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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. </p></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/pdqcis/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-pdqcis-lrg.png" alt="Cover of PDQ Cancer Information Summaries" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>PDQ Cancer Information Summaries [Internet].</h2><a data-jig="ncbitoggler" href="#__NBK549123_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK549123_dtls__"><div>Bethesda (MD): <a href="http://www.cancer.gov/" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">National Cancer Institute (US)</a>; 2002-.</div></div><div class="half_rhythm"></div><div class="bk_noprnt"><form method="get" action="/books/n/pdqcis/" id="bk_srch"><div class="bk_search"><label for="bk_term" class="offscreen_noflow">Search term</label><input type="text" title="Search this book" id="bk_term" name="term" value="" data-jig="ncbiclearbutton" /> <input type="submit" class="jig-ncbibutton" value="Search this book" submit="false" style="padding: 0.1em 0.4em;" /></div></form></div></div></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK549123_"><span class="title" itemprop="name">Childhood Pancreatic Cancer Treatment (PDQ®)</span></h1><div class="subtitle whole_rhythm">Health Professional Version</div><p class="contrib-group"><span itemprop="author">PDQ Pediatric Treatment Editorial Board</span>.</p><p class="small">Published online: October 6, 2020.</p><p class="small">Created: <span itemprop="datePublished">October 22, 2019</span>.</p></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="_abs_rndgid_" itemprop="description"><p id="CDR0000799716__1556">This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of pediatric pancreatic cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.</p><p id="CDR0000799716__1557">This summary is reviewed regularly and updated as necessary by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).</p></div><div id="CDR0000799716__2185"><h2 id="_CDR0000799716__2185_">General Information About Childhood Pancreatic Cancer</h2><p id="CDR0000799716__1355">Malignant pancreatic tumors are rare in children and adolescents, with an incidence of 0.46 cases per 1 million individuals younger than 30 years.[<a class="bk_pop" href="#CDR0000799716_rl_2185_1">1</a>-<a class="bk_pop" href="#CDR0000799716_rl_2185_4">4</a>] </p><p id="CDR0000799716__1513">The primary pancreatic tumors of childhood can be classified into the following four categories: </p><ul id="CDR0000799716__1356"><li class="half_rhythm"><div><a href="#CDR0000799716__1357">Solid pseudopapillary tumor of the pancreas.</a></div></li><li class="half_rhythm"><div><a href="#CDR0000799716__1361">Pancreatoblastoma.</a></div></li><li class="half_rhythm"><div><a href="#CDR0000799716__1367">Islet cell tumors.</a></div></li><li class="half_rhythm"><div><a href="#CDR0000799716__1372">Pancreatic carcinoma.</a></div></li></ul><div id="CDR0000799716_rl_2185"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000799716_rl_2185_1">Chung EM, Travis MD, Conran RM: Pancreatic tumors in children: radiologic-pathologic correlation. Radiographics 26 (4): 1211-38, 2006 Jul-Aug. [<a href="https://pubmed.ncbi.nlm.nih.gov/16844942" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16844942</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_2185_2">Perez EA, Gutierrez JC, Koniaris LG, et al.: Malignant pancreatic tumors: incidence and outcome in 58 pediatric patients. J Pediatr Surg 44 (1): 197-203, 2009. [<a href="https://pubmed.ncbi.nlm.nih.gov/19159743" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19159743</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_2185_3">Dall'igna P, Cecchetto G, Bisogno G, et al.: Pancreatic tumors in children and adolescents: the Italian TREP project experience. Pediatr Blood Cancer 54 (5): 675-80, 2010. [<a href="https://pubmed.ncbi.nlm.nih.gov/19998473" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19998473</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_2185_4">Brecht IB, Schneider DT, Klöppel G, et al.: Malignant pancreatic tumors in children and young adults: evaluation of 228 patients identified through the Surveillance, Epidemiology, and End Result (SEER) database. Klin Padiatr 223 (6): 341-5, 2011. [<a href="https://pubmed.ncbi.nlm.nih.gov/22012608" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22012608</span></a>]</div></li></ol></div></div><div id="CDR0000799716__1357"><h2 id="_CDR0000799716__1357_">Solid Pseudopapillary Tumor of the Pancreas</h2><div id="CDR0000799716__2134"><h3>Incidence</h3><p id="CDR0000799716__2135">Solid pseudopapillary tumor of the pancreas, also known as Frantz tumor, is the most common pediatric pancreatic tumor, accounting for up to 70% of cases in most institutional series.[<a class="bk_pop" href="#CDR0000799716_rl_1357_1">1</a>,<a class="bk_pop" href="#CDR0000799716_rl_1357_2">2</a>] This tumor has low malignant potential and most commonly affects females of reproductive age (median age, 21 years), with a predilection for blacks and East Asians.[<a class="bk_pop" href="#CDR0000799716_rl_1357_2">2</a>-<a class="bk_pop" href="#CDR0000799716_rl_1357_4">4</a>] There is no known genetic or hormonal factor to explain the strong female predilection, although it has been noted that all tumors express progesterone receptors.[<a class="bk_pop" href="#CDR0000799716_rl_1357_5">5</a>]</p></div><div id="CDR0000799716__2136"><h3>Histology</h3><p id="CDR0000799716__2137">Histologically, the tumors are characterized by a combination of solid, pseudopapillary, and cystic changes. The fragility of the vascular supply leads to secondary degenerative changes and cystic areas of hemorrhage and necrosis. The cells surrounding the hyalinized fibrovascular stalks form the pseudopapillae.[<a class="bk_pop" href="#CDR0000799716_rl_1357_3">3</a>] A highly specific paranuclear dot-like immunoreactivity pattern for CD99 has been described.[<a class="bk_pop" href="#CDR0000799716_rl_1357_6">6</a>]</p></div><div id="CDR0000799716__2138"><h3>Clinical Presentation</h3><p id="CDR0000799716__2139">Solid pseudopapillary tumor of the pancreas is a very friable tumor, and tumor rupture and hemoperitoneum have been reported.[<a class="bk_pop" href="#CDR0000799716_rl_1357_2">2</a>-<a class="bk_pop" href="#CDR0000799716_rl_1357_4">4</a>] Tumors can occur throughout the pancreas and are often exophytic. On imaging, the mass shows typical cystic and solid components, with intratumoral hemorrhage and a fibrous capsule.[<a class="bk_pop" href="#CDR0000799716_rl_1357_3">3</a>] A retrospective review of the National Cancer Database identified 21 pediatric patients (younger than 18 years) and 348 adult patients with solid pseudopapillary neoplasm of the pancreas.[<a class="bk_pop" href="#CDR0000799716_rl_1357_7">7</a>] When compared with their adult counterparts, children with solid pseudopapillary neoplasms had similar disease severity at presentation, received similar treatments, and experienced equivalent postoperative outcomes.</p></div><div id="CDR0000799716__2140"><h3>Outcome</h3><p id="CDR0000799716__2141">The outcome of solid pseudopapillary tumors of the pancreas is excellent, with 10-year survival rates exceeding 95%.[<a class="bk_pop" href="#CDR0000799716_rl_1357_5">5</a>]</p></div><div id="CDR0000799716__2142"><h3>Treatment of Solid Pseudopapillary Tumor of the Pancreas</h3><p id="CDR0000799716__2143">Treatment options for solid pseudopapillary tumor of the pancreas include the following:</p><ol id="CDR0000799716__2144"><li class="half_rhythm"><div>Surgery.</div></li><li class="half_rhythm"><div>Chemotherapy.</div></li></ol><p id="CDR0000799716__2145">Treatment of solid pseudopapillary tumor of the pancreas is surgical; however, preoperative and operative spillage is not unusual.[<a class="bk_pop" href="#CDR0000799716_rl_1357_8">8</a>] Whipple procedures (pancreaticoduodenectomy) are often necessary, but non-Whipple pancreatic-sparing resections may be possible utilizing a pancreatico-jejunostomy procedure. Surgery is usually curative, although local recurrences occur in 5% to 15% of the cases.[<a class="bk_pop" href="#CDR0000799716_rl_1357_4">4</a>] A retrospective review of the Italian Pediatric Rare Tumor Registry identified 43 pediatric patients diagnosed with solid pseudopapillary tumor of the pancreas between 2000 and 2018.[<a class="bk_pop" href="#CDR0000799716_rl_1357_9">9</a>][<a href="/books/n/pdqcis/glossary_loe/def-item/glossary_loe_CDR0000335144/" class="def">Level of evidence: 3iiA</a>] The median age at diagnosis was 13.2 years (range, 7–18 years). Only one patient presented with metastatic disease. At follow-up (median, 8.4 years; range, 0–17 years), one recurrence occurred in a patient who had intraoperative rupture, and all patients were alive.</p><p id="CDR0000799716__2146">Metastatic disease, usually in the liver, may occur in up to 15% of the cases.[<a class="bk_pop" href="#CDR0000799716_rl_1357_2">2</a>-<a class="bk_pop" href="#CDR0000799716_rl_1357_6">6</a>] Single-agent gemcitabine has been reported to be effective in cases of unresectable or metastatic disease.[<a class="bk_pop" href="#CDR0000799716_rl_1357_10">10</a>]</p></div><div id="CDR0000799716_rl_1357"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000799716_rl_1357_1">Rojas Y, Warneke CL, Dhamne CA, et al.: Primary malignant pancreatic neoplasms in children and adolescents: a 20 year experience. J Pediatr Surg 47 (12): 2199-204, 2012. [<a href="https://pubmed.ncbi.nlm.nih.gov/23217876" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23217876</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_2">Dall'igna P, Cecchetto G, Bisogno G, et al.: Pancreatic tumors in children and adolescents: the Italian TREP project experience. Pediatr Blood Cancer 54 (5): 675-80, 2010. [<a href="https://pubmed.ncbi.nlm.nih.gov/19998473" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19998473</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_3">Chung EM, Travis MD, Conran RM: Pancreatic tumors in children: radiologic-pathologic correlation. Radiographics 26 (4): 1211-38, 2006 Jul-Aug. [<a href="https://pubmed.ncbi.nlm.nih.gov/16844942" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16844942</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_4">Papavramidis T, Papavramidis S: Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in English literature. J Am Coll Surg 200 (6): 965-72, 2005. [<a href="https://pubmed.ncbi.nlm.nih.gov/15922212" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15922212</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_5">Estrella JS, Li L, Rashid A, et al.: Solid pseudopapillary neoplasm of the pancreas: clinicopathologic and survival analyses of 64 cases from a single institution. Am J Surg Pathol 38 (2): 147-57, 2014. [<a href="https://pubmed.ncbi.nlm.nih.gov/24418850" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24418850</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_6">Laje P, Bhatti TR, Adzick NS: Solid pseudopapillary neoplasm of the pancreas in children: a 15-year experience and the identification of a unique immunohistochemical marker. J Pediatr Surg 48 (10): 2054-60, 2013. [<a href="https://pubmed.ncbi.nlm.nih.gov/24094957" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24094957</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_7">Leraas HJ, Kim J, Sun Z, et al.: Solid Pseudopapillary Neoplasm of the Pancreas in Children and Adults: A National Study of 369 Patients. J Pediatr Hematol Oncol 40 (4): e233-e236, 2018. [<a href="https://pubmed.ncbi.nlm.nih.gov/29240036" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29240036</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_8">Vasudevan SA, Ha TN, Zhu H, et al.: Pancreaticoduodenectomy for the treatment of pancreatic neoplasms in children: A Pediatric Surgical Oncology Research Collaborative study. Pediatr Blood Cancer 67 (9): e28425, 2020. [<a href="/pmc/articles/PMC7674210/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7674210</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32658372" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32658372</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_9">Crocoli A, Grimaldi C, Virgone C, et al.: Outcome after surgery for solid pseudopapillary pancreatic tumors in children: Report from the TREP project-Italian Rare Tumors Study Group. Pediatr Blood Cancer 66 (3): e27519, 2019. [<a href="https://pubmed.ncbi.nlm.nih.gov/30362240" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30362240</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1357_10">Maffuz A, Bustamante Fde T, Silva JA, et al.: Preoperative gemcitabine for unresectable, solid pseudopapillary tumour of the pancreas. Lancet Oncol 6 (3): 185-6, 2005. [<a href="https://pubmed.ncbi.nlm.nih.gov/15737835" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15737835</span></a>]</div></li></ol></div></div><div id="CDR0000799716__1361"><h2 id="_CDR0000799716__1361_">Pancreatoblastoma</h2><div id="CDR0000799716__2147"><h3>Incidence and Risk Factors</h3><p id="CDR0000799716__2148">Pancreatoblastoma accounts for 10% to 20% of all pancreatic tumors during childhood. It is the most common pancreatic tumor of young children and typically presents in the first decade of life, with a median age at diagnosis of 5 years.[<a class="bk_pop" href="#CDR0000799716_rl_1361_1">1</a>,<a class="bk_pop" href="#CDR0000799716_rl_1361_2">2</a>]</p><p id="CDR0000799716__2149">Patients with Beckwith-Wiedemann syndrome have an increased risk of developing pancreatoblastoma; this syndrome is identified in up to 60% of cases of pancreatoblastoma developing during early infancy and in 5% of children developing pancreatoblastoma later in life.[<a class="bk_pop" href="#CDR0000799716_rl_1361_3">3</a>] Pancreatoblastoma has also been associated with familial adenomatous polyposis syndromes.[<a class="bk_pop" href="#CDR0000799716_rl_1361_4">4</a>]</p></div><div id="CDR0000799716__2150"><h3>Histology and Molecular Features</h3><p id="CDR0000799716__2151">This tumor is thought to arise from the persistence of the fetal analog of pancreatic acinar cells. Pathology shows an epithelial neoplasm with an arrangement of acinar, trabecular, or solid formations separated by dense stromal bands.[<a class="bk_pop" href="#CDR0000799716_rl_1361_1">1</a>]
|
|
<i>CTNNB1</i> and <i>IGF2</i> gene mutations have been described in some cases, suggesting that pancreatoblastoma might result from alterations in the normal pancreas differentiation.[<a class="bk_pop" href="#CDR0000799716_rl_1361_5">5</a>,<a class="bk_pop" href="#CDR0000799716_rl_1361_6">6</a>]</p></div><div id="CDR0000799716__2152"><h3>Clinical Presentation</h3><p id="CDR0000799716__2153">Although approximately one-half of the cases originate in the head of the pancreas, jaundice is uncommon. Close to 80% of the tumors secrete alpha-fetoprotein, which can be used to measure response to therapy and monitor for recurrence.[<a class="bk_pop" href="#CDR0000799716_rl_1361_2">2</a>] In some cases, the tumor may secrete adrenocorticotropic hormone (ACTH) or antidiuretic hormone, and patients may present with Cushing syndrome and the syndrome of inappropriate antidiuretic hormone secretion.[<a class="bk_pop" href="#CDR0000799716_rl_1361_3">3</a>] Metastases are present in 30% to 40% of the patients, usually involving liver, lungs, and lymph nodes.[<a class="bk_pop" href="#CDR0000799716_rl_1361_2">2</a>]</p></div><div id="CDR0000799716__2154"><h3>Outcome</h3><p id="CDR0000799716__2155">Using a multimodality approach, close to 80% of patients can be cured.[<a class="bk_pop" href="#CDR0000799716_rl_1361_2">2</a>]</p></div><div id="CDR0000799716__2156"><h3>Treatment of Pancreatoblastoma</h3><p id="CDR0000799716__2157">Treatment options for pancreatoblastoma include the following:</p><ol id="CDR0000799716__2158"><li class="half_rhythm"><div>Surgery.</div></li><li class="half_rhythm"><div>Chemotherapy.</div></li></ol><p id="CDR0000799716__2159">Surgery is the mainstay in the treatment of pancreatoblastoma, and a complete surgical resection is required for cure. Because of the common origin in the head of the pancreas, a Whipple procedure is usually required.[<a class="bk_pop" href="#CDR0000799716_rl_1361_7">7</a>,<a class="bk_pop" href="#CDR0000799716_rl_1361_8">8</a>]</p><p id="CDR0000799716__2160">For large, unresectable, or metastatic tumors, preoperative chemotherapy is indicated; pancreatoblastoma commonly responds to chemotherapy, and a cisplatin-based regimen is usually recommended. The PLADO regimen, which includes cisplatin and doxorubicin, is the most commonly used regimen, and treatment is modeled after the management of hepatoblastoma, with two to three cycles of preoperative therapy, followed by resection and adjuvant chemotherapy.[<a class="bk_pop" href="#CDR0000799716_rl_1361_2">2</a>,<a class="bk_pop" href="#CDR0000799716_rl_1361_4">4</a>,<a class="bk_pop" href="#CDR0000799716_rl_1361_9">9</a>,<a class="bk_pop" href="#CDR0000799716_rl_1361_10">10</a>]</p><p id="CDR0000799716__2161">Although radiation therapy has been used in unresectable or relapsed cases, its role in the treatment of microscopic disease after surgery has not been defined.[<a class="bk_pop" href="#CDR0000799716_rl_1361_4">4</a>]</p><p id="CDR0000799716__2162">Response has been seen for patients with relapsed or persistent pancreatoblastoma treated with gemcitabine in one case [<a class="bk_pop" href="#CDR0000799716_rl_1361_11">11</a>] and vinorelbine and oral cyclophosphamide in two cases.[<a class="bk_pop" href="#CDR0000799716_rl_1361_12">12</a>]</p><p id="CDR0000799716__2163">High-dose chemotherapy with autologous hematopoietic stem cell rescue has been reported to be effective in selected cases.[<a class="bk_pop" href="#CDR0000799716_rl_1361_9">9</a>,<a class="bk_pop" href="#CDR0000799716_rl_1361_13">13</a>]</p></div><div id="CDR0000799716_rl_1361"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000799716_rl_1361_1">Chung EM, Travis MD, Conran RM: Pancreatic tumors in children: radiologic-pathologic correlation. Radiographics 26 (4): 1211-38, 2006 Jul-Aug. [<a href="https://pubmed.ncbi.nlm.nih.gov/16844942" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16844942</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_2">Bien E, Godzinski J, Dall'igna P, et al.: Pancreatoblastoma: a report from the European cooperative study group for paediatric rare tumours (EXPeRT). Eur J Cancer 47 (15): 2347-52, 2011. [<a href="https://pubmed.ncbi.nlm.nih.gov/21696948" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21696948</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_3">Chisholm KM, Hsu CH, Kim MJ, et al.: Congenital pancreatoblastoma: report of an atypical case and review of the literature. J Pediatr Hematol Oncol 34 (4): 310-5, 2012. [<a href="https://pubmed.ncbi.nlm.nih.gov/22278199" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22278199</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_4">Glick RD, Pashankar FD, Pappo A, et al.: Management of pancreatoblastoma in children and young adults. J Pediatr Hematol Oncol 34 (Suppl 2): S47-50, 2012. [<a href="https://pubmed.ncbi.nlm.nih.gov/22525406" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22525406</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_5">Honda S, Okada T, Miyagi H, et al.: Spontaneous rupture of an advanced pancreatoblastoma: aberrant RASSF1A methylation and CTNNB1 mutation as molecular genetic markers. J Pediatr Surg 48 (4): e29-32, 2013. [<a href="https://pubmed.ncbi.nlm.nih.gov/23583162" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23583162</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_6">Isobe T, Seki M, Yoshida K, et al.: Integrated Molecular Characterization of the Lethal Pediatric Cancer Pancreatoblastoma. Cancer Res 78 (4): 865-876, 2018. [<a href="https://pubmed.ncbi.nlm.nih.gov/29233928" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29233928</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_7">Vasudevan SA, Ha TN, Zhu H, et al.: Pancreaticoduodenectomy for the treatment of pancreatic neoplasms in children: A Pediatric Surgical Oncology Research Collaborative study. Pediatr Blood Cancer 67 (9): e28425, 2020. [<a href="/pmc/articles/PMC7674210/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7674210</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32658372" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32658372</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_8">Lindholm EB, Alkattan AK, Abramson SJ, et al.: Pancreaticoduodenectomy for pediatric and adolescent pancreatic malignancy: A single-center retrospective analysis. J Pediatr Surg 52 (2): 299-303, 2017. [<a href="/pmc/articles/PMC5253309/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5253309</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27894759" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27894759</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_9">Dall'igna P, Cecchetto G, Bisogno G, et al.: Pancreatic tumors in children and adolescents: the Italian TREP project experience. Pediatr Blood Cancer 54 (5): 675-80, 2010. [<a href="https://pubmed.ncbi.nlm.nih.gov/19998473" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19998473</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_10">Défachelles AS, Martin De Lassalle E, Boutard P, et al.: Pancreatoblastoma in childhood: clinical course and therapeutic management of seven patients. Med Pediatr Oncol 37 (1): 47-52, 2001. [<a href="https://pubmed.ncbi.nlm.nih.gov/11466723" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 11466723</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_11">Belletrutti MJ, Bigam D, Bhargava R, et al.: Use of gemcitabine with multi-stage surgical resection as successful second-line treatment of metastatic pancreatoblastoma. J Pediatr Hematol Oncol 35 (1): e7-10, 2013. [<a href="https://pubmed.ncbi.nlm.nih.gov/23042010" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23042010</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_12">Dhamne C, Herzog CE: Response of Relapsed Pancreatoblastoma to a Combination of Vinorelbine and Oral Cyclophosphamide. J Pediatr Hematol Oncol 37 (6): e378-80, 2015. [<a href="https://pubmed.ncbi.nlm.nih.gov/26056794" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26056794</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1361_13">Hamidieh AA, Jalili M, Khojasteh O, et al.: Autologous stem cell transplantation as treatment modality in a patient with relapsed pancreatoblastoma. Pediatr Blood Cancer 55 (3): 573-6, 2010. [<a href="https://pubmed.ncbi.nlm.nih.gov/20658635" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20658635</span></a>]</div></li></ol></div></div><div id="CDR0000799716__1367"><h2 id="_CDR0000799716__1367_">Islet Cell Tumors</h2><div id="CDR0000799716__2164"><h3>Incidence and Risk Factors</h3><p id="CDR0000799716__2165">Islet cell tumors represent approximately 15% of pediatric pancreatic tumors in most series.[<a class="bk_pop" href="#CDR0000799716_rl_1367_1">1</a>-<a class="bk_pop" href="#CDR0000799716_rl_1367_3">3</a>] These tumors usually present in middle age and may be associated with multiple endocrine neoplasia type 1 (MEN1) syndrome; less than 5% of islet cell tumors occur in children.[<a class="bk_pop" href="#CDR0000799716_rl_1367_4">4</a>]</p></div><div id="CDR0000799716__2166"><h3>Clinical Presentation</h3><p id="CDR0000799716__2167">The most common type of functioning islet cell tumor is insulinoma, followed by gastrinoma.</p><ul id="CDR0000799716__2168"><li class="half_rhythm"><div><b>Insulinoma.</b> Patients with insulinoma present with fasting hyperinsulinic hypoglycemia; in young children, presentation may include behavioral problems, seizures, or coma. </div></li><li class="half_rhythm"><div><b>Gastrinoma.</b> Gastrinoma presents with Zollinger-Ellison syndrome, with recurrent peptic ulcers in uncommon locations, and diarrhea caused by gastric hypersecretion. While most insulinomas are benign, a significant proportion of gastrinomas are malignant.[<a class="bk_pop" href="#CDR0000799716_rl_1367_3">3</a>] </div></li><li class="half_rhythm"><div><b>ACTHoma and VIPoma.</b> Other less common tumors seldom seen in children are the ACTHoma, which presents as Cushing syndrome, and the VIPoma, which presents as Verner-Morrison syndrome. </div></li></ul><p id="CDR0000799716__2169">Nonfunctioning tumors are extremely rare in pediatrics, except when associated with MEN1 syndrome. Islet cell tumors are typically solitary; when multiple tumors are present, the diagnosis of MEN1 syndrome should be considered.</p><p id="CDR0000799716__2170">On imaging, these tumors are usually small and well defined. Somatostatin receptor scintigraphy is useful for the location of islet cell tumors; however, only 60% to 70% express somatostatin receptor.[<a class="bk_pop" href="#CDR0000799716_rl_1367_4">4</a>]</p></div><div id="CDR0000799716__2171"><h3>Treatment of Islet Cell Tumors</h3><p id="CDR0000799716__2172">Treatment options for islet cell tumors include the following:</p><ol id="CDR0000799716__2173"><li class="half_rhythm"><div>Surgery.</div></li><li class="half_rhythm"><div>Chemotherapy.</div></li><li class="half_rhythm"><div>Mammalian target of rapamycin (mTOR) inhibitor therapy.</div></li></ol><p id="CDR0000799716__2174">Treatment of islet cell tumors includes medical therapy for control of the syndrome and complete surgical resection.[<a class="bk_pop" href="#CDR0000799716_rl_1367_5">5</a>] For patients with malignant tumors and unresectable or metastatic disease, chemotherapy and mTOR inhibitors are recommended.</p><p id="CDR0000799716__2175">The management of these tumors in children follows the consensus guidelines established for adult patients.[<a class="bk_pop" href="#CDR0000799716_rl_1367_3">3</a>,<a class="bk_pop" href="#CDR0000799716_rl_1367_6">6</a>] (Refer to the PDQ summary on adult <a href="/books/n/pdqcis/CDR0000062794/">Pancreatic Neuroendocrine Tumors [Islet Cell Tumors] Treatment</a> for more information.)</p></div><div id="CDR0000799716_rl_1367"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000799716_rl_1367_1">Rojas Y, Warneke CL, Dhamne CA, et al.: Primary malignant pancreatic neoplasms in children and adolescents: a 20 year experience. J Pediatr Surg 47 (12): 2199-204, 2012. [<a href="https://pubmed.ncbi.nlm.nih.gov/23217876" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23217876</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1367_2">Dall'igna P, Cecchetto G, Bisogno G, et al.: Pancreatic tumors in children and adolescents: the Italian TREP project experience. Pediatr Blood Cancer 54 (5): 675-80, 2010. [<a href="https://pubmed.ncbi.nlm.nih.gov/19998473" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19998473</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1367_3">Jensen RT, Cadiot G, Brandi ML, et al.: ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: functional pancreatic endocrine tumor syndromes. Neuroendocrinology 95 (2): 98-119, 2012. [<a href="/pmc/articles/PMC3701449/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3701449</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22261919" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22261919</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1367_4">Chung EM, Travis MD, Conran RM: Pancreatic tumors in children: radiologic-pathologic correlation. Radiographics 26 (4): 1211-38, 2006 Jul-Aug. [<a href="https://pubmed.ncbi.nlm.nih.gov/16844942" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16844942</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1367_5">Vasudevan SA, Ha TN, Zhu H, et al.: Pancreaticoduodenectomy for the treatment of pancreatic neoplasms in children: A Pediatric Surgical Oncology Research Collaborative study. Pediatr Blood Cancer 67 (9): e28425, 2020. [<a href="/pmc/articles/PMC7674210/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7674210</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32658372" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32658372</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1367_6">Kulke MH, Benson AB, Bergsland E, et al.: Neuroendocrine tumors. J Natl Compr Canc Netw 10 (6): 724-64, 2012. [<a href="https://pubmed.ncbi.nlm.nih.gov/22679117" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22679117</span></a>]</div></li></ol></div></div><div id="CDR0000799716__1372"><h2 id="_CDR0000799716__1372_">Pancreatic Carcinoma</h2><div id="CDR0000799716__2176"><h3>Incidence and Risk Factors</h3><p id="CDR0000799716__2177">Pancreatic carcinomas (acinar cell carcinoma and ductal adenocarcinoma) are extremely rare in children. These malignancies represent less than 5% of pediatric pancreatic tumors and include the following:[<a class="bk_pop" href="#CDR0000799716_rl_1372_1">1</a>,<a class="bk_pop" href="#CDR0000799716_rl_1372_2">2</a>]</p><ul id="CDR0000799716__2178"><li class="half_rhythm"><div><b>Acinar cell carcinoma.</b> Although rare in pediatrics, acinar cell carcinoma is more common than ductal cell adenocarcinoma, the most common pancreatic carcinoma in adults. Acinar cell carcinoma is considered to be the adult counterpart of pancreatoblastoma, and histological differentiation between both entities may be difficult.[<a class="bk_pop" href="#CDR0000799716_rl_1372_3">3</a>]</div></li><li class="half_rhythm"><div><b>Ductal adenocarcinoma.</b> Ductal adenocarcinoma is rare in the first four decades of life and even rarer during childhood and adolescence.[<a class="bk_pop" href="#CDR0000799716_rl_1372_4">4</a>] Ductal adenocarcinoma is associated with several cancer predisposition syndromes, such as hereditary pancreatitis (<i>PRSS1</i> mutations), familial atypical mole and multiple melanoma (<i>CDKN2</i> mutations), Peutz-Jeghers syndrome and other hereditary nonpolyposis colon carcinomas (<i>STK11</i> and germline mismatch repair genes), and syndromes associated with DNA repair gene mutations (such as <i>BRCA2</i> and <i>ATM</i>).[<a class="bk_pop" href="#CDR0000799716_rl_1372_5">5</a>]</div></li></ul></div><div id="CDR0000799716__2179"><h3>Clinical Presentation</h3><p id="CDR0000799716__2180">Presenting symptoms are nonspecific and are related to local tumor growth. However, 4% to 15% of adult patients with acinar cell carcinoma may present with a lipase hypersecretion syndrome, manifesting as peripheral polyarthropathy and painful subcutaneous nodules.</p></div><div id="CDR0000799716__2181"><h3>Treatment of Pancreatic Carcinoma</h3><p id="CDR0000799716__2182">(Refer to the PDQ summary on <a href="/books/n/pdqcis/CDR0000062951/">Pancreatic
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Cancer Treatment [Adult]</a> for information about the treatment of pancreatic carcinoma.)</p></div><div id="CDR0000799716_rl_1372"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000799716_rl_1372_1">Rojas Y, Warneke CL, Dhamne CA, et al.: Primary malignant pancreatic neoplasms in children and adolescents: a 20 year experience. J Pediatr Surg 47 (12): 2199-204, 2012. [<a href="https://pubmed.ncbi.nlm.nih.gov/23217876" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23217876</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1372_2">Dall'igna P, Cecchetto G, Bisogno G, et al.: Pancreatic tumors in children and adolescents: the Italian TREP project experience. Pediatr Blood Cancer 54 (5): 675-80, 2010. [<a href="https://pubmed.ncbi.nlm.nih.gov/19998473" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19998473</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1372_3">Chung EM, Travis MD, Conran RM: Pancreatic tumors in children: radiologic-pathologic correlation. Radiographics 26 (4): 1211-38, 2006 Jul-Aug. [<a href="https://pubmed.ncbi.nlm.nih.gov/16844942" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16844942</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1372_4">Lüttges J, Stigge C, Pacena M, et al.: Rare ductal adenocarcinoma of the pancreas in patients younger than age 40 years. Cancer 100 (1): 173-82, 2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/14692038" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 14692038</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1372_5">Rustgi AK: Familial pancreatic cancer: genetic advances. Genes Dev 28 (1): 1-7, 2014. [<a href="/pmc/articles/PMC3894408/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3894408</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24395243" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24395243</span></a>]</div></li></ol></div></div><div id="CDR0000799716__1945"><h2 id="_CDR0000799716__1945_">Treatment Options Under Clinical Evaluation for Childhood Pancreatic Cancer</h2><p id="CDR0000799716__1946">Information about National Cancer Institute (NCI)–supported clinical trials can be found on the <a href="https://www.cancer.gov/about-cancer/treatment/clinical-trials/search" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NCI website</a>. For information about clinical trials sponsored by other organizations, refer to the <a href="https://clinicaltrials.gov/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">ClinicalTrials.gov website</a>.</p><p id="CDR0000799716__1947">The following is an example of a national and/or institutional clinical trial that is currently being conducted:</p><ul id="CDR0000799716__1948"><li class="half_rhythm"><div class="half_rhythm"><b><a href="https://www.cancer.gov/clinicaltrials/NCT03155620" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">APEC1621 (NCT03155620)</a></b> (Pediatric MATCH: Targeted Therapy Directed by Genetic Testing in Treating Pediatric Patients with Relapsed or Refractory Advanced Solid Tumors, Non-Hodgkin Lymphomas, or Histiocytic Disorders)<b>:</b> NCI-COG Pediatric Molecular Analysis for Therapeutic Choice (MATCH), referred to as Pediatric MATCH, will match targeted agents with specific molecular changes identified using a next-generation sequencing targeted assay of more than 4,000 different mutations across more than 160 genes in refractory and recurrent solid tumors. Children and adolescents aged 1 to 21 years are eligible for the trial.</div><div class="half_rhythm">Tumor tissue from progressive or recurrent disease must be available for molecular characterization. Patients with tumors that have molecular variants addressed by treatment arms included in the trial will be offered treatment on Pediatric MATCH. Additional information can be obtained on the <a href="https://www.cancer.gov/about-cancer/treatment/clinical-trials/nci-supported/pediatric-match" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NCI website</a> and <a href="https://clinicaltrials.gov/ct2/show/NCT03155620" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">ClinicalTrials.gov website</a>.
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</div></li></ul></div><div id="CDR0000799716__1864"><h2 id="_CDR0000799716__1864_">Special Considerations for the Treatment of Children With Cancer</h2><p id="CDR0000799716__1865">Cancer in children and adolescents is rare, although the overall incidence of childhood cancer has been slowly increasing since 1975.[<a class="bk_pop" href="#CDR0000799716_rl_1864_1">1</a>] Referral to medical centers with multidisciplinary teams of cancer specialists experienced in treating cancers that occur in childhood and adolescence should be considered for children and adolescents with cancer. This multidisciplinary team approach incorporates the skills
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of the following health care professionals and others to ensure that children receive treatment, supportive care, and rehabilitation
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that will achieve optimal survival and quality of life:</p><ul id="CDR0000799716__1866"><li class="half_rhythm"><div>Primary care physicians.</div></li><li class="half_rhythm"><div>Pediatric surgeons.</div></li><li class="half_rhythm"><div>Radiation
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oncologists.</div></li><li class="half_rhythm"><div>Pediatric medical oncologists/hematologists.</div></li><li class="half_rhythm"><div> Rehabilitation
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specialists.</div></li><li class="half_rhythm"><div>Pediatric nurse specialists.</div></li><li class="half_rhythm"><div>Social workers.</div></li><li class="half_rhythm"><div>Child-life professionals.</div></li><li class="half_rhythm"><div>Psychologists.</div></li></ul><p id="CDR0000799716__1867"> (Refer to the PDQ <a href="https://www.cancer.gov/publications/pdq/information-summaries/supportive-care" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Supportive and Palliative Care</a> summaries for specific information about supportive care for children and adolescents with cancer.)</p><p id="CDR0000799716__1868">Guidelines for
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pediatric cancer centers and their role in the treatment of pediatric patients
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with cancer have been outlined by the American Academy of Pediatrics.[<a class="bk_pop" href="#CDR0000799716_rl_1864_2">2</a>] At
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these pediatric cancer centers, clinical trials are available for most types of cancer that occur in children and adolescents, and the opportunity
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to participate in these trials is offered to most patients and their families. Clinical
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trials for children and adolescents diagnosed with cancer are generally
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designed to compare potentially better therapy with therapy that is currently
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accepted as standard. Most of the progress made in identifying curative
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therapy for childhood cancers has been achieved through clinical trials.
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Information about ongoing clinical trials is available from the <a href="https://www.cancer.gov/about-cancer/treatment/clinical-trials" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NCI website</a>.</p><p id="CDR0000799716__1869">Dramatic improvements in survival have been achieved for children and adolescents with cancer. Between 1975 and 2010, childhood cancer mortality decreased by more than 50%.[<a class="bk_pop" href="#CDR0000799716_rl_1864_3">3</a>] Childhood and adolescent cancer survivors require close monitoring because cancer therapy side effects may persist or develop months or years after treatment. (Refer to the PDQ summary on <a href="/books/n/pdqcis/CDR0000343584/">Late Effects of Treatment for Childhood Cancer</a> for specific information about the incidence, type, and monitoring of late effects in childhood and adolescent cancer survivors.)</p><p id="CDR0000799716__1870">Childhood cancer is a rare disease, with about 15,000 cases diagnosed annually in the United States in individuals younger than 20 years.[<a class="bk_pop" href="#CDR0000799716_rl_1864_4">4</a>] The U.S. <a href="https://history.nih.gov/research/downloads/PL107-280.pdf" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Rare Diseases Act of 2002</a> defines a rare disease as one that affects populations smaller than 200,000 persons. Therefore, all pediatric cancers are considered rare.</p><p id="CDR0000799716__1881">The designation of a rare tumor is not uniform among pediatric and adult groups. Adult rare cancers are defined as those with an annual incidence of fewer than six cases per 100,000 people, and they are estimated to account for up to 24% of all cancers diagnosed in the European Union and about 20% of all cancers diagnosed in the United States.[<a class="bk_pop" href="#CDR0000799716_rl_1864_5">5</a>,<a class="bk_pop" href="#CDR0000799716_rl_1864_6">6</a>] Also, the designation of a pediatric rare tumor is not uniform among international groups, as follows:</p><ul id="CDR0000799716__1871"><li class="half_rhythm"><div class="half_rhythm">The Italian cooperative project on rare pediatric tumors (Tumori Rari in Eta Pediatrica [TREP]) defines a pediatric rare tumor as one with an incidence of less than two cases per 1 million population per year and is not included in other clinical trials.[<a class="bk_pop" href="#CDR0000799716_rl_1864_7">7</a>]</div></li><li class="half_rhythm"><div class="half_rhythm">The Children's Oncology Group has opted to define rare pediatric cancers as those listed in the International Classification of Childhood Cancer subgroup XI, which includes thyroid cancer, melanoma and nonmelanoma skin cancers, and multiple types of carcinomas (e.g., adrenocortical carcinoma, nasopharyngeal carcinoma, and most adult-type carcinomas such as breast cancer, colorectal cancer, etc.).[<a class="bk_pop" href="#CDR0000799716_rl_1864_8">8</a>] These diagnoses account for about 4% of cancers diagnosed in children aged 0 to 14 years, compared with about 20% of cancers diagnosed in adolescents aged 15 to 19 years.[<a class="bk_pop" href="#CDR0000799716_rl_1864_9">9</a>]</div><div class="half_rhythm">Most cancers within subgroup XI are either melanomas or thyroid cancer, with the remaining subgroup XI cancer types accounting for only 1.3% of cancers in children aged 0 to 14 years and 5.3% of cancers in adolescents aged 15 to 19 years.</div></li></ul><p id="CDR0000799716__1872">These rare cancers are extremely challenging to study because of the low incidence of patients with any individual diagnosis, the predominance of rare cancers in the adolescent population, and the lack of clinical trials for adolescents with rare cancers.</p><p id="CDR0000799716__1829">Information about these tumors may also be found in sources relevant to
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adults with cancer such as the PDQ summaries on <a href="/books/n/pdqcis/CDR0000062951/">Pancreatic
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Cancer Treatment (Adult)</a> and adult <a href="/books/n/pdqcis/CDR0000062794/">Pancreatic Neuroendocrine Tumors (Islet Cell Tumors) Treatment</a>.</p><div id="CDR0000799716_rl_1864"><h3>References</h3><ol><li><div class="bk_ref" id="CDR0000799716_rl_1864_1">Smith MA, Seibel NL, Altekruse SF, et al.: Outcomes for children and adolescents with cancer: challenges for the twenty-first century. J Clin Oncol 28 (15): 2625-34, 2010. [<a href="/pmc/articles/PMC2881732/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2881732</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20404250" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20404250</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_2">Corrigan JJ, Feig SA; American Academy of Pediatrics: Guidelines for pediatric cancer centers. Pediatrics 113 (6): 1833-5, 2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/15173520" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15173520</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_3">Smith MA, Altekruse SF, Adamson PC, et al.: Declining childhood and adolescent cancer mortality. Cancer 120 (16): 2497-506, 2014. [<a href="/pmc/articles/PMC4136455/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4136455</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24853691" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24853691</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_4">Ward E, DeSantis C, Robbins A, et al.: Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin 64 (2): 83-103, 2014 Mar-Apr. [<a href="https://pubmed.ncbi.nlm.nih.gov/24488779" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24488779</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_5">Gatta G, Capocaccia R, Botta L, et al.: Burden and centralised treatment in Europe of rare tumours: results of RARECAREnet-a population-based study. Lancet Oncol 18 (8): 1022-1039, 2017. [<a href="https://pubmed.ncbi.nlm.nih.gov/28687376" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28687376</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_6">DeSantis CE, Kramer JL, Jemal A: The burden of rare cancers in the United States. CA Cancer J Clin 67 (4): 261-272, 2017. [<a href="https://pubmed.ncbi.nlm.nih.gov/28542893" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28542893</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_7">Ferrari A, Bisogno G, De Salvo GL, et al.: The challenge of very rare tumours in childhood: the Italian TREP project. Eur J Cancer 43 (4): 654-9, 2007. [<a href="https://pubmed.ncbi.nlm.nih.gov/17049226" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17049226</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_8">Pappo AS, Krailo M, Chen Z, et al.: Infrequent tumor initiative of the Children's Oncology Group: initial lessons learned and their impact on future plans. J Clin Oncol 28 (33): 5011-6, 2010. [<a href="/pmc/articles/PMC3020699/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3020699</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20956621" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20956621</span></a>]</div></li><li><div class="bk_ref" id="CDR0000799716_rl_1864_9">Howlader N, Noone AM, Krapcho M, et al., eds.: SEER Cancer Statistics Review, 1975-2012. Bethesda, Md: National Cancer Institute, 2015. <a href="http://seer.cancer.gov/csr/1975_2012/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">Also available online</a>. Last accessed October 05, 2020.</div></li></ol></div></div><div id="CDR0000799716__2183"><h2 id="_CDR0000799716__2183_">Changes to This Summary (10/06/2020)</h2><p id="CDR0000799716__2184">The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.</p><p id="CDR0000799716__2187"><b><a href="#CDR0000799716__1357">Solid Pseudopapillary Tumor of the Pancreas</a></b></p><p id="CDR0000799716__2188">Added Vasudevan et al. as <a href="#CDR0000799716__2145">reference 8</a>.</p><p id="CDR0000799716__2189"><b><a href="#CDR0000799716__1361">Pancreatoblastoma</a></b></p><p id="CDR0000799716__2190">Added Vasudevan et al. as <a href="#CDR0000799716__2159">reference 7</a>.</p><p id="CDR0000799716__2191"><b><a href="#CDR0000799716__1367">Islet Cell Tumors</a></b></p><p id="CDR0000799716__2192">Added Vasudevan et al. as <a href="#CDR0000799716__2174">reference 5</a>.</p><p id="CDR0000799716__disclaimerHP_3">This summary is written and maintained by the <a href="https://www.cancer.gov/publications/pdq/editorial-boards/pediatric-treatment" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">PDQ Pediatric Treatment Editorial Board</a>, which is
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editorially independent of NCI. The summary reflects an independent review of
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the literature and does not represent a policy statement of NCI or NIH. More
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information about summary policies and the role of the PDQ Editorial Boards in
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maintaining the PDQ summaries can be found on the <a href="#CDR0000799716__AboutThis_1">About This PDQ Summary</a> and <a href="https://www.cancer.gov/publications/pdq" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">PDQ® - NCI's Comprehensive Cancer Database</a> pages.
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</p></div><div id="CDR0000799716__AboutThis_1"><h2 id="_CDR0000799716__AboutThis_1_">About This PDQ Summary</h2><div id="CDR0000799716__AboutThis_2"><h3>Purpose of This Summary</h3><p id="CDR0000799716__AboutThis_3">This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of pediatric pancreatic cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.</p></div><div id="CDR0000799716__AboutThis_4"><h3>Reviewers and Updates</h3><p id="CDR0000799716__AboutThis_5">This summary is reviewed regularly and updated as necessary by the <a href="https://www.cancer.gov/publications/pdq/editorial-boards/pediatric-treatment" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">PDQ Pediatric Treatment Editorial Board</a>, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).</p><p id="CDR0000799716__AboutThis_22"> Board members review recently published articles each month to determine whether an article should:</p><ul id="CDR0000799716__AboutThis_6"><li class="half_rhythm"><div>be discussed at a meeting,</div></li><li class="half_rhythm"><div>be cited with text, or</div></li><li class="half_rhythm"><div>replace or update an existing article that is already cited.</div></li></ul><p id="CDR0000799716__AboutThis_7">Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.</p><p>The lead reviewers for Childhood Pancreatic Cancer Treatment are:</p><ul><li class="half_rhythm"><div>Denise Adams, MD (Children's Hospital Boston)</div></li><li class="half_rhythm"><div>Karen J. Marcus, MD, FACR (Dana-Farber Cancer Institute/Boston Children's Hospital)</div></li><li class="half_rhythm"><div>Paul A. Meyers, MD (Memorial Sloan-Kettering Cancer Center)</div></li><li class="half_rhythm"><div>Thomas A. Olson, MD (Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta - Egleston Campus)</div></li><li class="half_rhythm"><div>Alberto S. Pappo, MD (St. Jude Children's Research Hospital)</div></li><li class="half_rhythm"><div>Arthur Kim Ritchey, MD (Children's Hospital of Pittsburgh of UPMC)</div></li><li class="half_rhythm"><div>Carlos Rodriguez-Galindo, MD (St. Jude Children's Research Hospital)</div></li><li class="half_rhythm"><div>Stephen J. Shochat, MD (St. Jude Children's Research Hospital)</div></li></ul><p id="CDR0000799716__AboutThis_9">Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's <a href="https://www.cancer.gov/contact/email-us" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Email Us</a>. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.</p></div><div id="CDR0000799716__AboutThis_10"><h3>Levels of Evidence</h3><p id="CDR0000799716__AboutThis_11">Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Pediatric Treatment Editorial Board uses a <a href="/books/n/pdqcis/CDR0000062796/">formal evidence ranking system</a> in developing its level-of-evidence designations.</p></div><div id="CDR0000799716__AboutThis_12"><h3>Permission to Use This Summary</h3><p id="CDR0000799716__AboutThis_13">PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”</p><p id="CDR0000799716__AboutThis_14">The preferred citation for this PDQ summary is:</p><p id="CDR0000799716__AboutThis_15">PDQ® Pediatric Treatment Editorial Board. PDQ Childhood Pancreatic Cancer Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: <a href="https://www.cancer.gov/types/pancreatic/hp/child-pancreatic-treatment-pdq" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">https://www.cancer.gov/types/pancreatic/hp/child-pancreatic-treatment-pdq</a>. Accessed <MM/DD/YYYY>. </p><p id="CDR0000799716__AboutThis_16">Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in <a href="https://visualsonline.cancer.gov/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Visuals Online</a>, a collection of over 2,000 scientific images.
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</p></div><div id="CDR0000799716__AboutThis_17"><h3>Disclaimer</h3><p id="CDR0000799716__AboutThis_18">Based on the strength of the available evidence, treatment options may be described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the <a href="https://www.cancer.gov/about-cancer/managing-care" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Managing Cancer Care</a> page.</p></div><div id="CDR0000799716__AboutThis_20"><h3>Contact Us</h3><p id="CDR0000799716__AboutThis_21">More information about contacting us or receiving help with the Cancer.gov website can be found on our <a href="https://www.cancer.gov/contact" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Contact Us for Help</a> page. Questions can also be submitted to Cancer.gov through the website’s <a href="https://www.cancer.gov/contact/email-us" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Email Us</a>.</p></div></div></div></div>
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<div xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Views</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="PDF_download" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/NBK549123.2/?report=reader">PubReader</a></li><li><a href="/books/NBK549123.2/?report=printable">Print View</a></li><li><a data-jig="ncbidialog" href="#_ncbi_dlg_citbx_NBK549123" data-jigconfig="width:400,modal:true">Cite this Page</a><div id="_ncbi_dlg_citbx_NBK549123" style="display:none" title="Cite this Page"><div class="bk_tt">PDQ Pediatric Treatment Editorial Board. Childhood Pancreatic Cancer Treatment (PDQ®): Health Professional Version. 2020 Oct 6. In: PDQ Cancer Information Summaries [Internet]. 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class="bk_col_itm"><a href="/books/NBK549123.1/">NBK549123.1</a></span> October 25, 2019</li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>In this Page</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="page-toc" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="#CDR0000799716__2185" ref="log$=inpage&link_id=inpage">General Information About Childhood Pancreatic Cancer</a></li><li><a href="#CDR0000799716__1357" ref="log$=inpage&link_id=inpage">Solid Pseudopapillary Tumor of the Pancreas</a></li><li><a href="#CDR0000799716__1361" ref="log$=inpage&link_id=inpage">Pancreatoblastoma</a></li><li><a href="#CDR0000799716__1367" ref="log$=inpage&link_id=inpage">Islet Cell Tumors</a></li><li><a href="#CDR0000799716__1372" ref="log$=inpage&link_id=inpage">Pancreatic Carcinoma</a></li><li><a href="#CDR0000799716__1945" ref="log$=inpage&link_id=inpage">Treatment Options Under Clinical Evaluation for Childhood Pancreatic Cancer</a></li><li><a href="#CDR0000799716__1864" ref="log$=inpage&link_id=inpage">Special Considerations for the Treatment of Children With Cancer</a></li><li><a href="#CDR0000799716__2183" ref="log$=inpage&link_id=inpage">Changes to This Summary (10/06/2020)</a></li><li><a href="#CDR0000799716__AboutThis_1" ref="log$=inpage&link_id=inpage">About This PDQ Summary</a></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Related publications</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="document-links" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" 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PubMed</div></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Similar articles in PubMed</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="PBooksDiscovery_RA" id="Shutter"></a></div><div class="portlet_content"><ul><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/26389394" ref="ordinalpos=1&linkpos=1&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Pancreatic Cancer Treatment (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer Information Summari...]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Pancreatic Cancer Treatment (PDQ®): Health Professional Version.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">PDQ Adult Treatment Editorial Board. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">PDQ Cancer Information Summaries. 2002</em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/31909946" ref="ordinalpos=1&linkpos=2&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Childhood Melanoma Treatment (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer Information Summari...]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Childhood Melanoma Treatment (PDQ®): Health Professional Version.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">PDQ Pediatric Treatment Editorial Board. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">PDQ Cancer Information Summaries. 2002</em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/31909945" ref="ordinalpos=1&linkpos=3&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Childhood Chordoma Treatment (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer Information Summari...]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Childhood Chordoma Treatment (PDQ®): Health Professional Version.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">PDQ Pediatric Treatment Editorial Board. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">PDQ Cancer Information Summaries. 2002</em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/26389243" ref="ordinalpos=1&linkpos=4&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Childhood Rhabdomyosarcoma Treatment (PDQ®): Health Professional Version.</a><span class="source">[PDQ Cancer Information Summari...]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Childhood Rhabdomyosarcoma Treatment (PDQ®): Health Professional Version.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">PDQ Pediatric Treatment Editorial Board. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">PDQ Cancer Information Summaries. 2002</em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/31593384" ref="ordinalpos=1&linkpos=5&log$=relatedreviews&logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Childhood Cardiac Tumors Treatment (PDQ®): Health Professional Version.</a><span 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<noscript><img alt="statistics" src="/stat?jsdisabled=true&ncbi_db=books&ncbi_pdid=book-part&ncbi_acc=NBK549123&ncbi_domain=pdqcis&ncbi_report=record&ncbi_type=fulltext&ncbi_objectid=&ncbi_pcid=/NBK549123.2/&ncbi_pagename=Childhood Pancreatic Cancer Treatment (PDQ®) - PDQ Cancer Information Summaries - NCBI Bookshelf&ncbi_bookparttype=chapter&ncbi_app=bookshelf" /></noscript>
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<script type="text/javascript" src="//static.pubmed.gov/portal/portal3rc.fcgi/4216699/js/3879255/4121861/3501987/4008961/3893018/3821238/4062932/4209313/4212053/4076480/3921943/3400083/3426610.js" snapshot="books"></script></body>
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