Objective: At the "8th Pancreatic Cancer Classroom Workshop in Kashiwanoha" held in November 2018, a questionnaire was used to evaluate the ideal pancreatic cancer classroom.

Methods: A survey was conducted using a self-administered questionnaire form at nine major institutions that convened pancreatic cancer classroom sessions.

Results: This questionnaire reinforced the significance of the pancreatic cancer classroom, and confirmed that (1) the relationship between patients, family members, and medical professionals had improved, and motivation for treatment had increased, and (2) the classroom, regardless of type or frequency of sessions, facilitated mutual understanding and education of all involved parties regardless of role. In addition, the following issues concerning the classroom sessions were confirmed: (1) selection of target patients by disease and disease stage should continue, (2) the timing of classroom sessions will be convened and time allocated for the sessions were clarified, and (3) expansion and maintenance of operational skills and the collaborative system for healthcare professionals were identified.

Conclusion: In order to continue pancreatic cancer classroom sessions that are currently and have been voluntarily convened at each institution for a long time, there is a need for the pancreatic cancer classroom study group to lead and conduct prospective studies of classroom participants to clarify their utility.

To continue anti-cancer therapy, elderly patients need to observe their own symptoms and perform self-care support such as dealing with physical symptoms and lifestyle changes caused by treatment. Our hospital evaluates the self-care ability of elderly patients with cancer by medical staff evaluations and a screening tool for functional evaluation of the elderly to determine whether standard treatment is appropriate. In outpatient settings, nurses help patients to understand their symptoms through interviews including telephone interview support. We value the will of individual patients through decision-making support. We evaluated the self-care ability and decision-making support of 10 patients with pancreatic cancer aged 65 years or older who received anti-cancer therapy at our hospital. Six patients were able to observe their own symptoms and continue treatment while preventing or managing adverse events. Patients noted that issues such as "Cooperation from medical treatment to social welfare services", "Sharing the risk of developing delirium across departments", and "Utilization" were raised.

We have had a support group for patients with unresectable pancreatic cancer receiving chemotherapy in our hospital since 2014. We review how a mutual support system based on group dynamics could work for individuals with a limited prognosis and how it could assist in decision making. In addition, we consider what is essential for the practice of evidence based medicine for patients with unresectable pancreatic cancer patients and discuss what kind of medical treatment should be considered to be the end point of treatment of such patients, "Patient happiness and maximum satisfaction" through specific examples.

Pancreatic cancer is rapidly progressive and difficult to detect in its early stages. It is important to provide support to patients and their families from various perspectives, including palliative care and social support from the outset. PANDA (PANcreatic Direct Approach team) is a system that allows multi-professional staff to practice direct care by utilizing their specialized knowledge and skills. Information about palliative care can be distressing for patients and their families at a time when they are starting to make an ambitious commitment to cancer treatment, due to the common misconception that palliative care is medical treatment administered when cancer treatment is no longer available. PANDA is committed to supporting patients with pancreatic cancer and their families from the outset by providing multi-disciplinary team medical care for their physical pain, mental distress, and social difficulties, including such misunderstandings. In addition, we examined and developed ways to practice holistic care while continuing cancer chemotherapy, which is considered necessary for nurses in an outpatient chemotherapy center.

Recent evidence has shown the effectiveness of advance care planning (ACP). The Clinical Practice Guidelines for Pancreatic Cancer 2019 suggest that ACP be conducted for patients with pancreatic cancer. However, little is known about how best to practice ACP for patients with pancreatic and biliary tract cancer and their families. To help them initiate ACP, we developed educational and supportive materials by utilizing a video. Based on the International Patient Decision Aids Standards (IPDAS) that involved feedback of patients, families, and interdisciplinary health-care professionals, we developed 10-minutes of materials including a 5-minute video. A total of 3 educational sessions confirmed the feasibility of the materials. We describe the comprehensive developmental process, and discuss what is needed for such materials regarding ACP. The use of educational and supportive materials involving a video may be feasible and promising in helping patients and families initiate ACP in various institutions.

Digestive enzyme and insulin replacement therapy are needed for patients with pancreatic diabetes complicated by pancreatic exocrine insufficiency. We determine the effect of these treatments based on nutritional assessment and glycemic control. We use HbA1c and glycoalbumin levels for assessment of long-term glycemic control, and SMBG (self-monitoring of blood glucose) to assess the daily blood glucose profile. However, the confirmation of unconscious hypoglycemia and nocturnal hypoglycemia is difficult using these methods.

Continuous glucose monitoring is effective for the confirmation of unconscious hypoglycemia and nocturnal hypoglycemia. Objective assessment of hypoglycemia frequency is enabled by adding "time below target glucose range: TBR" as an assessment item for glycemic control.

Pancreatic diabetes is often complicated by exocrine pancreatic insufficiency. Pancreatic enzyme replacement therapy should be given with sufficient caloric intake and adequate insulin therapy to patients with pancreatic diabetes with exocrine pancreatic insufficiency. In the treatment of patients with pancreatic diabetes with exocrine pancreatic insufficiency, it is important to understand diet, digestion/absorption and nutrition status as the trinity of nutritional evaluation. If appropriate therapy was given, there is a risk that pancreatic enzyme replacement therapy will be discontinued in patients with changes such as emergency hospitalization.

We report a patient with pancreatic diabetes with pancreatic malabsorption caused by discontinuation of pancreatic enzyme replacement therapy, and clarify the problems of pancreatic diabetes.

Patients with pancreatic diabetes have to maintain self-care behavior throughout their lifetime. They need improvement in self-care skills, as well as knowledge of insulin therapy and the skills needed to modify it. These matters need self-efficacy to be effective in their individual situation, and medical professionals need support capabilities, not simply providing knowledge. The state of self-efficacy is divided into four patterns, and each one is considered to have its own approach. Medical professionals should support self-efficacy by reviewing the medical condition and treatment plan while considering each patient's psychological state.

Nutrition support is often required for patients with pancreatic disease, because exocrine and endocrine insufficiency can lead to malabsorption and diabetes. There is substantial evidence supporting nutritional therapy for patients with chronic pancreatitis, and an individualized approach based on disease severity and stage is recommended. To provide appropriate nutritional support, evaluation of skeletal muscle volume and physical function is important. A decreased volume of skeletal muscle and sarcopenia are associated with lower quality of life (QOL) and an increased risk of hospitalization and mortality. Evidence for the use of nutritional therapy in patients with acute pancreatitis (subacute or later phase) and pancreatic cancer is still poor, but our studies suggest that adequate nutritional support is also important for patients with these diseases. This article reviews the clinical relevance of nutritional therapy for patients with chronic pancreatitis, acute pancreatitis, and pancreatic cancer, showing some of the results of our recent research.

Patients with pancreatitis benefit from different types of dietary fat depending on their condition and require appropriate nutritional guidance to improve their quality of life. A middle aged woman who required fat restriction for drug-induced pancreatitis, was given nutritional guidance. The doctor instructed her to restrict her fat intake to 20g/day, and provided information regarding the fat content of different foods, meal plans, and food preparation techniques. However, this guidance was only provided once. Thereafter, a fat-restricted diet was considered unnecessary by the doctor and provided only at the request of the patient. Although the doctor permitted increased fat intake, the patient continued a fat-restricted diet as a precautionary measure to avoid recurrent pancreatitis. This led to significant loss of weight and muscle strength, which impeded her ability to work. Nutritional guidance was then reintroduced. In coordination with the doctor, a registered dietician evaluated the nutritional intake of the patient every month. After considerably increasing the amounts of fat, protein, and energy in her diet, the patient regained her original working situation. A registered dietician should coordinate with the doctor to actively provide routine and detailed nutritional guidance to improve the nutritional status and quality of life of patients with pancreatitis.

Drinking alcohol and smoking increase the risk of developing chronic pancreatitis. In some patients it is difficult to know the prevalence of these habits. Some patients have many personal difficulties, others cannot obtain assistance from their community, such as family and friends and have become unemployed. We recognized the importance of mutual cooperation with medical professionals for these patients who had been suffering from chronic pain of pancreatitis, were unemployed and had irregular visits to the outpatient clinic. We define the problems of patient support in this review, sending out questionnaires about knowledge regarding chronic pancreatitis and the circumstances of patient support among doctors and nurses in our ward. Consequently, the problems were identified as not only insufficient cooperation among professionals but also limited knowledge of each professional. To take action, we developed a questionnaire and foster the sense of sharing information and raising awareness of these issues in each professional. Most patients with chronic pancreatitis cannot resolve their difficulties by themselves alone. Therefore, intervention by other professionals and community support must be considered.

The employment of patients with chronic pancreatitis (CP) in Japan was examined based on a nationwide survey. Sixty-six (8.7%) of 755 patients less than 65 years old with CP were not capable of working. Among patients with CP with pain, diabetes mellitus and maldigestion 9.8%, 13.5% and 21.7%, respectively were not able to work. Patients with CP due to alcoholism (10.3%) had a higher rate of inability to work than those with idiopathic CP (2.5%). The malnutrition rate of patients with CP unable to work was higher than in patients with CP who were capable of working. These results suggest that consideration of alcohol-related problems and nutritional status as well as pain, diabetes mellitus and maldigestion is necessary so that patients with CP patients can stay employed.

The 5-year survival of patients with pancreatic cancer is so dismal that it is regarded as the most aggressive gastrointestinal cancer. Surgical resection concomitant with adjuvant therapy is the only potential cure for patients with pancreatic cancer, and neoadjuvant therapy is also being used. The JASPAC01 trial reported a remarkable effect of S-1 as adjuvant therapy which has been the standard treatment in Japan. Recently, the adjuvant use of FOLFIRINOX was reported. Following the results of the Prep-02/JSAP-05 trial, Gemcitabine and S-1 will be the standard option for neoadjuvant therapy in patients with resectable pancreatic cancer. The first randomized trial showed a benefit of neoadjuvant therapy in patients with borderline resectable pancreatic cancer. The benefit of neoadjuvant therapy in patients with locally advanced pancreatic cancer remains an unsolved clinical issue.

Background: Suspected pancreatic mucinous cystic neoplasms (MCN) are often resected in Japan, but patients without malignant findings have undergone observation only in Europe and the United States. Therefore, we examined the propriety and methods of follow-up of patients with suspected MCNs.

Methods: We examined factors predictive of malignancy in 46 patients treated at our hospital with suspected MCN or a confirmed diagnosis of MCN.

Results: The positive predictive value of preoperative diagnosis of MCN was 71% and the sensitivity was 89%. Outcomes were classified according to 29 patients with MCN (malignant 9 / benign 20), 10 with similar diseases (malignant 3 / benign 7), and 7 suspected MCN lesions (not resected). There were no deaths among patients with MCN adenomas and noninvasive carcinomas. All MCNs with mural nodules <5mm and cyst diameter <40mm were adenomas. In patients with similar diseases, it was possible to distinguish between benign and malignant by this criterion. In addition, it was suggested that an increase in size of >10mm/year and calcification might be a predictive factor for malignancy.

Conclusion: Based on the criteria of "a mural nodule <5mm and cyst diameter <40mm", it is considered possible to follow-up lesions suspected to be MCN.

Three patients with pancreatic lymphoma were seen. Primary pancreatic lymphoma accounts for less than 2% of extranodal malignant lymphomas and less than 0.5% of malignant tumors of the pancreas. In patients with pancreatic lymphoma, an accurate diagnosis is crucial because the tumor is difficult to distinguish from other pancreatic tumors-especially pancreatic cancer-based on imaging findings alone, and because the treatment depends on the specific type of lymphoma. Two of these patients improved after chemoradiation therapy. EUS-FNA was useful for determining the type of lymphoma and determining the treatment strategy.

Acinar cell carcinoma (ACC) of the pancreas developed in a 71-year-old man, The tumor behaved in an unusual manner with two episodes of alternate shrinkage and expansion without any treatment until operation. Although ACC is alleged to have a poor prognosis, this patient survived for six years after surgery without adjuvant chemotherapy. He developed dull back pain and presented in April 200X. Imaging studies had shown an unrecognized solid ellipsoid tumor, 40mm in diameter, between the liver and the pancreatic head in June 200X−6. After two episodes of alternate shrinkage and expansion, the lesion became a hypervascular inhomogeneous ellipsoid mass, 65mm in diameter, in April 200X and demonstrated expansive growth with portal vein depression. Laboratory data showed an elevated CEA (62.0ng/ml), and transabdominal fine needle aspiration biopsy revealed adenocarcinoma. Tumor extirpation was performed in July 200X. Pathology demonstrated ACC of the pancreas. The patient died of primary pulmonary cancer without recurrence of the pancreatic ACC 6 years after resection.

A 47-year-old woman was incidentally found to have a mass in the tail of the pancreas on a contrast-enhanced CT scan. EUS-FNA was performed but the specimen was non-diagnostic and she was referred to our hospital. Contrast-enhanced CT scan showed a hypovascular mass with delayed enhancement in the periphery. Repeat EUS showed a heterogenous hypoechoic mass in B mode and contrast-enhanced EUS using Perflubutane showed poor enhancement in the central part of the mass but early contrast enhancement in the margin. Several imaging findings highly suggested the mass to be a pancreatic duct adenocarcinoma. Prompt surgery without re-biopsy was preferred and curative distal pancreatectomy performed. Pathological examination showed the mass to be a NET G2. Pathological findings of hyaline necrosis and fibrosis in the central part of the tumor also reflected the imaging findings. While typical pancreatic NET tumors are hypervascular and relatively easy to diagnose, atypical lesions with disparate imaging findings are often encountered. A NET with a reduced contrast effect is considered to be relatively high grade and the poor enhancement is generally seen in larger masses. This tumor was small but highly atypical.