Practical usefulness of lymphatic and connective tissue clearance for the carcinoma of the pancreas head

Association of p53 gene mutations with short survival in pancreatic adenocarcinoma

Mutations of the p53 gene have been found in a variety of human cancers and are implicated in the biologic functions of cancer. To investigate the clinical implications of p53 mutations in pancreatic adenocarcinoma, we examined the association of mutations of the p53 gene with patients' prognosis. Single-strand conformational polymorphism analysis and direct DNA sequencing were used to detect p53 gene mutations in 37 pancreatic adenocarcinomas. p53 gene mutations were detected in 16 (43%) of the 37 pancreatic adenocarcinomas. Direct sequencing did not reveal preferential clustering at any specific codon. There was no significant association of the presence of p53 gene mutations with histologic types, extent of tumor invasion, the presence of lymph node metastasis, or tumor stage. Univariate analysis showed that survival of patients with p53-gene-mutated tumors was significantly poorer than that of patients with p53-gene-nonmutated tumors (P = 0.02). Cox's multivariate analysis of ten clinicopathologic features including p53 gene mutations revealed that presence of p53 gene mutations (P = 0.026) and curativity of operation (P = 0.014) were independent predictors of survival. Furthermore, the survival of patients with p53-gene-mutated tumor was significantly poorer than that of patients with p53-gene-nonmutated tumors, both in patients who underwent curative operation (P = 0.04) and in patients who underwent non-curative operation (P = 0.01). These results suggested that mutations of the p53 gene might play an important role in cancer aggressiveness and could be a clinically useful predictor of prognosis in patients with pancreatic adenocarcinoma.

Digestive and nutritional consequences of pancreatic resections. The classical vs the pylorus-sparing procedure

Digestive and nutritional alterations are a common occurrence after pancreatic resections. The authors report the results of a multiparametric evaluation performed in a group of 26 patients submitted to total or cephalic pancreatectomy. Patients were divided into two groups according to the surgical procedure; group A (n = 13) included gastroresected patients and group B (n = 13) included those submitted to pylorus-sparing pancreatic resection. Subclinical digestive and absorptive impairment has been found in 61.5% of group A patients; the nutritional status was clinically poor in four cases from the same group. Digestive alterations have also been found in 69.2% of group B cases, but nutritional status was always satisfactory in the whole group. The more positive results obtained with the pylorus-sparing technique encourage wider adoption of this procedure.

Current management of pancreatic carcinoma

OBJECTIVE

The author seeks to provide an update on the current management of pancreatic carcinoma, including diagnosis and staging, surgical resection and adjuvant therapy for curative intent, and palliation.

SUMMARY BACKGROUND DATA

During the 1960s and 1970s, the operative mortality and long-term survival after pancreaticoduodenectomy for pancreatic carcinoma was so poor that some authors advocated abandoning the procedure. Several recent series have reported a marked improvement in perioperative results with 5-year survival in excess of 20%. Significant advances also have been made in areas of preoperative evaluation and palliation for advanced disease.

CONCLUSION

Although carcinoma of the pancreas remains a disease with a poor prognosis, advances in the last decade have led to improvements in the overall management of this disease. Resection for curative intent currently should be accomplished with minimal perioperative mortality. Surgical palliation also may provide the optimal management of selected patients.

Clinical significance of portal invasion by pancreatic head carcinoma

BACKGROUND

The purpose of the present study was to clarify the indication of aggressive surgery for pancreatic head carcinoma.

METHODS

Laparatomy was performed in 153 patients with carcinoma, 101 of whom underwent resection of the carcinoma. With histologic examination the degree of carcinoma invasion into the portal vein was classified into grades 0, I, or II according to the depth of invasion by the carcinoma. Macroscopic carcinoma invasion into portal vein was classified into types A, B, C, or D according to preoperative findings on the portal phase of superior mesenteric angiography or intraoperative portography.

RESULTS

Macroscopic findings correlated with the histologic invasion grades. The 1-year survival rate was 39.6% in grade 0, 11.3% in grade I, and 5.5% in grade II cases. The survival rates of patients with type A (p < 0.01), B (p < 0.05), and C invasion (p < 0.01) were higher than those of patients who did not undergo resection; however, no significant difference in the survival rates between patients who did not undergo resection and patients with type D invasion was observed.

CONCLUSIONS

For locally advanced carcinoma of the pancreatic head or entire pancreas, patients with type D invasion have no indication of aggressive surgery.

Long-term survival after resection for ductal adenocarcinoma of the pancreas. Is it really improving?

OBJECTIVE

The authors review their recent experience with resected pancreatic ductal adenocarcinoma.

SUMMARY BACKGROUND DATA

Ductal adenocarcinoma of the pancreas has traditionally had a 5-year survival rate less than 10% after curative resection. Recently, several groups have reported markedly improved 5-year survival rates (approaching 25%) for patients undergoing curative resection.

METHODS

Institutional experience with 186 consecutive patients (1981-1991) with pathologic diagnoses of ductal adenocarcinoma undergoing pancreatic resection was reviewed. Histologic specimens of all 3-year survivors (n = 31) were re-reviewed by two pathologists, one internal and one external; nonductal pancreatic cancers then were excluded.

RESULTS

After histologic re-review, 12 patients did not have ductal adenocarcinoma, leaving a total of 174 patients for analysis (102 men, 72 women; mean age 63 years, range 34-82 years). Mean follow-up was 22 months (range 4-109). Classical pancreaticoduodenectomy was performed in 71%, pylorus-preserving resection in 9%, and total pancreatectomy in 20%. Hospital mortality was 3%. Twenty-eight patients (16%) had macroscopically incomplete resections; 98 (56%) had lymph node metastases within the resected specimens, and 21 patients (12%) had extensive perineural invasion. Overall actuarial 5-year survival was 6.8%. Five-year survival was greater for node-negative versus node-positive patients (14% vs. 1%, p < 0.001), and for smaller (< 2 cm) versus larger tumors (20% vs. 1%, p < 0.001). The 5-year survival for the subset of patients with negative nodes and no perineural or duodenal invasion (69 patients) was 23% (p < 0.001). Mean survival of the 12 excluded patients was 53 +/- 7 months compared with 17.5 +/- 1 months in the 174 patients with ductal pancreatic cancer.

CONCLUSIONS

Five-year survival for patients undergoing pancreatic resection for lesions deemed to be clinically "curable" intraoperatively and histologically reviewed/confirmed to be ductal adenocarcinoma of the pancreas is approximately 7%. Survival is greater (23%) in the subset of patients with negative nodes and no duodenal or perineural invasions. Pathologic review of all patients with pancreatic ductal cancer adenocarcinoma is mandatory if survival data are to be meaningful.

Liver perfusion chemotherapy via both the hepatic artery and portal vein to prevent hepatic metastasis after extended pancreatectomy for adenocarcinoma of the pancreas

Since hepatic metastasis is a common cause of treatment failure after curative pancreatectomy for adenocarcinoma of the pancreas, we developed a new method of postoperative hepatic perfusion chemotherapy via both the hepatic artery and portal vein. The present study was conducted to determine if this method decreases the hepatic recurrence and improves the survival rate. Following extended pancreatectomy with wide lymphatic and connective tissue clearance for pancreatic cancer, one catheter was placed in the hepatic artery and one in the portal vein. Immediately after surgery, 5-fluorouracil (125 mg/d) was continuously infused via these two routes simultaneously for 28 to 35 days. There were no treatment-related complications in the 20 patients who survived surgery. The 3-year survival rate was 54%, and the cumulative rate of death from hepatic metastasis was 8%. These figures were significantly better than those of our historical control groups. We conclude that this method should be evaluated in a prospective, randomized controlled study.

Intraoperative radiation therapy for pancreatic carcinoma. The choice of treatment modality

Ninety patients with carcinoma of the pancreas treated between 1976 and 1990 were reviewed retrospectively. Intraoperative radiation therapy (IORT) in combination with external beam radiation therapy (EBRT) for localized but unresectable tumors (n = 29) prolonged survival significantly more than IORT alone (n = 16) (p < 0.01); it seems EBRT enhanced or contributed to the better results obtained with IORT plus EBRT. Moreover, IORT, alone or in combination, relieved pain. Adjuvant IORT for residual tumors (n = 20) might not effectively prolong survival, because the difference in survival rate between noncurative resection plus IORT and nonresection plus IORT in combination with EBRT was not significant. Curative tumor resection of stage III disease in combination with IORT (n = 9) resulted in significantly longer survival as compared with curative tumor resection alone (n = 8) (p < 0.05). It may be advisable to administer IORT in combination with EBRT to patients with advanced pancreatic carcinoma, avoiding aggressive tumor resection, when curative tumor resection cannot be performed.

Intraoperative radiation therapy adjuvant to resection in the treatment of pancreatic cancer

BACKGROUND

Local recurrence is the most frequent site of failure after resection for pancreatic cancer. Tolerance, local control, and survival obtained by the association of resection and intraoperative radiation therapy (IORT) were reported.

METHODS

Between June 1985 and March 1993, 90 resections for pancreatic cancer were performed at the authors' institution. For 43 patients, IORT was added to resection (Group 1), whereas the other 47 patients underwent resection alone (Group 2), because of either the unavailability of linear accelerator or the patient's refusal. In Group 1, radiation doses from 12.5 to 20 Gy, with electron beam energies between 6 and 12 MeV, were delivered. Extension of the disease was similar in the two groups of patients: mean diameter of the tumor was 3.2 cm in Group 1 and 3.4 cm in Group 2; percentage of third degree stage disease (International Union Against Cancer classification) was 65.1% in Group 1 and 57.4% in Group 2; and tumor clearance was incomplete in 39.5% of patients in Group 1 and in 34.0% in Group 2.

RESULTS

Operative mortality and overall early post-operative complications were respectively 2.3% and 23.2% in Group 1 and 2.1% and 23.4% in Group 2. One-year, 2-year, and 3-year survival rates were respectively 71%, 24%, and 7% in Group 1 and 49%, 16%, and 10% in Group 2 (P was not significant). Median disease free survival was 13 months in Group 1 and 8 months in Group 2 (P was not significant). A local recurrence was detected in 27.0% of patients in Group 1 and in 56.4% of patients in Group 2 (P < 0.01).

CONCLUSIONS

The results suggest a better local control in patients with pancreatic cancer undergoing adjuvant IORT.

Thin-section contrast-enhanced computed tomography accurately predicts the resectability of malignant pancreatic neoplasms

A prospective diagnostic study was designed to determine the ability of thin-section contrast-enhanced computed tomography (CT) to predict the resectability of malignant neoplasms of the pancreatic head. Patients with a presumed resectable pancreatic neoplasm referred during a 21-month period were studied with abdominal CT performed at 1.5-mm section thickness and 5-mm slice interval during the bolus phase of intravenous contrast enhancement. CT criteria for resectability included the absence of extrapancreatic disease, no evidence of arterial encasement, and a patent superior mesenteric-portal venous confluence. Of 145 patients evaluated, 42 were considered to have resectable tumors by CT criteria, and 37 (88%) underwent potentially curative pancreaticoduodenectomy. Six patients were found to have a microscopically positive retroperitoneal resection margin; no patient had a grossly positive resection margin. Five (12%) of 42 patients were found at laparotomy to have unresectable, locally advanced or metastatic tumors. Thin-section contrast-enhanced CT is an essential component of the preoperative evaluation for pancreaticoduodenectomy and can prevent needles laparotomy in most patients with locally advanced or metastatic disease.

Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.

Carcinoma of the pancreas and periampullary region: palliation versus cure

A retrospective study of 310 patients with carcinoma of the head of the pancreas or periampullary region was performed. Preoperative bile drainage by placement of a stent reduced the number of postoperative complications, especially bleeding (P = 0.03). The operative mortality rate was nil in patients with periampullary cancer aged under 70 years and 23 per cent in those over 70 years of age (P < 0.001). In the last 2 years of the study, the mortality rate following resection decreased to 2 per cent. Tumour-containing resection margins did not influence survival after resection (P = 0.48). Tumour dimension of pancreatic and periampullary cancer and the presence of tumour in locoregional lymph nodes (N1a) resected with the primary tumour in cancer of the head of the pancreas were of no prognostic value. Following palliative resection of carcinoma of the pancreatic head, median survival was significantly better than when no resection was performed (10.1 versus 3.9 months, P < 0.001). In conclusion, even palliative resection may benefit some patients. Preoperative bile drainage is indicated in those with jaundice. Resection should be performed, irrespective of tumour size, provided that the unit's operative mortality rate is sufficiently low.

Ductal adenocarcinoma of the pancreas: clinicopathologic features and survival

AIMS AND BACKGROUND

The prognosis after surgical resection for pancreatic cancer has not been clearly defined because conflicting results have been reported.

METHODS

Fifty-five patients who underwent surgical resection for pancreatic carcinoma between 1970 and 1987 were retrospectively reviewed to determine factors influencing long-term survival.

RESULTS

The actuarial 5-year survival rate for all 55 patients was 12.5%. Type of operation, tumor stage, direct extension into adjacent organs, grading and lymph node involvement were found to significantly influence survival. Age, sex, tumor site, size, invasion into peripancreatic tissue, invasion of lymphatic vessels and small veins, perineural infiltration, tumor necrosis, round cell infiltrate at the tumor margin, associated chronic pancreatitis, and atypia of pancreatic ductal epithelium demonstrated no predictive capacity. No 5-year survival was observed among the patients who underwent vascular resection. Three of 9 patients who underwent left-sided pancreatectomy for cancer of the tail of the pancreas survived more than 5 years. Multivariate analysis confirmed that lymph node involvement, moderate-poor histologic tumor differentiation, and treatment with total pancreatectomy were significantly associated with a worse prognosis.

CONCLUSIONS

Lymph node status, grading of the tumor and type of operation have a significant impact on prognosis in resected pancreatic cancer.

Intraoperative radiation therapy following pancreaticoduodenectomy

OBJECTIVE

To determine the morbidity and mortality of pancreaticoduodenectomy followed by electron-beam intraoperative radiation therapy (EB-IORT).

SUMMARY BACKGROUND DATA

Local recurrence following pancreaticoduodenectomy occurs in 50% to 90% of patients who undergo a potentially curative surgical resection for adenocarcinoma of the pancreatic head. To improve local disease control, a more aggressive retroperitoneal dissection has been combined with adjuvant EB-IORT.

METHODS

Forty-one patients with malignant neoplasms of the periampullary region underwent pancreaticoduodenectomy followed by EB-IORT between January 1989 and May 1992. EB-IORT was delivered in a dedicated operative suite, eliminating the need for patient relocation. Electron-beam energies of 6 to 12 MeV were used to deliver 10 to 20 Gy to the treatment field following resection but before pancreatic, biliary, and gastrointestinal reconstruction.

RESULTS

Median operative time was 9 hours, blood loss was 1 L, perioperative transfusion requirement was 2 units, and hospital stay was 20 days. One patient died of a postoperative myocardial infarction, and four patients required reoperation, one for an anastomotic leak. No patient failed to receive EB-IORT because of operative complications during the time period of this study.

CONCLUSION

Adjuvant EB-IORT after pancreaticoduodenectomy can be delivered safely, with low mortality and acceptable morbidity.

Expression of nucleoside diphosphate kinase/nm23 gene product in human pancreatic cancer: an association with lymph node metastasis and tumor invasion

The expression of nucleoside diphosphate (NDP) kinase/nm23 has been reported to be inversely related to metastasizing potential of experimental cells and human breast cancer. In the present study, levels of NDP kinase/nm23 gene product in curatively resected human pancreatic adenocarcinomas were examined immunohistochemically using anti-NDP kinase antibody. Immunoreactivity for NDP kinase varied between tumors. Of 31 pancreatic tumors examined, 17 (55%; positive staining group) showed strong immunoreactivity for the NDP kinase, while 14 (45%; negative staining group) showed low or no immunoreactivity. Positive staining was associated with higher incidence of lymph node metastasis (13/17; 77%) and perineural invasion (13/17; 77%) than negative staining (5/14, 36%, P < 0.03; 4/14, 29%, P < 0.01, respectively). Positive staining was also associated with shorter overall survival and relapse-free survival than negative staining (P < 0.01, P < 0.01, respectively). No significant difference in age, sex, size, location of tumor, serum carcinoembryonic antigen (CEA) level, or histological type was found between the two groups. These results showed that, in contrast to the reports on breast cancer, NDP kinase/nm23 expression in human pancreatic cancer is positively associated with lymph node metastasis or perineural invasion and with poor prognosis. These, together with other previous reports, suggest that NDP kinase may play an important role in cancer progression or aggressiveness by altering its expression in a tissue-specific manner.

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.

Conventional external irradiation alone as adjuvant treatment in resectable pancreatic cancer: results of a prospective study

Between 1/85 and 1/90, 14 consecutive patients were entered into a prospective study of conventional adjuvant post-operative external beam radiotherapy after complete resection for a pancreatic adenocarcinoma. The surgical procedure was a Whipple resection in nine patients, a distal pancreatectomy in four patients and a total pancreatectomy in one patient. There were three T1b, eight T2 and three T3 tumours (UICC 1987); nodal involvement was present in five cases. The radiotherapy was delivered using a four-field box technique with a 23 x MV photon beam. All patients received a total dose of 54 Gy to the tumour bed. The mean treated volume was 900 cm3. Acute toxicities consisted mainly of weight loss (mean: 2 kg). Two patients had a grade 2 diarrhoea and two patients a grade 2 gastritis. Late effects were minimal and only observed in two patients. The overall locoregional recurrence (LR) rate was 50%. The median disease-free survival was 12 months, and the median survival was 23 months. This post-operative conventional radiotherapy treatment gives results that are comparable to the results of the GITSG-adjuvant study using a combination of split-course radiotherapy and 5-fluorouracil (5-FU).

Carcinoma of the body and tail of the pancreas

Recently, several institutions have reported improved results in the treatment of patients with carcinoma of the head of the pancreas. In an attempt to determine whether similar trends could be demonstrated for patients with carcinoma of the body and tail of the pancreas, the records of all 113 patients with an adenocarcinoma of the body or tail of the pancreas treated at The Johns Hopkins Hospital between 1972 and 1989 were reviewed. The patients were divided into two groups: those diagnosed between 1972 and 1982 (41 patients) and those between 1983 and 1989 (72 patients). No significant differences in tumor stage were observed between the two groups. The proportion of patients who underwent surgery decreased from 68% to 47% (p = 0.02). The number of patients who had bypass operations (15% versus 17%) or pancreatic resection (5% versus 10%) was similar in the two groups, but the proportion of patients who underwent exploratory laparotomy with biopsy only decreased from 49% to 21% (p = 0.002). The postoperative 30-day mortality (7% versus 3%), postoperative morbidity (18% versus 21%), median survival (4 months versus 3 months), and the 1-year survival (8% versus 9%) did not differ significantly between the two groups. One patient survived for 6 years after resection, and another patient is still alive 3 years after resection. Thus, unlike adenocarcinoma of the head of the pancreas, it appears that treatment results for patients with adenocarcinoma of the body or tail of the pancreas have not improved in recent years, the only change being a decreased need for exploratory laparotomy with biopsy only.

Preoperative indications for extended pancreatectomy for locally advanced pancreas cancer involving the portal vein

This retrospective study attempted to determine the indications for extended pancreatectomy for locally advanced carcinoma of the pancreas, in terms of postoperative prognosis. An extended pancreatectomy with portal vein or superior mesenteric vein (PV/SMV) resection and regional lymphadenectomy was performed in 35 of 50 consecutive cancers that extended into the retroperitoneal spaces and involved the PV or SMV. Among the many background factors in the 35 resected specimens, the degree of PV/SMV invasion by the cancer was most closely associated with prognosis, despite resection of all involved PV/SMV. This factor generally correlated with the preoperative findings on the portal phase of superior mesenteric arteriograph. In 17 selected patients in whom PV/SMV invasion had been angiographically both semicircular or less and 1.2 cm (1.4 cm on the film) or less in length, the 3-year survival rate was 59%. This survival rate was significantly higher than the 29% 3-year survival rate in all 35 patients (p less than 0.05). Conversely, among the 18 patients in whom invasion was angiographically either beyond semicircular or more than 1.2 cm (1.4 cm on the film) in length, there were no 1.5-year survivors, and this result was even worse than that of 15 nonresectable cases. Based on postoperative survival, the degrees of PV/SMV invasion on preoperative angiography (narrowing pattern and length) are good indicators for aggressive pancreatectomy for locally advanced pancreatic cancer.

Surgery offers the best palliation for carcinoma of the pancreas

This debate discusses the palliative management of pancreatic cancer. The arguments in favour of surgical palliation are that this approach allows all symptoms to be treated or prevented, the diagnosis can be confirmed histologically and a final assessment of resectability can be made. The arguments against the use of surgery are that survival is short and that effective alternative therapies are available: endoscopic intubation, percutaneous coeliac plexus block and pancreatic enzyme supplements. The most appropriate policy, however, is to tailor the management plan to suit the individual patient.

Pylorus-preserving pancreatoduodenectomy--technical aspects

Pylorus-preserving pancreatododenectomy is the resection of choice for patients with carcinoma of the head of the pancreas and periampullary area and for certain patients with chronic pancreatitis. Preoperative preparation, operative technique, and results are discussed.

An appraisal of pancreatectomy for advanced cancer of the pancreas based on survival rate and postoperative physical performance

The follow-up results of surgical procedures for cancer of the pancreas at three affiliated hospitals during the past 15 years (1974-1989) were retrospectively analyzed to evaluate the merit of pancreatectomy in surgical treatment of advanced stages of this disease. Included were 4 cases of stage I, 14 cases of stage II, 19 cases of stage III, 43 cases of localized stage IV, and 35 cases of generalized stage IV. Pancreatectomy was performed in 67 cases; 100%, 92.9%, 89.5%, 67.4%, and 11.4% of the stage I, II, III, localized IV, and generalized IV cases, respectively. For the localized stage IV cases, in which the cancerous lesions were advanced but limited to the peripancreatic region, 29 pancreatectomies, 12 bypass operations, and 2 exploratory laparotomies were performed. This group included 17 curative and 12 noncurative pancreatectomies. The 50% survival periods were 257 days after curative pancreatectomy, 226 days after noncurative pancreatectomy, 120 days after bypass operation, and 33 days after exploratory laparotomy. The difference in overall survival rate between curative and noncurative pancreatectomies was not significant. The overall survival rates after both curative and noncurative pancreatectomies were significantly higher than the rate after bypass operation. The postoperative physical performance status after pancreatectomy was significantly better than after the palliative procedures. No significant difference in the status was found between patients after standard and extended pancreatectomies. There was no significant difference in the survival rates or the physical performance status between the pancreatectomy group and the palliative surgery group for the generalized stage IV cases, in which the cancerous lesions extended beyond the peripancreatic region. On the basis of these findings, it is concluded that pancreatectomy extends the postoperative survival period without impairment of the physical performance status in patients with advanced cancer of the pancreas. Even when the pancreatectomy proves to be a noncurative resection, this aggressive surgical approach may be of benefit to this group of patients. It should be noted, however, that pancreatectomy is not beneficial to patients whose lesions have already become generalized.

Staging of cancer of the pancreas

Staging of cancer of the pancreas is relatively reliable when based on pathological material obtained from operative specimens or at autopsy. At operation, the assessment of disease stage, and therefore of operability, is more difficulty-particularly in relation to the extent of lymph node involvement and liver metastases. Preoperative staging, which, clinically, is the most essential, is difficult and unsatisfactory at the present time.

Lymph node involvement as a prognostic factor in pancreatic cancer

The finding of metastatic disease in lymph nodes predicts a poor outcome for patients with adenocarcinoma of the head of the pancreas. Nodal metastases occur in as many as one-half of the patients who currently undergo resection with small tumors (less than 2 cm in diameter). There is some evidence that a more extensive lymphatic and soft tissue resection than is commonly done could prolong survival. This possibility should be tested in a prospectively designed study.

Pancreatic resection for pancreatic cancer

In the majority of patients, pancreatic resection is performed for a proved carcinoma or for a mass in the pancreas with clinical features of carcinoma. Preoperative preparation is similar to that for other cancer operations, and good nutritional status and normal clotting factors are important. In many patients with resectable lesions, preoperative histologic diagnosis is not possible.