pancreatic CA, 1 NET, 15 IPMNs, 65 cysts

• Only 4/262 (1.5%) underwent surgery

Al-Sukhni W, et al. Screening for pancreatic cancer in a high risk cohort: an eight-year experience. J Gastrointest Surg 2012;

16:771-83

German Study 2

Philipps University, Marburg, Germany

• 94 of 284 families fulfilled inclusion criteria in FaPaCa

- 72 patients in 284 families enrolled in FaPaCa registry

• EUS and MRI/MRCP

• Pancreatic CA or IPMN or multifocal PanIN2/3 in 4 of 72

(5.5%) of resected specimens or 9 (12.5%) of suspected lesions

Schneider R, et al. German national case collection for familial pancreatic cancer (FaPaCa): ten year experience. Familial

Cancer 2011; 10:323-30

CAPS3 Study


CT MRI/MRCP LESION EUS

ANY

SOLID

11% (24/216)

1.4% (3/216)

33.3% (72/216) 42.5% (92/216)

0.4% (1/216) 1.4% (3/216)

CYSTIC

COMMUNICATION

W/ PD

MURAL NODULE

11% (24/216)

36%

4.2%

(8/24)

(1/24)

33%

53%

(72/216)

(38/72)

36%

27%

(79/216)

(21/79)

1.4% (1/72) 3.8% (3/79)

PD DILATION 2.4% (5/216) 2.4% (5/216) 9.5% (21/216)

Canto MI, et al. Frequent detection of pancreatic lesions in asymptomatic high-risk individuals. Gastroenterol 2012; 142:796-

804

Swedish Study

Swedish Study

• 2010 to 2013

• MR-based surveillance program

• 40 patients with mean follow-up 12.9 months

• Familial [5 in 2 pts (5%), 4 in 5 pts (12.5%), 3 in 17 pts (42.5%), 2 in 14 pts (35%) and 1 in 2 pts (5%)]

• Cytogenetics: p16 (4 pts(10%)), BRCA2 (3 pts (7.5%)), BRCA1 (1 pt

(2.5%))

• Suspicious lesion in 16 pts (40%): IPMN [14 (35%)], Cancer [2 (5%)]

Abstrct: Del Chiaro M, et al. J Pancreas JOP 2013 Sep 15; 14:540

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