Periampullary cancer is a kind of malignant cancer of digestive tract.It arises within 2 cm of the major duodenal papilla and eomprises cancers of the ampulla,distal comliiOll bile duct,pancreas and duodenum.Their clinical features and anatomic locations are similar,as are the therapeutic approaches.However,their long-term outcomes vary.Due to the bad prognosis,it is very important to make an early,accurate diagnosis and differential diagnosis of periampullary cancer.This article summarizes some basic methods and new developments of early and differential diagnosis of poriampullary cancer.

Pancreatic head cancer is one of the most malignant tumor in gastrointestinal tract, which has the characteristics of rapid progression and low resection rate due to the involving of superior mesenteric vessels and portal vein. Pancreaticoduodenectomy still plays the center role in surgical management of pancreatic head cancer, however it remains some controversial in operative methods choice and extended pancreatectomy procedure. Surgeons should take sufficient considerations and make appropriate strategy preoperatively to ensure the safety, resectability and radical resection of surgery treatment.

Insulinoma is derived from beta cells, and the yearly incidence of insulinoma is 1-4 per one million. Insulinoma patients were often misdiagnosed with epilepsy or cerebrovascular diseases because of the clinical and epidemiological features of insulinoma. The diagnosis of the insulinoma is usually made biochemically with the presence of low blood glucose ( <2.5 mmol/L), elevated insulin ( ≥6 mU/L) and C-peptide levels ( ≥ 200 pmol/L), and no sulfonylureas in the blood.Supervised 72-hour fasting test has been verified as the gold standard in establishing a biochemical diagnosis of insulinoma.Localization of insulinoma is useful for selecting surgical procedures, and the methods for localization can be divided into noninvasive (transabdominal ultrasound, computed tomography,magnetic resonance imaging and endoscopic ultrasound), invasive (angiography and arterial stimulation venous sampling) and intraoperative diagnosis. Surgical treatment is the only curative method at present, and the common approaches include enuclea tion, partial pancreatic resection, resection of the body and tail of pancreas and duodenum-preserving pancreatic head resection.Most patients with sporadic insulinoma had long-term survival after the surgery. For insulinoma patients with multiple endocrine neoplasia type 1, an aggressive surgical approach is recommended.

Pancreatic cancer is the most lethal common cancer and the most complicated disease to diagnose and treat.A large amount of clinical researches have been conducted in the area of pancreatic cancer over the past century,which have directly improved the level of diagnosis and treatment for pancreatic cancer.Through reviewing the achievements of clinical researches for pancreatic cancer,the approaches to carry out high-level clinical researches and the importance of surgeons' participation in clinical research,this article aims to promote the development of clinical researches for pancreatic cancer,and improve the level of diagnosis and treatment for pancreatic cancer.

For decades,the improvement of diagnosis and treatment of pancreatic cancer is being extremely difficult,and the survival rates remain extremely low.The primary objective of translational medicine is to remove the barriers among basic medical research,clinical medicine,new therapies and pharmaceutical research and development,to realize the actual combination of laboratory,clinical and other related departments,and accelerate the translation of acquired knowledge and achievements in basic research into clinical diagnosis,evaluation and treatment of diseases,promoting the spread of scientific clinical notion and methods.To strengthen the translational medical research in pancreatic cancer,the establishment of professional team and research platform of translational medicine is necessary.Based on this platform,comprehensive research on early diagnosis and pathogenesis of pancreatic cancer can be carried out to screen highly efficient tumor markers and treatment targets.For these tumor markers and targeted drugs need to be further verified in clinics.At the same time,through appropriate animal model,the chemotherapy regimen can be optimized to improve the chemotherapy sensitivity,and individual treatment can truly be achieved.

Hedgehog (Hh) signaling is critical for embryonic development and in differentiation,proliferation,and maintenance of multiple adult tissues.Deregulation of the Hh pathway is associated with Multiple pathological steps of PDAC(Pancreatic ductal adenocarcinoma).A prominent desmoplastic stromal reaction is the pathological hallmark of PDAC,it contributes to the formation of the hypovascular and hypoxic microenvironment of PDAC.And Hedgehog signaling is one of the most crucial pathways that maintains and activates the stroma.Clinical trials of Hedgehog signaling inhibitors in treatment of PDAC has been conducted,but results have been disappointing.Recently,to undercover the reason of the failure of clinical trial,more work has been done to uncovering the underlying role of stroma in PDAC.

Gemcitabine has become a first-line chemotherapeutic durg.Unfortunately,many patients fail to derive benefits from gemcitabine in clinics.The variability of human equilibrative nucleoside transporter 1 (hENT1)expression in tumor cells,which plays a dominant role in the transport of gemcitabine across the cell membrane,may be one of the reason for gemcitabine chemoresistance in pancreatic cancer.

Adenocarcinoma of exocrine pancreas is a highly malignant tumor with extremely low resectability.Radiotherapy,by inducing necrosis and apoptosis of tumor cells through irradiation effects on cellular DNA,in combination with chemotherapy,has made great contribution to multimodal treatment of this malignancy.The development of radiation therapy for pancreatic carcinoma in recent years was reviewed in neoadjuvant and adjuvant settings,and for locally advanced disease.Further evidence is required to show the impact of radiochemotherapy in the treatment of unresectable disease.

Pancreatic adenocarcinoma is a highly malignant tumor and its prognosis is poor. The key factors for cure and prolonged survival are early detection, adequate evaluation of resectability and surgical resection with microscopic tumor clearance. Surgeons should pay attention to standardize operative procedures to increase the R0 resection rate. Whipple specimens should be inked and examined carefully. Postoperative adjuvant radiotherapy and chemotherapy are beneficial in the prevention of local tumor recurrence and distant metastasis. Inter-disciplinary cooperation and multimodality treatment are helpful to improve the prognosis and quality of life of patients with pancreatic cancer.

Pancreatic cancer is an aggressive malignant gastrointestinal tumor,surgical resection offers the only chance of cure. Due to its anatomic and biological characters,early stage pancreatic cancer is usually clinically silent,80％-85％ of patients present with advanced unresectable disease. Furthermore,pancreatic cancer responds poorly to most radiochemotherapeutic agents.In this article,we discuss some clinical aspects including early diagnosis,preoperative systemic assessment,surgery and perioperartive adjuvant therapy,and we hope to find the challenges as well as strategies for pancreatic cancer in order to further improve the current level of diagnosis and treatment in China.