Phase II study of weekly chemotherapy with paclitaxel and gemcitabine as second-line treatment for advanced non-small cell lung cancer

17096

Background: Second-line chemotherapy has become almost routine in non-small cell lung cancer (NSCLC) patients (pts) with good performance status (PS). The availability of the new pharmacological agents opens up new possibilities for their use in pts who have retained a good PS following relapse or progression after first-line chemotherapy. Paclitaxel (PTX) and Gemcitabine (GEM) are among the most active new agents in NSCLC and are worth considering for second-line chemotherapy. In phase II study, we evaluated the tolerability and activity of the combination of weekly PTX and GEM in second-line treatment of NSCLC. Methods: PTX (100mg/m2) and GEM (1000 mg/m2) were administered on days 1 and 8 at every 3–4 weeks. A total of 40 pts (M/F, 27/13 pts; median age 59.3 years [33–75]; PS 0/1/2, 7/27/6 pts) were enrolled between October 2000 and July 2003. Results: The number of cycles conducted was 1 in 5 pts, 2 in 8 pts, 3 in 10 pts, and 4 in 17 pts (mean: 4). The final efficacy was PR in 13, NC in 26 and PD in 1 for a response rate of 32.5 % (95% CI: 18.0–47.0%). The median survival time was 41.7 weeks (95% CI: 28.5–54.7 weeks). The median time to progressive disease was 19 weeks. Hematologic toxicities observed included Grade 3 or 4 neutropenia in 60%, Grade 3 or 4 anemia in 20%, and Grade 3 or 4 thrombocytepenia in 10%. Non-hematologic toxicities were mild except Grade 3 diarrhea in 3 pts and Grade 3 pneumonitis in 2 pts. There were no toxic deaths. Conclusions: The combination of weekly PTX and GEM is a feasible, well-tolerated, and active scheme for second-line treatment of advanced NSCLC.

No significant financial relationships to disclose.

Immunological evaluation of personalized peptide vaccination with gemcitabine for advance pancreatic cancer patients

14029

Background: A phase I clinical study was performed to determine safety and immunogenicity of personalized peptide vaccination with gemcitabine (GEM) in advanced pancreatic cancer patients (APC). Methods: Thirteen human histocompatibility leukocyte antigen (HLA)-A24+ or A2+ patients with unresectable (n=10) or recurrent (n=3) pancreatic cancer were treated with GEM plus up to four peptides that were positive for pre-vaccination measurement of peptide-specific IgG antibodies and/or cytotoxic T lymphocyte (CTL) precursors in the circulation (personalized peptide vaccine). GEM was administered at 1000mg/m2 as a 30-min intravenous infusion once a week for three week, followed by 1 week of rest. All patients were treated on outpatient basis. The cycle was repeated every 8 weeks. Results: Peptide doses of vaccination per week were planned as follows: level 1, 1mg; level 2, 2mg; and level 3, 3mg. The main grade 3 toxicities observed during the first cycle in each level were neutropenia (15%), anemia (23%) and thrombocytopenia (15%). No significant differences in the toxicities were found between each level. There was no dose limiting toxicity (DLT) observed in each level. Augmentation of peptide-specific CTL responses in the post-vaccination peripheral blood mononuclear cells was observed in each level, while increased titer of peptide-specific IgG antibodies was observed in the post-vaccination plasma in level 2 and level 3. Applicable responses were no complete response, two partial responses (15%), and 7 stable diseases (55%). Nevertheless 7 patients of them (54%) were under the second-line chemotherapy, disease control rate was 70%, the median TTP (time to progression) was 18.5 weeks and the MST (median survival time) was 7.6 months in this study. Conclusions: The combination therapy of personalized peptide vaccination with GEM for APC patients is feasible and safe. Because of positive immune responses under a full dose of GEM, the peptide vaccination of 3 mg is recommended.

No significant financial relationships to disclose.

Circulating dendritic cell as a new prognostic factor in pancreatic cancer patients

4095

Background: Pancreatic cancer is a cancer with very poor prognosis that might be associated with impaired immune defense. Dendritic cells (DC) are important for immune surveillance and play a central role in protection against infection and malignancy. A defective host antitumor immune response may allow tumor cells to escape from the host immune system. The aim of this study is to determine whether circulating DC could be one of new immunological markers that may predict the prognosis of the pancreatic cancer. Methods: We evaluated pretreatment circulating myeloid-lineage DC (C-DC1) rate in the peripheral blood mononuclear cell and various clinical parameters to determine their prognostic value in 104 pancreatic cancer patients (41 resected and 63 unresected patients) seen at our institution. Results: In unresected patients, univariate analysis demonstrated two risk factors for prognosis of albmin < 3.8g/dl (p = 0.0468), and C-DC1 < 0.27% (p = 0.0006), when all patients were divided by the median value of C-DC1 rate. Consequently, multivariate analysis demonstrated that only C-DC1 was a predominant independent predictor of survival (Hazard ratio; 9.330, 95% Confidential interval; 2.595–33.549, p = 0.0006). In resected patients, C-DC1 in patients with advanced disease (Stages 2b-4, n=28) was significantly lower than that in patients with lower staged cancer (Stage 1–2a, n = 13: 0.43 ± 0.67%, Stage 2b-4: 0.24 ± 0.30%, p < 0.05). The overall survival rates in patients with C-DC1 ≥ 0.27% were significantly longer than those in patients with C-DC1 < 0.27 (C-DC1 ≥ 0.27%, n = 20, 1/3 year survival: 100%/64%. C-DC1 < 0.27, n = 21, 1/3 year survival: 68%/26%. P < 0.05). Conclusions: The C-DC1 less than 0.27% could be one of prognostic factors in patients with pancreatic cancer, and such patients could be targets for the future therapeutic trials.

No significant financial relationships to disclose.

Ghrelin does not stimulate gastrointestinal motility and gastric emptying: an experimental study of conscious dogs

Ghrelin is a peptide that was discovered in endocrine cells of the stomach. However, its action in regulating the fasted and fed motor activity of the digestive tract is not fully understood. In the present study, we examined the effects of an intravenous (i.v.) injection of canine ghrelin on the physiological fasted and fed motor activities in the stomach, duodenum, jejunum and colon of freely moving conscious dogs. An i.v. injection of canine ghrelin released growth hormone in a dose-dependent manner; however, it did not stimulate the motor activity of the digestive tract in either the fasted or the fed state. Moreover, an i.v. injection of high-dose canine ghrelin significantly reduced the motility index in the gastric body in the fasted state. Ghrelin did not accelerate gastric emptying, either. These results differ from previous reports dealing with rodents. It is significant that such results were obtained in research with dogs, which are larger animals.

Induction of inducible nitric oxide synthase in hepatocytes isolated from rats with ischemia-reperfusion injury

BACKGROUND

Recent evidence indicates that nitric oxide (NO) has a crucial role in hepatic ischemia-reperfusion (I/R) injury. However, little is known about how I/R influences the gene expression of inducible nitric oxide synthase (iNOS) in hepatocytes. Under inflammatory conditions, we compared the induction of iNOS in hepatocytes isolated from normal and I/R-treated rats.

METHODS

Hepatocytes were isolated using the collagenase perfusion method from rats treated with I/R (30-minute ischemia of middle and left lobes, followed by 3-hour reperfusion) or sham operation (control): Primary cultures of rat hepatocytes were incubated with an inflammatory cytokine, interleukin-1beta (IL-1beta), to compare the iNOS induction/NO production between the 2 groups.

RESULTS

Both control and I/R groups had no production of nitrite (a stable metabolite of NO) in the absence of IL-1beta. In the control group, IL-1beta stimulated dose- and time-dependent production of NO. The I/R group showed more than 2-fold increased levels of NO production. Western and Northern blot analyses revealed that the I/R group also showed increased levels of iNOS protein and its messenger RNA.

CONCLUSION

These results suggest that I/R directly affects the inducibility of the iNOS gene in hepatocytes by IL-1beta. Increased NO may be associated with protective or toxic effects in hepatic I/R injury.

Effects of pirfenidone on endotoxin-induced liver injury after partial hepatectomy in rats

BACKGROUND

In living donor liver transplantation, restrictions on graft size are a serious obstacle to expand indications for adult recipients. The sequence of gram-negative infection, septicemia, and multiple-organ failure is a common cause of early mortality after liver transplantation. An effective therapy has not been established for endotoxemia following extended hepatectomy in donors or small-for-size grafts in recipients. Pirfenidone (PFD), a new experimental antifibrotic agent, was used to ameliorate on endotoxin-induced liver injury following partial hepatectomy.

METHODS

Male Sprague-Dawley rats were intravenously administered lipopolysaccharide (LPS) 48 hours after 70% hepatectomy. Prior to LPS administration, PFD (300 mg/kg) or its vehicle (0.5% carboxymethylcellulose) was given orally twice.

RESULTS

The survival rate of the PFD-treated group was markedly improved compared with that of the controls. PFD prevented the increases in the activities of serum enzymes (aspartate transaminase [AST], alanine transaminase [ALT], and lactate dehydrogenase [LDH]) and total bilirubin. The serum and liver tissue levels of inflammatory cytokines, such as tumor necrosis factor-alpha, interleukin-1beta, interferon-gamma, and interleukin-6, were significantly lower among the PFD than the control group. Furthermore, the degree of necrosis in the remnant liver was significantly decreased in the PFD-treated rats compared with controls.

CONCLUSION

These results indicate that PFD alleviates endotoxin-induced liver injury after partial hepatectomy through the inhibition of production of inflammatory cytokines in the residual liver. PFD may be useful to prevent endotoxin-induced liver injury after hepatectomy.

Duodenogastric reflux following biliary reconstruction after excision of choledochal cyst

Duodenogastric reflux (DGR) was assessed in patients surgically treated for choledochal cyst, with emphasis on two different biliary reconstruction methods: Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). Gastric bile monitoring with the Bilitec device revealed excessive DGR in patients in the HD group. Endoscopic findings demonstrated mild to moderate gastric mucosal erosion in patients after HD. In contrast, neither DGR nor gastritis was found in patients after HJ. This preliminary study suggests that HJ, rather than HD, should be recommended as a method of biliary reconstruction for pediatric patients with choledochal cyst. Careful observation of DGR should be continued in patients who have undergone HD.

[An adult congenital bronchoesophageal fistula with massive hemoptysis; report of a case]

A 67-year-old female was referred to our hospital because of bronchoesophageal fistula detected by upper gastro-intestinal series for cancer screening. The patient has had a history of coughing on liquid ingestion since childhood and she has been hospitalized 4 times for treatment of pneumonia during the past 20 years. While waiting the treatment, she was emergently admitted to the hospital because of massive hemoptysis. Transcatheter embolization of feeding arteries including the right inferior phrenic artery successfully controlled her hemoptysis. After reembolization of the feeding arteries for preventing massive hemorrhage during operation, posterolateral thoracotomy was performed. Surgical findings disclosed the bronchoesophageal fistula without inflammatory changes. She underwent fistulectomy combined resection of the middle and lower lobes which were destroyed by the repeated pneumonia. This case was considered type I congenital bronchoesophageal fistula according to Braimbridge and Keith classification because of the presence of diverticular projection which connected to the bronchus. Early diagnosis and rapid treatment are thought to be important for treating this disease.

Effect of hepatocyte growth factor on induction of cytokine-induced neutrophil chemoattractant in rat hepatocytes

BACKGROUND

Restrictions on graft size are a serious obstacle to the expansion of indications for adult recipients in living donor liver transplantation. Hepatocyte growth factor (HGF) has a crucial role in regeneration following hepatic injury. Rat cytokine-induced neutrophil chemoattractant (CINC), a member of the interleukin-8 superfamily in humans, has been implicated in chronic liver diseases or development of liver ischemia-reperfusion injury. Studies were performed to examine whether HGF influences the induction of CINC in hepatocytes.

METHODS

Primary cultures of rat hepatocytes were treated with or without recombinant human (rh) HGF. The release of CINC into the culture medium and levels of CINC mRNA were measured using an enzyme-linked immunosorbent assay and Northern blot analysis. Transcription of nuclear factor (NF)-kappa B was detected by electrophoretic mobility shift assays.

RESULTS

rhHGF increased the release of CINC in the medium dose- and time-dependently, showing a maximal effect at 100 ng/mL. Genistein (100 mumol/L) blocked the release of CINC stimulated by rhHGF. Levels of CINC mRNA were also increased, reaching a maximum at 8 hours after addition of rhHGF. Electrophoretic mobility shift assays revealed rhHGF activated transcription factor, NF-kappa B.

CONCLUSION

These results suggest that HGF stimulates the induction of CINC gene expression through activation of NF-kappa B. CINC may be involved in the function of HGF during liver regeneration.

Safety of hepatectomy for living donors as evaluated using asialoscintigraphy

In the living donor operation, accurate estimation of hepatic functional reserve is essential. Technetium-99m-galactosyl-human serum albumin (GSA) is a liver scintigraphy agent that binds to asialoglycoprotein receptors. We evaluated the preoperative assessment of the safety of an elective hepatectomy using GSA liver scintigraphy in 152 patients. GSA scintigraphy was performed after intravenous injection of GSA. The maximal removal rate of GSA (GSA-Rmax) was calculated using a radiopharmacokinetic model. We determined the areas for resection preoperatively depending on the operative procedures and calculated the local GSA-Rmax in the predicted residual liver (GSA-RL). A significant correlation was obtained between the GSA-Rmax and the 15-minute retention rate of indocyanine green. With sub- and monosegmentectomy, 2 patients had postoperative hepatic failure; in those 2 patients, the GSA-RL was 0.127 and 0.133, respectively, but these patients recovered well. Among those having di- and tri-segmentectomy, 5 patients experienced postoperative hepatic failure, in all subjects the GSA-RL was <0.15. Two patients died of postoperative liver failure 1 to 2 months after the operation. We concluded that GSA-RL is useful to select the procedure for hepatectomy in living donors and that GSA-RL should be >0.15 (mg/min/50 kg body weight) to avoid postoperative hepatic failure.

Functional hepatic regeneration following hepatectomy using galactosyl-human serum albumin liver scintigraphy

In extended hepatectomy and liver transplantation, accurate estimation of functional hepatic regeneration is more important than volumetric regeneration. We investigated the usefulness of measuring the functional hepatic volume by 99m-technetium galactosyl-human serum albumin scintigraphy (GSA). Extended hepatectomy was performed in 32 patients. These patients were divided into subgroups with or without chronic hepatitis or cirrhosis. Functional hepatic volume GSA scintigraphy (GSA-LV) and determination of hepatic volume by CT (CT-LV) measurements were performed preoperatively, at 2 and 4 weeks and at 3 and 6 months after surgery. The preoperative GSA-LV values were significantly correlated with the hepatocyte volume and the 15-minute retention rate of indocyanine green (ICGR15). Similarly, the hepatocyte volume correlated well with the CT-LV and ICGR15. However, the CT-LV correlated only with the ICGR15. Recovery of the GSA-LV was delayed, and about 90% of the volumetric and functional regeneration was observed within 6 months after the hepatectomy. In contrast, the CT-LV in patients with normal liver remnants returned to approximately 90% of the initial volume within 1 month after the hepatectomy, whereas patients with injured livers regeneration showed gradual recovery to approximately 80% of the preoperative value by 6 months after hepatectomy. We conclude that measurement of functional hepatic volume using the GSA-LV is useful to evaluate hepatic function based on hepatocyte volume.

Fibronectin suppresses apoptosis and protects mice from endotoxic shock

Multiple-organ failure related to septicemia is a common cause of early mortality after liver transplantation. Endotoxemia following living donor hepatectomy may be a cause of postoperative death. Plasma fibronectin (Fn) exerts a broad range of biological effects on cellular adhesion, motility, differentiation, apoptosis, hemostasis, wound healing, reticuloendothelial system function, and ischemic injury. We studied the therapeutic effect of plasma Fn in mice after an intraperitoneal injection of lipopolysaccharide (LPS) and d-galactosamine (GalN). Female Balb/c mice received simultaneous intraperitoneal injection of LPS (50 microg/kg) and GalN (400 mg/kg). Thirty minutes prior to GalN/LPS administration, plasma Fn or bovine serum albumin was given intravenously. A single administration of plasma Fn (500 mg/kg) protected in dose-dependent fashion against lethal shock after GalN/LPS challenge. Plasma Fn significantly reduced the serum tumor necrosis factor-alpha, interferon-gamma, and interleukin-6 levels and significantly increased the serum interleukin-10 levels after GalN/LPS administration. Furthermore, plasma Fn significantly inhibited liver necrosis at 9 hours after GalN/LPS injection. The fraction of apoptotic-positive cells in these plasma Fn-treated mice was significantly lower than in the control group. These results support the protective treatment of endotoxin-induced liver injury by plasma Fn.

Pirfenidone protects endotoxin-induced liver injury after hepatic ischemia in rats

BACKGROUND

Pirfenidone (PFD), an experimental antifibrotic agent, was investigated for its effects on endotoxin-induced liver injury after hepatic ischemia-reperfusion.

METHODS

Male Sprague-Dawley rats were subjected to 30 minutes of partial hepatic ischemia, followed by reperfusion for 24 hours. Lipopolysaccharide (LPS) was injected at 30 minutes of reperfusion. PFD (300 mg/kg) or its vehicle (0.5% carboxymethylcellulose) was given orally following LPS administration.

RESULTS

PFD prevented the increase in activities of serum alanine transaminase, aspartate transaminase, and lactate dehydrogenase after reperfusion. PFD inhibited the increase of cytokine-induced neutrophil chemoattractant in serum and liver tissue. The number of neutrophils infiltrating the liver was significantly lower in the PFD-treated group than the control group.

CONCLUSION

These results indicate that PFD prevents endotoxin-induced liver injury after hepatic ischemia-reperfusion, in part through the decrease of neutrophil infiltration to the liver.

Effect of pirfenidone on induction of chemokines in rat hepatocytes

BACKGROUND

Hepatic ischemia-reperfusion results in a neutrophil-dependent liver injury. The process of neutrophil recruitment and activation in this injury is at least partially dependent on the induction of chemokines, such as cytokine-induced neutrophil chemoattractant (CINC) and macrophage inflammatory protein-2 (MIP-2) in rats. In the liver, parenchymal cells (hepatocytes), in addition to nonparenchymal cells such as Kupffer cells, have been reported to produce chemokines in the regulation of hepatic inflammation. Pirfenidone (PFD) is a new experimental drug used as an antifibrotic agent. Studies were performed to determine whether PFD influences the production of CINC and MIP-2 stimulated by interleukin (IL)-1beta in a primary culture model of rat hepatocytes.

METHODS

Primary cultures of rat hepatocytes were treated with IL-1beta in the presence and absence of PFD. The protein and mRNA of CINC and MIP-2 were analyzed using enzyme-linked immunosorbent assays and Northern blots.

RESULTS

IL-1beta increased the release of CINC and MIP-2 into culture media in a dose- and time-dependent manner. PFD inhibited both CINC and MIP-2 release in dose-dependent fashion. However, PFD had no effect on the levels of CINC mRNA induced by IL-1beta.

CONCLUSION

These results suggest that PFD inhibits the production of CINC and MIP-2 by IL-1beta at a posttranscriptional step in hepatocytes.

Clinicopathologic evaluation after resection for ductal adenocarcinoma of the pancreas: a retrospective, single-institution experience

INTRODUCTION

Between April 1992 and December 2000, 167 patients with pancreatic carcinoma were evaluated and treated in our department. One hundred eight patients (64.7%) with pancreatic carcinoma underwent pancreatectomy. Of these patients, 94 had histologically proven ductal adenocarcinoma. The overall postoperative mortality rate was 3.2% (3 patients), and the morbidity rate was 35.1% (33 patients). The estimated 1-, 2-, 3-, and 5-year survival rates were 43.6%, 28.7%, 21.8%, and 12.9%, respectively. There were only six long-term survivors who survived >5 years after surgery. METHODOLOGY AND AIMS: Institutional experience with 94 consecutive patients with ductal adenocarcinoma who underwent pancreatectomy was reviewed to clarify the influence of 29 prognostic factors (5 host, 17 tumor, and 7 treatment factors). Special reference was made to determine whether these significant factors have an effect on long-term survival. Univariate and multivariate models were used to analyze the effect of prognostic factors on survival.

RESULTS

Univariate analysis indicated that blood loss, operative time, postoperative complications, histopathologic lymphatic and venous permeation, lymph node metastasis, conclusive stage, conclusive curability, resection margins, serosal invasion, size of tumor, retroperitoneal invasion, major arterial invasion, and mode of histologic infiltration were associated with significantly longer survival (p < 0.05). By Cox proportional hazards survival analysis, the most powerful predictors of outcome were venous permeation, lymph node metastasis, tumor diameter, and conclusive curability. The longest-term survivor had the most advanced stage (stage IV(b)) of disease and curability C. No long-term survivors had all of the good prognostic factors (according to multivariate analysis).

CONCLUSIONS

The prognosis after surgical resection of pancreatic carcinoma mostly depends on tumor factors. In this study, it was difficult to identify the determinants of long-term survival in patients with resectable tumors.

Prevention of pleural effusion following hepatectomy using argon beam coagulation

BACKGROUND

Postoperative pleural effusion occurs frequently after hepatectomy. The value of the argon beam coagulator (ABC) for the prevention of pleural effusion after hepatectomy in patients with hepatocellular carcinoma was studied.

METHODS

Sixty patients were divided randomly into two groups: an ABC group (n = 28), in which the cut surface of the hepatic ligaments and bare area of the retroperitoneum were cauterized using an ABC, and a control group (n = 32) in which the ABC was not applied. Patient characteristics, preoperative and postoperative liver function, and postoperative pleural effusion were compared between the two groups.

RESULTS

There were no significant differences between the two groups with respect to histological findings, clinical stage, type of resection, operative data, and preoperative and postoperative laboratory data. One of 28 patients in the ABC group and nine of 32 patients in the control group had pleural effusion. The incidence was significantly lower in the ABC group than in the control group (P = 0.01). Pleurocentesis was needed in two of the ten patients and thoracic drainage in four patients.

CONCLUSION

Application of an ABC to the cut surface of the hepatic ligaments and bare area of retroperitoneum after liver mobilization may prevent postoperative pleural effusion.

Gonadal function in patients with testicular germ cell tumors

The gonadal function of 18 patients with testicular germ cell tumors was evaluated. Seminal parameters after orchiectomy were examined in 15 patients. Six of them were available for follow-up observation after 2 or 3 courses of adjuvant chemotherapy. Serum gonadal hormones before and after orchiectomy were evaluated in 7 patients (testosterone and PRL were not examined in one patient). Five of 15 (33.3%), 8 of 15 (53.3%), 13 of 15 (86.7%), 7 of 13 (53.8%), and 9 of 12 (75.0%) had abnormal values in seminal volume, sperm concentration, motility, morphology, and vitality, respectively. The sperm concentration gradually improved after chemotherapy following orchiectomy in 5 of 6 (83.3%) patients. In all the patients examined, serum levels of follicular stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) increased after orchiectomy. Serum levels of testosterone increased in 4 patients, but decreased in 2 after orchiectomy. These findings suggest that several factors, including preexisting intrinsic defect and disturbance of the hypothalamus-pituitary-gonadal axis, are involved in the deterioration of gonadal function in patients with testicular germ cell tumors.

[Synchronous tumors consisted of bronchial carcinoid and adenocarcinoma of the lung]

We report a case of synchronous tumors consisted of bronchial carcinoid and adenocarcinoma of the lung. A 58-year-old female was referred to our hospital after screening, because an abnormal shadow was noted in the right lung on her computed tomography (CT) of the chest. CT scans showed a peripheral pulmonary mass in the right middle lobe and a nodule around the right lower lobe bronchus. The nodular lesion like swollen lymph node was diagnosed as bronchial carcinoid originated in B6 by bronchoscopy. The pulmonary mass was diagnosed as adenocarcinoma by using core needle biopsy during operation. Right middle and lower bilobectomy and mediastinal lymph node dissection were performed. Coincidence of a bronchial carcinoid and an adenocarcinoma of the same side of the lung is a rare occurrence.

Preoperative laparoscopic examination using surgical manipulation and ultrasonography for pancreatic lesions

BACKGROUND AND STUDY AIMS

Unnecessary laparotomies in patients with advanced pancreatic disease are unlikely to provide any benefits and may compromise both the quality and duration of survival. The purpose of this study was to determine the contribution of laparoscopy and laparoscopic ultrasound to the diagnosis or staging, or both, of pancreatic lesions.

PATIENTS AND METHODS

Fifty-two patients were diagnosed preoperatively with pancreatic cancer. The diagnoses made by laparoscopic ultrasonography (LUS) were compared with those made prior to the operation. Laparoscopic visualization of the body of the pancreas was obtained via an infragastric approach. For the laparoscopic examination of the head of the pancreas, a retroduodenal approach was used.

RESULTS

In 52 patients with cancer of the pancreatic head and body, unresectable findings were observed in 13 patients. Portal vein displacement without other unresectable findings was evident in six patients using LUS, and was confirmed at exploratory laparotomy in five patients. The surgical approaches were changed, with seven patients undergoing an open exploration for biliary drainage and the other six patients receiving endoscopic endoprostheses. In six of the 52 patients, LUS-guided needle biopsies and frozen-section examinations detected chronic pancreatitis (n = 4), a malignant lymphoma (n = 1), and an abdominal tuberculosis (n = 1), which were diagnosed preoperatively as pancreatic cancers and cysts. Only one patient undergoing the laparoscopic procedure had acute pancreatitis; this patient was treated conservatively.

CONCLUSIONS

LUS, when combined with laparoscopic manipulations, may overcome many of the limitations of laparoscopy alone in the investigation of pancreatic lesions by providing an accurate diagnosis and assessment of the size and extent of the local dissemination.