Survival after resection for ductal adenocarcinoma of the pancreas

A retrospective study was performed of 113 patients who underwent surgical resection of carcinoma of the pancreas from 1970 to 1992. The postoperative mortality rate was 15 per cent (5 per cent in the last 11 years). The actuarial 5-year survival rate was 12 per cent. Survival was significantly influenced by age (P = 0.03), vascular resection (P = 0.02), radicality of operation (P = 0.01), number of transfused blood units (P = 0.01), tumour differentiation (P = 0.002), lymph node status (P = 0.001), perineural invasion (P = 0.01), tumour size (P = 0.008), preoperative diabetes (P = 0.001) and stage (P = 0.0001). Multivariate analysis showed that stage, diabetes, age and grade were independent predictors of long-term survival. The type of pancreatic resection (Whipple, subtotal, total or distal pancreatectomy) did not influence prognosis. The 5-year survival rate was 14 per cent in the period 1970-1981 and 11 per cent in the period 1982-1992, with no statistical difference. These results suggest that patient characteristics and tumour findings rather than operative procedures affect long-term survival after resection for pancreatic carcinoma.

Nuclear DNA content and pathology in radically treated pancreatic carcinoma. The prognostic significance of DNA ploidy, histology and nuclear grade

BACKGROUND

Nuclear DNA content and pathology are considered to be prognostically relevant in several solid tumors, but controversial findings have emerged in pancreatic carcinoma (PC). Histopathology and DNA ploidy were each correlated with survival in radically treated PC to ascertain the hierarchy of their prognostic significance.

METHODS

DNA ploidy was assessed by flow cytometry (FC) in neoplastic tissue samples from 60 patients with PC who were followed until death. Representative neoplastic areas were obtained by microdissection from archival paraffin embedded material (excluding any carcinoma with a coefficient of variation of the G0/G1 peak higher than 8%). Histologic data and FC patterns were related to prognostic behavior using univariate multivariate statistical analysis.

RESULTS

Aneuploid cancers were detected in 39 of 60 patients. Univariate analysis showed that histologic grade, nuclear grade, and ploidy were significantly related to prognosis. On multivariate analysis, only histologic grade and DNA ploidy (diploid vs. aneuploid) were significant with significant interaction.

CONCLUSIONS

The prognostic value of pathology and ploidy was demonstrated in patients treated radically for PC. As in other tumors characterized by a short survival, the clinical usefulness of any prognostic parameters is somewhat limited. However, the significant relationship between prognosis and DNA ploidy might be of interest in a cost-benefit analysis for selecting patients in whom an attempt at radical surgical treatment or adjunctive chemotherapy may be justified.

An easier technique for end to end pancreaticojejunostomy

Breakdown of the pancreaticoenterostomy is responsible for a number of complications and for the high mortality associated with pancreaticoduodenectomy. Although in recent years the postoperative mortality has dropped to less than 10% and in some to less than 5%, pancreatic fistula remains the most common and troublesome complication. Various procedures, such as duct ligation or occlusion, resection of the pancreatic stump or pancreaticogastrostomy, have been proposed to treat the pancreatic stump when it is considered unsuitable for jejunal anastomosis. A little trick permitted us to perform 41 consecutive end to end pancreaticojejunostomies, irrespective of the conditions of the pancreatic stump, with only 3 pancreatic fistulas (7%) and without fistula related deaths.

Evaluation of cyst fluid analysis in the diagnosis of pancreatic cysts

The pre-operative differential diagnosis of pancreatic cystic lesions is often difficult because of the lack of reliable clinical or radiological criteria. In order to improve the pre-operative recognition of these lesions, we performed cyst fluid analysis for enzymes (amylase and lipase), tumour markers (CEA, CA 19-9, CA 125, CA 72-4), and cytology in 52 pancreatic cysts. The cases included 21 pseudocysts, 12 mucinous cystic neoplasms, 7 ductal carcinomas, 7 benign lesions, and 5 rare malignancies observed from 1989 to 1994. Cyst fluid amylase, lipase, CEA, and CA 19-9 were variable and not discriminant between the groups. CA 125 fluid levels were high in 63% of malignant cysts. CA 72-4 fluid levels were significantly higher in mucinous cystic tumours than in pseudocysts (p < 0.0001), showing 95% specificity in detecting mucinous or malignant cysts. Cytology showed a sensitivity of 61% and a specificity of 100%. CA 72-4 determination raised the sensitivity of cytology to 92% in detecting mucinous or malignant cysts. This study confirms the low sensitivity of cytologic examination and low amylase specificity in distinguishing cystic neoplasms from pseudocysts. Cyst tumour markers assay is useful to improve the sensitivity of cytology, and CA 72-4 shows the best specificity in detecting (pre)malignant neoplasms.

The role of 111In-octreotide scintigraphy in the detection of APUD tumours: our experience in eighteen patients

111In-Octreotide scintigraphy has been recently proposed as a sensitive technique for the detection of neuroendocrine tumours, based on the high radiotracer affinity towards the somatostatin receptors expressed by the APUD-system cells. In the present study, a group of 18 patients with carcinoid tumours and gastrointestinal (GI) apudomas was investigated to assess the accuracy of Octreotide scintigraphy in localizing primitive, recurrent or metastatic lesions. Both planar and SPECT studies were obtained 4 hours after the i.v. injection of 111In-Octreotide (111 MBq); planar images were also carried out 24 hours later. In accordance with other authors, the sensitivity of the method was found to be very high (94%) in our group of patients; only in one case of nesidioblastosis was the scintigraphy negative. No differences in sensitivity were observed between the planar and SPECT studies, but the latter provided a better topographic localization of the neoplastic foci. It should be pointed out that in 7 cases (3 primitive, 1 recurrent and 3 metastatic lesions) scintigraphy correctly localized the tumour, when the other morphological techniques, such as echography, computed tomography or magnetic resonance, failed. On the basis of our data, we believe that Octreotide scintigraphy should be the first study performed in the evaluation of patients affected by APUD tumours.

Pancreaticoduodenojejunostomy for chronic pancreatitis presenting with an inflammatory mass in the head of the pancreas

An inflammatory mass in the head of the pancreas is reported in 18-50% of patients with chronic pancreatitis. When the clinical history is misleading, differential diagnosis between chronic pancreatitis and pancreatic cancer may be very difficult. Pancreaticoduodenectomy is considered the treatment of choice, if cancer is still suspected despite negative biopsy. From January 1987 to December 1992 we performed 42 pancreaticoduodenectomies, 36 for malignancies of the pancreaticoduodenal area and 6 for chronic pancreatitis suspected to have a pancreatic cancer. In three additional cases of chronic pancreatitis, we performed a pancreaticoduodenojejunal anastomosis after complete opening of the pancreatic duct and excision of the papilla of Vater. Frozen section and definitive histological examination of the pancreas and ampulla excluded malignance in all three patients. They are alive and well 60, 36, and 20 months after operation. With this procedure, frozen-section examination of the distal part of the pancreatic and biliary duct, the papilla, and the periductal pancreatic tissue can be performed, while this is impossible with the usual pancreaticojejunostomy. We can therefore reasonably exclude a small cancer of the periampullary area and perform a wider derivative procedure, instead of a pancreaticoduodenectomy, in patients with an inflammatory mass of the head of the pancreas.

Solitary true cyst of the pancreas in adults. Report of three cases and review of the literature

Solitary true cysts of the pancreas are extremely rare: to date, only eight cases have been reported in the English literature, four of which had clinical significance. An additional three cases of solitary true cysts of the pancreas are presented. One patient was incidentally found at operation, performed for other disease, to have a cystic lesion in the body of the pancreas; the other two patients experienced abdominal pain and nausea. Abdominal US, CT, and MR showed a unilocular cyst in the body and tail of the pancreas. In both cases, preoperative diagnosis of pancreatic cystic neoplasm was made. Two patients underwent excision of the mass and one distal pancreatectomy. Analysis of the cyst fluid revealed high CA 19-9 levels in two and CA 125 levels in one case. All cysts were lined by cuboidal epithelium, without morphological alterations. Preoperative differential diagnosis with the most common cystic pancreatic lesions (inflammatory or neoplastic) is difficult.

Surgery for chronic pancreatitis: what quality of life ahead?

We attempted to evaluate the quality of life of patients with proved long-lasting chronic pancreatitis. We measured the clinical and psychological status of 60 patients who had undergone various surgical treatments for their disease. The presence and severity of depression and other symptoms of distress were assessed, as were disease-specific functional and physical problems. Few patients had serious conditions, such as pain, malnutrition, or psychoneurotic complaints. The relation between depression and the time of onset of symptoms and of surgery appeared doubtful, and no statistically significant correlations were found between severity of emotional disturbance and other functional characteristics. Insulin-dependent diabetes and correlated diseases had the most negative influence on everyday well-being. Postoperative follow-up and the need for recurrent medical control and care did not lead to negative feelings.

Effect of octreotide acetate on pancreatic exocrine and endocrine functions after pancreatoduodenal resection

In view of forecasting the effect of octreotide acetate (Sandostatin) in preventing fistula formation after pancreatic surgery, 9 patients, who had pancreatoduodenectomy 8-12 days before, underwent a 2-day study. The first day, by means of a catheter located in the jejunal loop separately anastomosed to the pancreatic remnant, basal and after secretin stimulation pancreatic secretion was evaluated. During the 2nd day the possible inhibitory effect of octreotide on basal and stimulated secretion was investigated. Under the experimental conditions of the study Sandostatin showed little effect on the water and bicarbonate increase as stimulated by secretin. A greater hormone inhibitory effect on amylase production and pancreatic endocrine function was seen. On the basis of these results the use of Sandostatin can hardly be seen as useful in preventing fistula formation after pancreatic resection.

Effect of cholecystokinin analogue caerulein and cholecystokinin antagonist lorglumide on pancreatic carcinogenesis in the rat

The effects of the cholecystokinin (CCK)-analogue, caerulein, and CCK-receptor antagonist lorglumide (CR-1409) on pancreatic carcinogenesis induced by 7,12-dimethylbenz(a)anthracene (DMBA) were studied. One hundred thirty rats were divided into the following 10 treatment groups: group 1, DMBA (2-3 mg); group 2, DMBA + caerulein (5 micrograms/kg); group 3, DMBA + caerulein + CR-1409 (12 mg/kg); group 4, caerulein + DMBA; group 5, caerulein + CR-1409 + DMBA; group 6, DMBA + CR-1409; group 7, CR-1409 + DMBA; group 8, caerulein; group 9, CR-1409; and group 10, sham operation + saline. DMBA was surgically implanted into the pancreas. Caerulein and/or CR-1409 was administered twice daily for 15 days after (in groups 2, 3, and 6) or before (in groups 4, 5, and 7) DMBA implantation. Six months after carcinogen administration, all rats were sacrificed and autopsied. The incidence of pancreatic cancer appeared significantly (P < 0.001) increased when caerulein was administered following DMBA implantation. CR-1409 significantly inhibited (P < 0.02) caerulein effects and reduced tumor growth when injected after carcinogen exposure.

Human fibrin sealant in pancreatic surgery: it is useful in preventing fistulas? A prospective randomized study

Some Authors have suggested the use of human fibrin sealants in pancreatic surgery to prevent fistulas. We performed a prospective randomized study including 97 patients (34F, 63M). Forty six were affected by pancreatic inflammatory diseases and 51 had pancreatic or peripancreatic neoplasms. All the patients were managed by the same surgical staff. Surgical treatment included 30 pancreaticoduodenectomies, 40 pancreatico-jejunostomies, 23 left pancreatic resections and 4 tumour excisions. The patients were randomized at the moment the surgical treatment was chosen and divided into 2 different groups: group A, including 43 subjects who had intraoperative fibrin sealing, and group B, including 54 patients who had no fibrin sealing during surgery. At the end of the trial, 6 patients in group A (13.9%) and 6 in group B (11.1%) developed a pancreatic fistula. No statistically significant difference was detected between the 2 groups. The highest incidence of fistulas was observed in the patients with pancreatic cancer in group A (18.7%) and in the patients who underwent pancreatico-duodenectomy in group A (25.0%).

Radical resection for ampullary carcinoma: long-term results

Of 36 patients with carcinoma of the ampulla of Vater who underwent surgery between 1971 and 1990, 31 had a radical operation. There was one operative death. The overall 5- and 10-year survival rates were 56 and 37 per cent respectively. Survival was significantly influenced by tumour stage (P = 0.0002), lymph node status (P = 0.006) and the degree of differentiation of the lesion (P = 0.01). Three patients developed local recurrence after local excision of the tumour. Local or hepatic recurrence was common, even 5 years after pancreatoduodenectomy (four of 18 patients who suffered relapse). Radical resection can be curative in selected patients with ampullary carcinoma but late recurrence suggests the need for careful lifelong follow-up.

CA 50 compared with CA 19-9 as a serum tumour marker for pancreatic carcinoma

This study compared the sensitivity and specificity of CA 50 and CA 19-9 as serum tumour markers for pancreatic cancer. One hundred and seventy one subjects were evaluated: 50 healthy controls, 50 patients with pancreatic carcinoma and 71 patients with chronic pancreatitis. Eighty per cent of the pancreatic cancer patients had raised CA 19-9 serum levels and 82% had raised CA 50 serum levels. In the group of patients ith chronic pancreatitis, false positive tests occurred in 8.4% for CA 19-9 and 11.3% for CA 50. For both markers the serum level showed a severe elevation in the advanced stage of cancer disease. Despite the good sensitivity and specificity of CA 50 as a serum tumour marker for pancreatic carcinoma, no major advantage was found compared to CA 19-9. Moreover, if the CA 50 cut-off, level is raised to 85 U/ml to exclude overlap with chronic pancreatitis, sensitivity falls sharply to 46% compared with 72% for CA 19-9 when a 100 U/ml cut-off level is used.

Surgical treatment of insulinoma

The role of preoperative and intraoperative procedures for the localization of insulinoma has been extensively debated. Transhepatic portal vein sampling before surgery has been recommended when other tests fail to localize the tumour. To determine the role of different investigations, 53 patients with insulinoma, four with hyperplasia or nesidioblastosis and one with insulin autoimmune syndrome were studied. Patients were operated on in three consecutive periods during each of which a different localization procedure was considered to represent the 'gold standard'. During the first period, of 16 patients (including one with hyperplasia) investigated by arteriography, 13 underwent successful resection. Tumours in the other three patients with insulinoma were resected at a second operation, one during the first period and one each during the second and third periods. During the second period, 28 patients underwent exploration after transhepatic portal sampling: the tumour was found in all 26 patients with insulinoma operated on in this hospital, one patient with hyperplasia is receiving medical treatment and one patient had unsuccessful surgical exploration elsewhere despite positive findings on arteriography and transhepatic portal sampling performed in this department. During the third period 13 procedures were performed. All were successful using intraoperative ultrasonography without transhepatic portal sampling. In three further patients intraoperative localization failed because of non-adenomatous beta cell disease. Left-sided resection successfully cured symptoms in two patients with hyperplasia and prompted the diagnosis of insulin autoimmune syndrome. High success rates for surgical treatment of insulinoma can be achieved with transhepatic portal vein sampling or intraoperative ultrasonography. Transhepatic portal sampling is therefore unnecessary before a first operation on the pancreas for insulinoma. In the rare failures of intraoperative localization of an insulinoma, a small left pancreatic resection can help to distinguish insulinoma from hyperplasia without precluding further segmental resection.

Percutaneous CT-guided fine needle aspiration cytology in the differential diagnosis of pancreatic lesions

Cytologic results were retrospectively evaluated in 83 patients who underwent CT-guided fine-needle aspiration of pancreatic lesions during a 5-year period. Sixty seven patients had malignant disease and 16 benign disease. The sensitivity, specificity, positive and negative predictive values, and diagnostic efficiency of fine-needle aspiration (FNA) cytology in detecting malignancy were 91%, 100%, 100%, 73%, and 93%, respectively. In solid pancreatic masses the sensitivity of FNA cytology rose to 98%, while in cystic pancreatic masses sensitivity fell to 62%. In 18 patients with cystic lesions (12 benign and 6 malignant), the cystic fluid was analyzed for amylase, CEA and CA 19-9 content. Amylase levels were high in pseudocysts and in 4/6 malignant cysts. CEA levels were low in benign cysts, and high in all malignant cysts. CA 19-9 levels were high in one pseudocyst and in all malignant cysts. Tumour marker content analysis enhanced the sensitivity of the cytologic diagnosis of malignant cysts to 92%. FNA cytology is a simple and highly accurate method in the differential diagnosis of solid pancreatic lesions. In cystic lesions, tumour marker fluid content determination increases the sensitivity of FNA cytology.

[Malignant mesenchymal tumors of the breast. Report of 3 new cases]

Malignant tumors of the breast arising from the connective tissue of the gland are rare and underestimated. Three new cases are here reported: 1 malignant fibrous histiocytoma and 2 malignant phylloides tumors. Tumor size, mammographic findings and cytologic aspect of the needlebiopsy lead to the correct diagnosis. Large excision or radical mastectomy are treatments of choice, while axillary lymph nodes dissection does not appear justified, since metastatic spread via lymphatics is rare. Postoperative radiation and chemotherapy seem not effective in preventing local recurrences.

Duodenal leiomyosarcoma mimicking a pancreatic pseudocyst

A case of duodenal leiomyosarcoma presenting as a cystic mass is reported. Amylase, tumour markers levels in the cyst fluid and radiological findings suggested an inflammatory pancreatic pseudocyst. Exploratory laparotomy and frozen section examination showed a smooth muscle tumour of the duodenum. Pancreatoduodenectomy with pylorus-preser vation was performed and the patient remained symptom-free at 8 months follow-up.

Biliary cyst. A case report

A case of type-IA biliary cyst, according to the Todani classification, is reported in a 44-years-old man admitted to hospital with epigastric pain. Ultrasound was misleading; CT scanning and preoperative cholangiography confirmed the biliary duct's dilatation. Cyst excision and hepaticojejunostomy were performed with a view to avoiding possible cyst cancerization.

Cystic neoplasms of the pancreas: problems in differential diagnosis

From 1970 to 1990 we observed 18 patients with histologically proven pancreatic cystic tumors. The average duration of symptoms prior to diagnosis was 14.1 months. A presumptive diagnosis was made preoperatively in nine patients. CT-guided fine needle cytology performed in three cases correctly showed a benign lesion in one patient and malignancy in two patients. Amylase and tumoral marker levels (CEA, CA19-9) were low in cystic fluid of two patients with cystadenomas who underwent preoperative percutaneous aspiration. Intraoperative biopsy of the cystic wall failed to detect epithelial lining in two cases; one patient had internal drainage for cystadenocarcinoma mistaken for pancreatic pseudocyst. Sixteen patients underwent surgery, two of whom died. Of the seven patients with a malignant condition, resection for cure was performed on three. The preoperative diagnosis of these very rare tumors remains difficult. Fine-needle cytology and cystic fluid examination may be a promising technique, but resection of all suspected lesions, whenever possible, is the procedure of choice for diagnosis and treatment.

[Adrenal cystic masses. Our experience]

Cystic masses of the adrenal gland are clinically and pathologically rare findings and few cases have been reported up to now in the medical literature. In the present work 5 new cases are reported: 3 adrenal pseudocysts, 1 lymphangioma, 1 cystic pheochromocytoma. In 3 cases there were clinical symptoms of retroperitoneal mass (lumbar pain, palpable mass, digestive symptoms); in 3 cases conventional radiology was helpful; ultrasonography was used for diagnosis in 1, CT scan in 2. In the pheochromocytoma case the real nature of the mass was determined through fluid hormone determination after fine needle puncture. All cases were treated by surgery.

CA 19-9 as a prognostic index after resection for pancreatic cancer

Serial serum CA 19-9 assays were performed in 30 consecutive patients who underwent resection for pancreatic cancer. Patients with preoperative CA 19-9 levels < 200 U/ml had significantly better prognosis than those with CA 19-9 > 200 U/ml (P < 0.001). Serum tumor marker normalized in 14 patients after tumor resection, and survival in this group was significantly higher than that of patients with persistently elevated CA 19-9 (P < 0.0001). Prognosis was also influenced by absence of lymph node metastases (P < 0.02) and radicality of resection (P < 0.005). Elevation of serum CA 19-9 levels after operation well predicted tumor recurrence from 1-10 months before clinical and radiological evidence. CA 19-9 determination is useful as a prognostic index after resection for pancreatic carcinoma and as a surveillance test in monitoring the efficacy of treatment.

Evaluation of surgical risk in palliation and resection of pancreatic cancer. Perspective study and tables to calculate the risk

High morbidity and mortality rates are reported for bypass and resective surgery of pancreatic cancer. In a retrospective study we correctly predicted the postoperative course in 88% of the patients who underwent bypass surgery and 83% of those who had a resection for pancreatic cancer. Before starting with clinical application of this scoring system, we undertook a prospective study to confirm its predictive value. Sixty-seven consecutive patients with pancreatic cancer were included: 42 patients underwent bypass surgery and 25 pancreatic resections. The operative mortality was 14% for palliative surgery and 0% for resective surgery. Surgical team and nurses were totally unaware of the predicted risk. The preoperative forecast proved to be correct in 81% of bypass surgery and in 88% of resective surgery, although surgical mortality had decreased from 21 to 14% for bypass surgery and from 17 to 0% for resective surgery. Tables are included to calculate the surgical risk for each of 162 combinations of the risk factors considered in the predictive model (81 for bypass surgery and 81 for resective surgery). Calculation of surgical risk is important when evaluating different treatments for pancreatic cancer are available.