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Evans DB, Lee JE, Pisters PW, Charnsangavej C, Ellis LM, Chiao PJ, Lenzi R, Abbruzzese JL. Advances in the diagnosis and treatment of adenocarcinoma of the pancreas. Cancer Treat Res 1997; 90:109-25. [PMID: 9367080 DOI: 10.1007/978-1-4615-6165-1_6] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- D B Evans
- M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Mosca F, Giulianotti PC, Balestracci T, Di Candio G, Pietrabissa A, Sbrana F, Rossi G. Long-term survival in pancreatic cancer: pylorus-preserving versus Whipple pancreatoduodenectomy. Surgery 1997; 122:553-66. [PMID: 9308613 DOI: 10.1016/s0039-6060(97)90128-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This study compared long-term survival in pancreatic or periampullary cancer treated with Whipple pancreatoduodenectomy (PD) and pylorus-preserving pancreatoduodenectomy (PPPD). METHODS Two hundred twenty-one patients with pancreatic head or periampullary cancer were treated. Prognostic variables included age, gender, type and period of operation, and tumor stage. In the ductal adenocarcinomas variables also included tumor and node status, type of lymphadenectomy, pathologic grade, and presence of microscopic residual tumor. The end point was death as a result of neoplastic recurrence. Survival curves were estimated by using the Kaplan-Meier method, and multifactorial analysis was also performed on the data from the ductal adenocarcinoma group. RESULTS The mortality rate was 8.2% in the PD group versus 7.0% in the PPPD group. Morbidity rates were 34.4% for PD and 45.8% for PPPD. Five-year survival was 9.6% in the ductal adenocarcinoma and 63.8% in the periampullary carcinoma groups. Univariate analysis failed to show statistically significant differences in survival curves between the two treatments in either patient group. Correcting for multiple variables in the ductal adenocarcinoma group did not reveal any significant differences in survival rates between the two treatments. CONCLUSIONS PPPD was as successful as classic PD in the treatment of ductal adenocarcinoma and periampullary cancer of the pancreas. Long-term survival was not influenced by the type of resection.
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Affiliation(s)
- F Mosca
- Istituto di Chirurgia Generale e Sperimentale, U.O. di Chirurgia Generale e Vascolare, Università di Pisa, Italy
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Coquard R, Ayzac L, Gilly FN, Romestaing P, Ardiet JM, Sondaz C, Sotton MP, Sentenac I, Braillon G, Gerard JP. Intraoperative radiotherapy in resected pancreatic cancer: feasibility and results. Radiother Oncol 1997; 44:271-5. [PMID: 9380827 DOI: 10.1016/s0167-8140(97)00107-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE To evaluate the impact of intraoperative radiotherapy (IORT) combined with postoperative external beam irradiation in patients with pancreatic cancer treated with curative surgical resection. MATERIALS AND METHODS From January 1986 to April 1995 25 patients (11 male and 14 female, median age 61 years) underwent a curative resection with IORT for pancreatic adenocarcinoma. The tumour was located in the head of the pancreatic gland in 22 patients, in the body in two patients and in the tail in one patient. The pathological stage was pT1 in nine patients, pT2 in nine patients, pT3 in seven patients, pN0 in 14 patients and pN1 in 11 patients. All the patients were pM0. A pancreaticoduodenectomy was performed in 22 patients, a distal pancreatectomy was performed in two patients and a total pancreatectomy was performed in one patient. The resection was considered to be complete in 20 patients. One patient had microscopic residual disease and gross residual disease was present in four patients. IORT using electrons with a median energy of 12 MeV was performed in all the patients with doses ranging from 12 to 25 Gy. Postoperative EBRT was delivered to 20 patients (median dose 44 Gy). Concurrent chemotherapy with 5-fluorouracil was given to seven patients. RESULTS The overall survival was 56% at 1 year, 20% at 2 years and 10% at 5 years. Nine local failures were observed. Twelve patients developed metastases without local recurrence. Twenty patients died from tumour progression and two patients died from early postoperative complications. Three patients are still alive; two patients in complete response at 17 and 94 months and one patient with hepatic metastases at 13 months. CONCLUSION IORT after complete resection combined with postoperative external beam irradiation is feasible and well tolerated in patients with pancreatic adenocarcinoma.
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Affiliation(s)
- R Coquard
- Service de Radiothérapie-Oncologie, Hospices Civils de Lyon, France
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205
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Dobelbower RR, Merrick HW, Khuder S, Battle JA, Herron LM, Pawlicki T. Adjuvant radiation therapy for pancreatic cancer: a 15-year experience. Int J Radiat Oncol Biol Phys 1997; 39:31-7. [PMID: 9300737 DOI: 10.1016/s0360-3016(97)00125-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE A retrospective analysis to determine differences in survival of patients with pancreatic adenocarcinoma treated by radical surgery with and without adjuvant radiation therapy. METHODS AND MATERIALS Between 1980 and 1995, 249 patients with pancreatic tumors were identified at the Medical College of Ohio. Forty-four of these patients underwent radical surgical procedures with curative intent. These patients were divided into four groups according to treatment: surgery alone (n = 14), surgery plus intraoperative radiation therapy (IORT) (n = 6), surgery plus external beam radiation therapy (EBRT) (n = 14), or surgery plus both IORT and EBRT (n = 10). Outcome and survival were analyzed among the four groups. RESULTS The median survival time of patients treated with radical surgery alone was 6.5 months. The median survival time for the surgery plus IORT group was 9 months; however, 33.3% (two of six) of these patients survived longer than 5 years. This survival pattern was borderline significantly better than that for the surgery alone group (p = 0.0765). The surgery plus EBRT and the surgery plus IORT and EBRT groups had median survival times of 14.5 and 17.5 months, respectively. These were significantly better than that of the surgery alone group (p = 0.0004 and p = 0.0002, respectively). The addition of radiation therapy did not affect the treatment complication rate. CONCLUSION The survival of patients who were treated with radical surgery alone was significantly poorer than that of patients who received adjuvant radiation therapy. These results are consistent with other studies in the literature. Patients treated with all three modalities (surgery, IORT, and EBRT) displayed the best median survival time.
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Affiliation(s)
- R R Dobelbower
- Department of Radiation Therapy, Medical College of Ohio, Toledo 43699-0008, USA
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206
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Nishimura Y, Hosotani R, Shibamoto Y, Kokubo M, Kanamori S, Sasai K, Hiraoka M, Ohshio G, Imamura M, Takahashi M, Abe M. External and intraoperative radiotherapy for resectable and unresectable pancreatic cancer: analysis of survival rates and complications. Int J Radiat Oncol Biol Phys 1997; 39:39-49. [PMID: 9300738 DOI: 10.1016/s0360-3016(97)00295-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Clinical results of intraoperative radiotherapy (IORT) and/or external beam radiotherapy (EBRT) for both resectable and unresectable pancreatic cancer were analyzed. METHODS AND MATERIALS Between 1980 and 1995, 332 patients with pancreatic cancer were treated with surgery and/or radiation therapy (RT). Of the 332 patients, 157 patients were treated with surgical resection of pancreatic tumor, and the remaining 175 patients had unresectable pancreatic tumors. Among the 157 patients with resected pancreatic cancer, 62 patients were not treated with RT, while 40 patients were treated with EBRT alone (mean RT dose; 46.3 Gy) and 55 patients with IORT (25.2 Gy) +/- EBRT (44.0 Gy). On the other hand, among the 175 patients with unresectable pancreatic cancer, 58 patients were not treated with RT, 46 patients were treated with EBRT alone (39.2 Gy), and the remaining 71 patients with IORT (29.3 Gy) +/- EBRT (41.2 Gy). RESULTS For 87 patients with curative resection, the median survival times (MSTs) of the no-RT, the EBRT, and the IORT +/- EBRT groups were 10.4, 13.0, and 15.5 months, respectively, without significant difference. For 70 patients with noncurative resection, the MSTs of the no-RT, the EBRT, and the IORT +/- EBRT groups were 5.3, 8.7, and 6.5 months, respectively. When the EBRT and the IORT +/- EBRT groups were combined, the survival rate was significantly higher than that of the no RT group for noncuratively resected pancreatic cancers (log rank test; p = 0.028). The 2-year survival probability of the IORT +/- EBRT group (16%) was higher than that of the EBRT group (0%). For unresectable pancreatic cancer, the MSTs of 52 patients without distant metastases were 6.7 months for palliative surgery alone, 7.6 months for EBRT alone, and 8.2 months for IORT +/- EBRT. The survival curve of the IORT +/- EBRT group was significantly better than that of the no-RT group (p < 0.05), and the difference between the IORT +/- EBRT and the EBRT alone groups was marginally significant (p = 0.056). In addition, the 2-year survival probability for the IORT +/- EBRT group was 14%, while no 2-year survival was observed in the no RT or the EBRT groups. Multivariate analysis using the Cox proportional hazards model revealed that tumor size, stage (Stages 1, 2 vs. Stages 3, 4), and curability of resection were significant variables for resectable pancreatic cancer, while distant metastases and performance of IORT were significant variables for unresectable pancreatic cancer. The dose of EBRT was a marginally significant factor for both resectable and unresectable tumors (both p = 0.06). In terms of complications, ulcers of gastrointestinal tract were noted in 14% of the 126 patients treated with IORT. CONCLUSION Although prolongation of the MST by IORT was not remarkable, long survivals (>2 years) were obtained by IORT +/- EBRT for noncuratively resected and unresectable pancreatic cancer. IORT combined with EBRT is indicated for noncurative resected or unresectable pancreatic cancer without distant metastases.
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Affiliation(s)
- Y Nishimura
- Department of Radiology, Faculty of Medicine, Kyoto University, Japan
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Neoptolemos JP, Baker P, Beger H, Link K, Pederzoli P, Bassi C, Dervenis C, Friess H, Büchler M. Progress report. A randomized multicenter European study comparing adjuvant radiotherapy, 6-mo chemotherapy, and combination therapy vs no-adjuvant treatment in resectable pancreatic cancer (ESPAC-1). INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1997; 21:97-104. [PMID: 9209950 DOI: 10.1007/bf02822380] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONCLUSION The ESPAC-1 trial is the largest study of its kind in pancreatic cancer and should definitively address the question of the role of conventional methods of adjuvant treatment in pancreatic cancer. BACKGROUND At the joint International Association of Pancreatology and the European Pancreatic Club meeting in Mannheim, Germany (June 12-15, 1996) a satellite meeting of the European Study Group for Pancreatic Cancer (ESPAC) met to discuss the progress of the ESPAC-1 trial. METHODS A randomized multicenter study to address which, if any, of the following adjuvant treatments are of benefit in patients with resectable pancreatic cancer: radiotherapy (40 Gy with 5-FU as a sensitizing agent), 6 mo of chemotherapy (5-FU and folinic acid), or a combination of these treatments. RESULTS From February 1994 to June 1996 (the time of the Mannheim meeting) 221 patients so far have been recruited into the three treatment arms and one control arm.
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Affiliation(s)
- J P Neoptolemos
- Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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209
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Dorandeu A, Raoul JL, Siriser F, Leclercq-Rioux N, Gosselin M, Martin ED, Ramée MP, Launois B. Carcinoma of the ampulla of Vater: prognostic factors after curative surgery: a series of 45 cases. Gut 1997; 40:350-5. [PMID: 9135524 PMCID: PMC1027085 DOI: 10.1136/gut.40.3.350] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Some adjuvant or neoadjuvant therapy could be important for patients operated on for tumours of the ampulla of Vater, especially for those having a higher risk of recurrence. AIM To evaluate prognostic factors after curative surgery based on a series of 45 cases of malignant tumours of the Oddi sphincter. PATIENTS From 1970 to 1992, a curative resection was performed in 45 patients (age 62.8 (SD 10.1) years) with adenocarcinoma of the ampulla. Surgical procedures included pancreatoduodenectomy (n = 42) and resection of the ampulla (n = 3). Actuarial survival was 44 (SD 9)% at five years. METHODS Various prognostic variables were studied: clinical manifestations, macroscopic aspect, differentiation, noninvasive adenomatous component, mucin histochemistry, immunohistochemistry (CEA, CA19.9, p53, Ki67), and accepted classifications (Blumgart and Kennedy, Martin, Yamaguchi and Enjoji, Talbot et al, pTNM). RESULTS Variables with prognostic power, in order of importance were: Classification of Talbot et al; CA19.9; pTNM; sialomucins; classification of Yamaguchi and Ejoji; Martin classification; sulphomucins; non-invasive adenomatous component (positive > negative); jaundice; tumour localisation. CONCLUSIONS This series confirmed the prognostic power of former classifications and showed the prognostic power of other variables (mucin, non-invasive adenomatous component, CA19.9).
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Affiliation(s)
- A Dorandeu
- Service d'Anatomie Pathologique, Centre Régional Hospitalier Universitaire de Rennes, France
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210
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Affiliation(s)
- S Rosewicz
- Department of Gastroenterology, Klinikum Benjamin Franklin, Berlin, Germany
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Sperti C, Pasquali C, Piccoli A, Pedrazzoli S. Recurrence after resection for ductal adenocarcinoma of the pancreas. World J Surg 1997; 21:195-200. [PMID: 8995078 DOI: 10.1007/s002689900215] [Citation(s) in RCA: 383] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We analyzed the pattern of failure and clinicopathologic factors influencing the disease-free survival of 78 patients who died after macroscopic curative resection for pancreatic cancer. Local recurrence was a component of failure in 56 patients (71.8%) and hepatic recurrence in 48 (61.5%), both accounting for 97% of the total recurrence rate. About 95% of recurrences occurred by 24 months after operation. Median disease-free survival time was 8 months, and cumulative 1-, 3-, and 5-year actuarial disease-free survival rates were 66%, 7%, and 3%, respectively. Multivariate analysis showed that tumor grade (p = 0.04), microscopic radicality of resection (p = 0.04), lymph node status (p = 0.01), and size of the tumor (p = 0.005) were independent predictors of disease-free survival. Patterns of failure and disease-free survival were not statistically influenced by the type of surgical procedure performed. Median survival time from the detection of recurrence until death was 7 months for local recurrence versus 3 months for hepatic or local plus hepatic recurrence (p < 0.05). From our experience and the data collected from the literature, it appears that surgery alone is an inadequate treatment for cure in patients with pancreatic carcinoma. Effective adjuvant therapies are needed to improve locoregional control of pancreatic cancer after surgical resection.
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Affiliation(s)
- C Sperti
- Department of Surgery, University of Padua, Padua, Italy
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212
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Andrén-Sandberg A, Bäckman PL, Andersson R. Results of adjuvant therapy in resected pancreatic cancer. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1997; 21:31-8. [PMID: 9127171 DOI: 10.1007/bf02785917] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
After an apparently curative resection, most patients develop local recurrence within the resection bed. In addition, almost all develop liver metastases. This implies that the surgical resection, even if extended, seldom is enough, and that an adjuvant treatment must be effective not only against systemic spread, but also against local recurrence. However, the time schedule may be different for different types of recurrence, resulting in different time frames for the adjuvant treatment. Although extended radical operations may increase the proportion of patients who can undergo resections, the incidence of local recurrences seems unchanged. There are, however, no randomized studies yet comparing the "Standard Whipple" with more extended resection. Intraoperative radiation (IORT) has failed to demonstrate a difference in long-term survival, but there have been reports of a decreased frequency of local progression at the site of the primary tumor. Therefore, it is encouraging that IORT seems to diminish the local recurrences after radical resections. However, randomized studies are also missing for this procedure. These are today only three published studies of adjuvant chemotherapy after radical pancreaticoduodenectomy, but a few more will be finished shortly. Still, the results have not convincingly shown that modern chemotherapy with or without radiotherapy prolongs the life of the patients, and there is little evidence for improving the quality of life. However, since the results are far from satisfactory after resection, more efforts should be made to find better treatment modalities, including adjuvant protocols.
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Robinson EK, Lee JE, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB. Reoperative pancreaticoduodenectomy for periampullary carcinoma. Am J Surg 1996; 172:432-7; discussion 437-8. [PMID: 8942539 DOI: 10.1016/s0002-9610(96)00218-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We have noted a continued increase in the number of patients referred to our institution for presumed or biopsy-proven periampullary carcinoma following an "exploratory" laparotomy during which tumor resection was not performed. Although previous work has demonstrated the safety of reoperative pancreaticoduodenectomy (PD), the need to avoid nontherapeutic laparotomy in these patients is obvious. In the current study, we sought to determine why PD was not performed at the initial operation. METHODS Using the prospective pancreatic cancer database, we identified all patients who underwent reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging prior to reoperation was standardized and based on thin-section, contrast-enhanced computed tomography (CT); helical CT was used in more recent cases. Pathologic data were obtained, and initial outside operative reports were reviewed to determine why a PD was not performed at the initial procedure. RESULTS Twenty-nine patients underwent reoperative PD. Resection was not performed at the initial laparotomy because of the surgeon's assessment of local unresectability (17 patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error in intraoperative management (1). In the 17 patients deemed to have unresectable disease, successful reoperative PD required vascular resection in 10. All 10 of these patients had resection with negative microscopic margins of excision. Of the 9 patients who did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered major complications from intraoperative large-needle biopsy. CONCLUSIONS Detailed preoperative imaging and a clearly defined operative plan would have allowed successful resection at the initial operation in 27 of 29 patients who underwent reoperative PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly against "exploratory" surgery in patients with presumed periampullary neoplasms.
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Affiliation(s)
- E K Robinson
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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214
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Willett CG, Daly WJ, Warshaw AL. CA 19-9 is an index of response to neoadjunctive chemoradiation therapy in pancreatic cancer. Am J Surg 1996; 172:350-2. [PMID: 8873528 DOI: 10.1016/s0002-9610(97)89547-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE This study examines the changes of serum levels of CA 19-9 in patients with pancreatic cancer following neoadjuvant irradiation and chemotherapy to define the potential role of this tumor marker in preoperative management of these patients. MATERIALS AND METHODS Serum CA 19-9 levels were measured in 42 patients before receiving external beam irradiation with concurrent 5-fluorouracil in preparation for laparotomy and Whipple procedure or intraoperative irradiation (IORT). The CA 19-9 levels were determined again after irradiation, and changes were correlated with findings of restaging computed tomography (CT) scan and laparotomy. RESULTS Following preoperative irradiation, 10 patients (24%) experienced an increase in CA 19-9 levels whereas 29 patients (69%) showed a decrease in CA 19-9. There was no change in the CA 19-9 levels of 3 patients (7%) after treatment. Of the 10 patients with increased CA 19-9 levels after irradiation, 9 (90%) had developed distant metastases or local tumor progression as determined by restaging CT scan or at laparotomy. In contrast, only 6 of 29 patients (21%) with declining CA 19-9 levels after irradiation demonstrated metastases or local tumor progression on restaging CT scan or at laparotomy. The correlation of CA 19-9 increase or decrease with disease progression or control, respectively, was statistically significant (P = 0.009). CONCLUSIONS Serum CA 19-9 levels may rise or fall during neoadjuvant therapy. A rising CA 19-9 reliably indicates cancer progression while a falling CA 19-9 connotes disease control in the majority of patients. In developing strategies for application of neoadjuvant therapy for pancreatic cancer, monitoring of CA 19-9 appears most useful for the identification of patients who manifest progressive tumor growth and metastasis in spite of this treatment.
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Affiliation(s)
- C G Willett
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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215
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Abstract
BACKGROUND Survival for adenocarcinoma of the pancreatic remains unchanged over the last two decades. The majority of patients (85%) are diagnosed with an inoperable tumor. Patterns of failure reveal that pancreatic cancer involves three compartments: the pancreatic bed and regional lymph nodes, the liver and the peritoneal surfaces. Twelve patients with advanced, unresectable pancreatic cancer, Stage II/III, were treated with regional intra-arterial chemotherapy and extracorporeal hemofiltration directed towards the pancreatic tumor-bearing area and the liver. METHODS Five patients had an arterial catheter/port system placed within the celiac axis; the rest had an angiographically placed arterial catheter. All patients had a 16 Fr PFM filtration catheter inserted in the vena cava positioning the tip at the level of the diaphragm and then connected to a hemofiltration unit. Mitomycin C was infused over 25 minutes followed by 5-FU over 10 minutes. The hemofiltration was begun before the drug infusion and continued for 70 minutes. The twelve patients underwent 33 cycles of regional chemotherapy plus hemofiltration. RESULTS Five patients had a partial response (45.5%), five had stable disease (45.5%), and one had progression (9%). Four patients were re-explored with one patient undergoing a curative resection. The average survival for patients with unresectable pancreatic adenocarcinoma is 13 months. Tumor implantation and progression on the peritoneal surfaces remains the major site of treatment failure. CONCLUSIONS Regional chemotherapy plus hemofiltration with MMC and 5-FU appears to improve the response of Stage II/III inoperable pancreatic cancer and can convert some patients to resectability without significant complications and with no mortality.
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Affiliation(s)
- J H Muchmore
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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216
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Abstract
There are approximately 27,000 new cases of carcinoma of the pancreas each year and most afflicted patients will die of the disease. Although smoking is a common denominator, chronic pancreatitis is considered an important precursor lesion in a smaller number of cancers. Pancreatic cancer is primarily a disease of the pancreatic ducts. The molecular events are under intense study, but c-K-ras mutation is involved in approximately 80% of the cases and p53 to a slightly lesser degree (60-80%). Early manifestations are usually occult, but jaundice is a common manifestation in patients with cancers of the pancreatic head. Thin-slice computed tomography, portography, and endoscopic retrograde cholangiopancreatography are currently the most sensitive detection techniques. The developing use of endoscopic ultrasound and laparoscopy appear to enhance detection and are under evaluation. In many patients with advanced disease, endoscopic bypass may eliminate the need for unnecessary surgery, although gastrointestinal bypass is still required in some patients (10-15%). Curative resection is possible in selected patients (perhaps 10-15%), with expectation of extended survival ranging from 6->20% in some series. The survival differences may be related to stage, patient selection, and the expertise of the operative team. Preoperative chemotherapy/radiation is under study and may improve outcome. Clinical trial participation is essential for improvement in treatment outcomes.
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Affiliation(s)
- H J Wanebo
- Department of Surgery, Roger Williams Medical Center, Providence, Rhode Island, USA
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Sperti C, Pasquali C, Piccoli A, Pedrazzoli S. Survival after resection for ductal adenocarcinoma of the pancreas. Br J Surg 1996; 83:625-31. [PMID: 8689203 DOI: 10.1002/bjs.1800830512] [Citation(s) in RCA: 149] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- C Sperti
- Department of Surgery, University of Padova, Padua, Italy
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219
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Conlon KC, Klimstra DS, Brennan MF. Long-term survival after curative resection for pancreatic ductal adenocarcinoma. Clinicopathologic analysis of 5-year survivors. Ann Surg 1996; 223:273-9. [PMID: 8604907 PMCID: PMC1235115 DOI: 10.1097/00000658-199603000-00007] [Citation(s) in RCA: 539] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The authors reviewed the clinicopathologic characteristics of patients who underwent resection with curative intent for ductal adenocarcinoma of the pancreas between 1983 and 1989. SUMMARY BACKGROUND DATA Recent studies have demonstrated a reduction in the morbidity and mortality of pancreatic resection and improvement in the actuarial 5-year survival for patients with resected ductal adenocarcinoma. METHODS Resection with curative intent was performed on 118 of 684 patients (17%) with pancreatic cancer admitted to the authors' institution. Clinical, demographic, treatment, and pathologic variables were analyzed. The original material for all cases was reviewed; nonductal cancers were excluded. RESULTS The head of the gland was the predominant tumor site (n = 102), followed by the body (n = 9), and tail (n = 7). Seventy-two percent of the patients underwent pancreaticoduodenectomies, 15% underwent total pancreatectomies, 10% underwent distal pancreatectomies, and 3% underwent distal subtotal pancreatectomies. Operative mortality was 3.4%. Median survival was 14.3 months after resection compared with 4.9 months if patients did not undergo resection (p < 0.0001). Twelve patients survived 5 years after surgery (10.2% overall actual 5-year survival rate). Three of the tumors were well differentiated, five were moderately differentiated, and four were poorly differentiated. Extrapancreatic invasion occurred in nine cases (75%), and perineural invasion was present in ten cases (83%). Five tumors exhibited invasion of duodenum, ampulla of Vater, and/or common bile duct, and an additional tumor invaded the portal vein. Lymph node involvement by carcinoma was noted in five cases (42%). Six patients remain alive without evidence of disease at a median follow-up of 101 months (range, 82-133 months). Five patients died of recurrent or metastatic pancreatic cancer at 60, 61, 62, 64, and 64 months, respectively. One patient died at 84 months of metastatic lung cancer without evidence of recurrent pancreatic disease. CONCLUSIONS This paper emphasizes the grim prognosis of pancreatic ductal adenocarcinoma. Five-year survival cannot be equated to cure. Although pancreatectomy offers the only chance for long-term survival, it should be considered as the best palliative procedure currently available for the majority of patients. This emphasizes the need for the development of novel and effective adjuvant therapies for this disease.
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Affiliation(s)
- K C Conlon
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Cunningham JD, Glajchen N, Brower ST. The use of spiral computed tomography in the evaluation of vessel encasement for pancreatic cancer. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1996; 19:9-14. [PMID: 8656031 DOI: 10.1007/bf02788370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
CONCLUSIONS Spiral CT allows for a noninvasive evaluation of the mesenteric arterial and venous vessels. This test can be performed quicker, with less expense, and with a reduced radiation and contrast load than angiography. Comparison studies of angiography and spiral CT are needed in patients with pancreatic cancer to determine the best method of evaluating possible vessel involvement. BACKGROUND Preoperative imaging of patients with pancreatic cancer is crucial in determining resectability and planning management. Computed tomography (CT) remains the diagnostic procedure of choice for the evaluation of the primary tumor and angiography is the gold standard to evaluate vessel encasement. This case evaluates the usefulness of spiral computed tomography in determining vessel encasement. METHODS A 53-yr-old female presented with vague abdominal complaints and evaluation revealed a mass in the pancreas. CT suggested portal vein involvement and collateralization was noted in the upper abdomen. Spiral CT revealed normal arterial anatomy and near complete obstruction of the portal vein at the superior mesenteric vein (SMV) splenic vein (SV) confluence. RESULTS Operative findings confirmed the involvement of the portal vein at the confluence of the SMV and SV. Pancreatico-duodenectomy with portal vein resection and primary anastomosis was performed. The patient's postoperative course was uneventful and she was discharged home on the 13th postoperative day.
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Affiliation(s)
- J D Cunningham
- Department of Surgery, Mount Sinai Medical Center, New York, NY 10029, USA
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221
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Kaneko T, Nakao A, Inoue S, Nomoto S, Nagasaka T, Nakashima N, Harada A, Nonami T, Takagi H. Extrapancreatic nerve plexus invasion by carcinoma of the head of the pancreas. Diagnosis with intraportal endovascular ultrasonography. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1996; 19:1-7. [PMID: 8656022 DOI: 10.1007/bf02788369] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
CONCLUSION The intraportal endovascular ultrasonography (IPEUS) could diagnose the second portion of the extrapancreatic nerve plexus invasion and provide precise information in operative strategy. But, the first portion was not visualized clearly owing to poor tissue penetration of the ultrasound beam, which may have reduced diagnostic accuracy. Improvement of the scanning area is expected to make intraportal endovascular US even more useful. BACKGROUND Pancreatic cancer easily invades the retroperitoneal tissue, especially the extrapancreatic nerve plexus. We evaluated the extrapancreatic nerve plexus invasion of the pancreatic cancer with IPEUS. IPEUS was performed intraoperatively in 20 consecutive resected cases with carcinoma of the head of the pancreas. METHODS IPEUS was performed with an 8-French, 20 MHz intravascular ultrasound catheter. IPEUS visualized the inferior pancreaticoduodenal artery (IPDA) in the extrapancreatic nerve plexus. The high-echoic area around the IPDA corresponds to the second portion of the extrapancreatic nerve plexus. The sonographic criterion for detection of the extrapancreatic nerve plexus invasion is low-echoic infiltration around the IPDA. RESULTS Extrapancreatic nerve plexus invasion was confirmed with resected specimens in 10 patients. The IPDA could not be visualized in two patients. In 18 patients, the diagnostic accuracy of invasion was evaluated. For diagnosis of extrapancreatic nerve plexus invasion with intraportal endovascular US, the sensitivity, specificity, and overall accuracy were 87.5, 90, and 88.7%, respectively.
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Affiliation(s)
- T Kaneko
- Department of Surgery II, Faculty of Medicine, Nagoya University
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222
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Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB. Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg 1996; 223:154-62. [PMID: 8597509 PMCID: PMC1235091 DOI: 10.1097/00000658-199602000-00007] [Citation(s) in RCA: 248] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Tumor invasion of the superior mesenteric-portal vein (SMPV) confluence is often considered a contraindication to pancreaticoduodenectomy for patients with malignant tumors of the pancreas or periampullary region. The authors sought to determine whether pancreaticoduodenectomy with en bloc resection of the SMPV confluence could be safely performed and whether tumors involving the SMPV confluence were associated with pathologic parameters suggesting poor prognosis. SUMMARY BACKGROUND DATA Several centers have reported high rates of retroperitoneal margin positivity after pancreaticoduodenectomy for tumors of the pancreatic head and periampullary region. Positive-margin or incomplete resection is associated with early tumor recurrence and no survival benefit compared with palliative therapy. Tumor adherence to the lateral of posterior wall of the SMPV confluence often represents the only barrier to complete tumor resection at the time of pancreaticoduodenectomy. METHODS Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreas or periampullary region over a 3.5-year period were entered prospectively in a pancreatic tumor database. To be considered for surgery, patients were required to fulfill the following computed tomography criteria for resectability: 1) the absence of extrapancreatic disease, 2) no tumor encasement of the superior mesenteric artery or celiac axis, and 3) a patent SMPV confluence. Tumor adherence to the superior mesenteric vein or SMPV confluence was assessed intraoperatively, and en bloc venous resection was performed when necessary to achieve complete tumor extirpation. Data on operative characteristics, morbidity, mortality, tumor size, nodal metastases, margin positivity, perineural invasion, and tumor DNA content were compared for patients who did and did not receive venous resection. RESULTS Fifty-nine patients underwent pancreaticoduodenectomy, 36 without venous resection and 23 with en bloc resection of the SMPV confluence. No differences in median hospital stay, morbidity, mortality, tumor size, margin positivity, nodal positivity, or tumor DNA content were observed between groups. CONCLUSIONS When necessary, segmental resection of the SMPV confluence may be performed safely during pancreaticoduodenectomy for periampullary malignant tumors. Tumors invading the SMPV confluence are not associated with histologic parameters suggesting a poor prognosis. Our data suggest that venous involvement is a function of tumor location rather than an indicator of aggressive tumor biology.
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Affiliation(s)
- G M Fuhrman
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
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223
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Staley CA, Lee JE, Cleary KR, Abbruzzese JL, Fenoglio CJ, Rich TA, Evans DB. Preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinoma of the pancreatic head. Am J Surg 1996; 171:118-24; discussion 124-5. [PMID: 8554125 DOI: 10.1016/s0002-9610(99)80085-3] [Citation(s) in RCA: 174] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Local recurrence in the bed of the resected pancreas is the most common site of tumor recurrence following a standard pancreaticoduodenectomy (PD) for adenocarcinoma of the pancreatic head. In an attempt to improve local and regional disease control and thereby enhance the quality and length of survival in patients undergoing potentially curative PD, we have used a protocol of preoperative multimodality therapy. PATIENTS AND METHODS All patients were treated with external-beam radiation (30.0 or 50.4 Gy) and concomitant 5-fluorouracil (300 mg/m2 per day) prior to PD. Electron-beam intraoperative radiation therapy was given to the bed of the resected pancreas before reconstruction. Patients were assessed for recurrence by physical examination, chest roentgenography, and computed tomography scan performed at 3-month intervals following treatment. RESULTS Thirty-nine patients completed all therapy; 1 perioperative death occurred. Thirty-eight tumor recurrences have been documented in 29 patients at a median of 11 months from the date of diagnosis; 23 patients died of disease. The liver was the most frequent site of recurrence, and liver metastases were a component of treatment failure in 53% of patients. Isolated local or peritoneal recurrences were documented in only 4 patients (11%). The only significant clinical or pathologic variable predictive of local-regional recurrence was a previous laparotomy and intraoperative biopsy. The median survival of all 39 patients was 19 months, and the 4-year actuarial survival rate was 19%. CONCLUSIONS Preoperative chemoradiation, PD, and electron-beam intraoperative radiation therapy for adenocarcinoma of the pancreatic head have resulted in improved local-regional tumor control, with distant metastatic disease becoming the predominant site of tumor recurrence. Future treatment strategies should incorporate effective multimodality therapy for local-regional disease as demonstrated in this study. Major improvements in overall survival will likely await the development of systemic or regional therapy for liver metastases.
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Affiliation(s)
- C A Staley
- Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston 77030, USA
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Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullary region: who benefits from portal vein resection? Am J Surg 1996; 171:170-4; discussion 174-5. [PMID: 8554135 DOI: 10.1016/s0002-9610(99)80094-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The prognosis of patients with carcinoma of the periampullary region infiltrating the portal vein is dismal. PATIENTS AND METHODS We assessed the morbidity, mortality, and prognosis of pancreatoduodenectomy in 31 patients in whom a tangential excision (n = 9) or a segmental resection (n = 22) of the portal vein or superior mesenteric vein was performed in an attempt to achieve complete tumor removal. RESULTS There was no postoperative mortality. Tumor infiltration of the resected vein could be documented histopathologically in 19 of the 31 (61.3%) patients. All patients with pancreatic or bile duct carcinoma (n = 29) died within 16 months of the resection (median survival 8 months). In contrast, 2 patients with cystadenocarcinoma and acinous cell carcinoma are alive with no evidence of recurrence at 23 and 54 months, respectively. CONCLUSION Portal vein resection does not prolong survival in patients undergoing partial pancreatoduodenectomy for carcinoma of the pancreas or distal bile duct. Only the occasional patient with a rare tumor at this region may benefit from this approach.
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Affiliation(s)
- J D Roder
- Department of Surgery, Technische Universität München, Klinikum rechts der Isar, Germany
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225
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Reith HB, Kozuschek W, Traverso LW. [Current indications for pylorus saving duodenopancreatic head resection in malignancy]. LANGENBECKS ARCHIV FUR CHIRURGIE 1996; 381:207-11. [PMID: 8965594 DOI: 10.1007/bf00571686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The Whipple procedure has been improved by preservation of a functioning pylorus. A functioning pylorus is important because marginal ulceration is avoided and, compared to the standard Whipple procedure with gastric resection, more patients can gain weight postoperatively. The most common indications are carcinomas of ampulla of Vater and periampullary tumors. In patients with pancreatic adenocarcinoma the pylorus-preserving variety results in equal or better survival rates. In 56 patients with pylorus preservation, 32 with ductal carcinoma, and 28 with Kausch-Whipple between 1985 and 1993, our results showed slightly better survival rates and better postoperative nutrition. The weakest aspect of the radical resection addresses the retroperitoneal margin of the pancreas head and not the gastric resection.
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Affiliation(s)
- H B Reith
- Chirurgische Universitätsklinik Bochum, Knappschaftskrankenhaus
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226
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Yeo CJ, Cameron JL. Pancreatic Nodal Metastases: Biologic Significance and Therapeutic Considerations. Surg Oncol Clin N Am 1996. [DOI: 10.1016/s1055-3207(18)30410-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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227
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Kaneko T, Nakao A, Inoue S, Harada A, Nonami T, Itoh S, Endo T, Takagi H. Intraportal endovascular ultrasonography in the diagnosis of portal vein invasion by pancreatobiliary carcinoma. Ann Surg 1995; 222:711-8. [PMID: 8526577 PMCID: PMC1235019 DOI: 10.1097/00000658-199512000-00004] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the value of intraportal endovascular ultrasonography (IPEUS) in the diagnosis of portal vein invasion by pancreatobiliary carcinoma. The authors reported their experiences with this new technique and compared it with conventional imaging technologies, such as portography and computed tomography (CT). SUMMARY BACKGROUND DATA Pancreatobiliary carcinoma often invades the portal vein. Observation of the echogenic band of the portal vein wall by means of a high-frequency, high-resolution intravascular ultrasound catheter allows for the accurate diagnosis of the portal vein invasion. METHODS A prospective study of 30 consecutive patients with pancreatobiliary carcinoma (16 pancreatic carcinomas, 8 bile duct carcinomas and 6 gallbladder carcinomas) was performed. In 23 cases IPEUS was performed intraoperatively from the superior mesenteric venous route with an 8 French, 20 MHz intravascular ultrasound catheter. In 7 cases IPEUS was performed before surgery from the percutaneous transhepatic route with a 6 French, 20 MHz intravascular ultrasound catheter. The finding of IPEUS was confirmed by pathologic examination of resected specimens and surgical exploration. The results of IPEUS were compared to those of portography and CT. RESULTS Intraportal endovascular ultrasonography visualized the portal vein wall as an echogenic band with a thickness of 0.5 mm to 1.0 mm. The diagnostic criterion of portal vein invasion was destruction of this echogenic band. Portal vein invasion was found in 15 of 30 cases. Vascular invasion was confirmed by pathologic examination of resected specimens in 10 patients and operative findings in 5. The sensitivity, specificity, and overall accuracy of IPEUS for diagnosis of portal vein invasion was 100%, 93.3%, and 96.7%, respectively. The values were 80%, 67.7%, and 73.3% for portography and 53.3%, 80%, and 66.7%, respectively, for CT. CONCLUSIONS Intraportal endovascular ultrasonography provided precise information about the relationship between the pancreatobiliary tumor and the portal vein wall. It was capable of accurately detecting or excluding early invasion of the portal vein wall by pancreatobiliary carcinoma.
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Affiliation(s)
- T Kaneko
- Department of Surgery II, Faculty of Medicine, Nagoya University, Japan
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228
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Abrams RA, Grochow LB. Adjuvant therapy with chemotherapy and radiation therapy in the management of carcinoma of the pancreatic head. Surg Clin North Am 1995; 75:925-38. [PMID: 7660255 DOI: 10.1016/s0039-6109(16)46737-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Surgical resection remains the backbone of the curative management of carcinoma of the pancreatic head. The primary cause of recurrence appears to be residual locoregional subclinical disease. Data supporting the use and continued study of adjuvant chemotherapy and radiation therapy are summarized.
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Affiliation(s)
- R A Abrams
- Johns Hopkins Oncology Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Leach SD, Rose JA, Lowy AM, Lee JE, Charnsangavej C, Abbruzzese JL, Katz RL, Evans DB. Significance of peritoneal cytology in patients with potentially resectable adenocarcinoma of the pancreatic head. Surgery 1995; 118:472-8. [PMID: 7652681 DOI: 10.1016/s0039-6060(05)80361-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Recurrence in the peritoneum occurs in up to 50% of patients after a potentially curative pancreaticoduodenectomy. Previous authors have implicated preoperative fine-needle aspiration (FNA) as a cause of intraperitoneal tumor dissemination, although prior studies of peritoneal cytology findings have largely involved patients with locally advanced disease. METHODS A consecutive series of patients referred to our institution between 1991 and 1993 with suspected or biopsy-proven adenocarcinoma of the pancreatic head was studied prospectively. All patients fulfilled criteria for resectability as assessed by computed tomography: no metastatic disease, no encasement of the superior mesenteric or hepatic arteries, and a patent superior mesenteric-portal venous confluence. Peritoneal washings were obtained at the time of staging laparoscopy and/or at subsequent laparotomy. Data regarding peritoneal cytology results, previous FNA, preoperative chemoradiation, eventual resection, pattern of disease recurrence, and survival were collected. RESULTS A total of 80 peritoneal washings from 60 consecutive patients were prospectively examined. Forty-nine (82%) of 60 patients underwent FNA before peritoneal washings were obtained. A total of four patients (7%) had positive peritoneal cytology findings: three (6%) of 49 who underwent prior FNA and one (9%) of 11 with no prior FNA. Similarly, no differences in eventual peritoneal failure or short-term survival were observed for patients who underwent prior FNA compared with patients who did not. All four patients with positive peritoneal cytology findings had metastatic disease (liver, three; peritoneum, one) at a median of 4.8 months after diagnosis; three of the four died of disease at a median of 8 months. CONCLUSIONS Positive peritoneal cytology findings are rare in patients with radiologically resectable adenocarcinoma of the pancreas. When found, positive peritoneal washings are an indicator of advanced disease characterized by unresectability, early metastasis, and short survival. Computed tomographic-guided FNA does not appear to increase the risk for positive peritoneal washings and represents a valid approach to the pretreatment diagnosis of patients with suspected pancreatic malignancy.
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Affiliation(s)
- S D Leach
- Department of Surgical Oncology, UT M.D. Anderson Cancer Center, Houston 77030, USA
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Okunieff P, Morgan D, Niemierko A, Suit HD. Radiation dose-response of human tumors. Int J Radiat Oncol Biol Phys 1995; 32:1227-37. [PMID: 7607946 DOI: 10.1016/0360-3016(94)00475-z] [Citation(s) in RCA: 231] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The dose of radiation that locally controls human tumors treated electively or for gross disease is rarely well defined. These doses can be useful in understanding the dose requirements of novel therapies featuring inhomogeneous dosimetry and in an adjuvant setting. The goal of this study was to compute the dose of radiation that locally controls 50% (TCD50) of tumors in human subjects. METHODS AND MATERIALS Logit regression was used with data collected from single institutions or from combinations of local control data accumulated from several institutions treating the same disease. RESULTS 90 dose response curves were calculated; 62 of macroscopic tumor therapy, 28 of elective therapy with surgery for primary control. The mean and median TCD50 for gross disease were 50.0 and 51.9 Gy, respectively. The mean and median TCD50 for microscopic disease control were 39.3 and 37.9 Gy, respectively. At the TCD50, an additional dose of 1 Gy controlled an additional 2.5% (median) additional patients with macroscopic disease and 4.2% (median) additional patients with microscopic disease. For both macro- and microscopic disease, an increase of 1% of dose at the TCD50 increased control rates approximately 1% (median) or 2-3% (mean). A predominance of dose response curves had shallow slopes accounting for the discrepancy between mean and median values. CONCLUSION Doses to control microscopic disease are approximately 12 Gy less than that required to control macroscopic disease, and are about 79% of the dose required to control macroscopic disease. The percentage increase in cures expected for a 1% increase in dose is similar for macroscopic microscopic disease, with a median value of approximately 1%/% and a mean of approximately 2.7%/%.
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Affiliation(s)
- P Okunieff
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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232
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Zerbi A, Balzano G, Patuzzo R, Calori G, Braga M, Di Carlo V. Comparison between pylorus-preserving and Whipple pancreatoduodenectomy. Br J Surg 1995; 82:975-9. [PMID: 7648124 DOI: 10.1002/bjs.1800820738] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Between 1989 and 1993, 62 patients underwent Whipple pancreatoduodenectomy and 75 pylorus-preserving pancreatoduodenectomy (PPPD); 35 patients in the first group and 37 in the second had pancreatic adenocarcinoma while 17 and 21 patients respectively had periampullary adenocarcinoma. The aim of this retrospective study was the comparison of operative outcome, nutritional recovery and survival of patients who underwent these two operations. No significant differences were found between the two groups in operative mortality or morbidity, duration of gastric aspiration and time to start of solid meals. Patients who underwent PPPD had a better nutritional recovery: the increase of both body-weight and serum albumin level at 6 months after discharge was significantly higher for those who had preservation of the whole stomach (P < 0.001 and P < 0.05 respectively). No significant difference in survival was found between the two procedures when patients with pancreatic or periampullary adenocarcinoma were analysed separately.
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Affiliation(s)
- A Zerbi
- Department of General Surgery, San Raffaele Hospital, University of Milan, Italy
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233
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Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, Dooley WC, Coleman J, Pitt HA. Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg 1995; 221:721-31; discussion 731-3. [PMID: 7794076 PMCID: PMC1234702 DOI: 10.1097/00000658-199506000-00011] [Citation(s) in RCA: 684] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas. SUMMARY OF BACKGROUND DATA In recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%. METHODS Two hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date. RESULTS The overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections; n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, < 800 mL intraoperative blood loss, < 2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection. CONCLUSIONS The survival of patients with pancreatic adenocarcinoma treated by pancreaticoduodenectomy is improving. Aspects of tumor biology, such as DNA content, tumor diameter, nodal status and margin status, are the strongest predictors of outcome.
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Affiliation(s)
- C J Yeo
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Allema JH, Reinders ME, van Gulik TM, Koelemay MJ, Van Leeuwen DJ, de Wit LT, Gouma DJ, Obertop H. Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region. Cancer 1995; 75:2069-76. [PMID: 7697596 DOI: 10.1002/1097-0142(19950415)75:8<2069::aid-cncr2820750807>3.0.co;2-7] [Citation(s) in RCA: 187] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The aim of this study was to determine prognostic factors for survival after pancreaticoduodenectomy (PD) for carcinoma of the pancreatic head region. METHODS From 1983 to 1992. 176 patients underwent PD for ampullary carcinoma (n = 67), distal bile duct carcinoma (n = 42), or pancreatic carcinoma (n = 67). The first choice for resection was subtotal PD (n = 146), but patients with a tumor-positive pancreatic margin or a brittle pancreatic duct underwent total PD (n = 30). RESULTS Hospital mortality was 4.7% after subtotal PD and 20% after total PD. Overall 5-year survival was 31%. Survival after PD for ampullary carcinoma care. (5-year, 50%) was significantly better (P < 0.001) than for distal bile duct carcinoma (24%) and pancreatic carcinoma (14%). Independent negative prognostic factors for survival (multivariate analysis) were involved resection margins (hazard rate ratio [HRR] 4.08), major vascular involvement (HRR 2.20), distal bile duct or pancreatic origin of carcinoma (HRR 1.93), and perioperative blood transfusion of more than 4 U (HRR 1.76). Tumor size (> 2 cm), regional lymph node involvement, and a poor differentiation grade were overall negative factors in univariate analysis but not in the subgroup of ampullary carcinoma. CONCLUSION Involvement of resection margins, major vascular ingrowth, site of origin of carcinoma, and perioperative blood transfusion were independent prognostic factors for survival after PD. Overall 5-year survival was 31%, and subtotal PD is advocated for all patients with a macroscopically resectable tumor in the pancreatic head region without major vascular involvement, even for those with larger tumors or local lymph node metastasis. Care should be taken to limit the need for perioperative blood transfusions.
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Affiliation(s)
- J H Allema
- Department of Surgery, University of Amsterdam, The Netherlands
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235
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Muchmore JH. Treatment of advanced pancreatic cancer with regional chemotherapy plus hemofiltration. ACTA ACUST UNITED AC 1995. [DOI: 10.1002/ssu.2980110213] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Combined modality therapy can be administered prior to surgical resection for patients with operable pancreatic cancer. One important criteria used to select patients for this treatment sequence is the absence of arterial vascular encasement by tumor on thin-section CT scanning; the absence of peritoneal seeding on surgical staging or laparoscopy has been another important parameter used in identifying patients with "localized" disease. Preoperative treatment with infusional chemoradiation uses multiple fields of irradiation delivering a dose of 50.4 Gy in 28 fractions over 5 1/2 weeks. This is done in conjunction with a continuous infusion of 5-fluorouracil intravenously at a dosage of 300 mg/m2/day with each day of radiotherapy treatment. The initial results of this protocol indicate acceptable toxicity and no evidence of increased perioperative morbidity or mortality compared to series using operation alone. We conclude that nearly all patients eligible for this combined modality treatment approach complete therapy as prescribed with acceptable toxicity.
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Affiliation(s)
- T A Rich
- Department of Radiotherapy, University of Texas M. D. Anderson Cancer Center, Houston 77030, USA
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238
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Evans DB, Abbruzzese JL, Lee JE, Leach SD, Charnsangavej C, Cleary KR, Buchholz DJ, Rich TA. Preoperative chemoradiation for adenocarcinoma of the pancreas: M.D. Anderson experience. ACTA ACUST UNITED AC 1995. [DOI: 10.1002/ssu.2980110210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Nitecki SS, Sarr MG, Colby TV, van Heerden JA. Long-term survival after resection for ductal adenocarcinoma of the pancreas. Is it really improving? Ann Surg 1995; 221:59-66. [PMID: 7826162 PMCID: PMC1234495 DOI: 10.1097/00000658-199501000-00007] [Citation(s) in RCA: 453] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- S S Nitecki
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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240
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Abstract
Pancreatic cancer is the fifth-leading cause of cancer death in the United States. It is estimated that 27,000 patients die each year with this diagnosis. The overall five-year survival of patients with pancreatic cancer remains less than 5%, but some subsets of patients may have a better prognosis. Advanced imaging and laparoscopy have improved staging to better select patients for potentially curative surgery, while the operative morbidity and mortality of the Whipple resection have decreased in recent years. Non-surgical therapies in current use include chemotherapy, external-beam radiation therapy, and brachytherapy, as well as pain management. More recently, gene insertion therapy has shown promise in animal models. This review discusses current diagnostic and treatment strategies for these patients and documents the need for new strategies in the future.
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Affiliation(s)
- D A Hunstad
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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241
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Bramhall SR, Allum WH, Jones AG, Allwood A, Cummins C, Neoptolemos JP. Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study. Br J Surg 1995; 82:111-5. [PMID: 7881926 DOI: 10.1002/bjs.1800820137] [Citation(s) in RCA: 358] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The trends in treatment and outcome of 13,560 patients with pancreatic cancer, and in incidence of the disease, in the West Midlands health region were determined between 1957 and 1986 using data from the West Midlands Region Cancer Registry. Patients were divided into those diagnosed in the first 20 years (1957-1976, n = 7888) and the most recent 10 years (1977-1986, n = 5672). The disease was more common in men and the incidence increased up to 1970 after which it levelled off. In the 1977-1986 period a lower proportion of patients had laparotomy alone (825 (14.5 per cent) versus 1552 (19.7 per cent)), a similar proportion had bypass surgery (2010 (35.4 per cent) versus 2760 (35.0 per cent)), while a greater proportion had supportive care (2710 (47.8 per cent) versus 3368 (42.7 per cent)) but the resection rates were the same (145 (2.6 per cent) versus 208 (2.6 per cent)). The 30-day mortality rates between the two periods improved for resection (40 (27.6 per cent) versus 94 (45.2 per cent)), bypass surgery (436 (21.7 percent) versus 691 (25.0 per cent)) and laparotomy (372 (45.1 per cent) versus 873 (56.3 per cent)). The 12-month survival rate for bypass did not significantly differ during the study (14.9 per cent versus 12.4 per cent) but there was a significant improvement in the 5-year survival for resection (9.7 per cent versus 2.6 per cent, P < 0.015). The resection rates were low and 30-day mortality rates for surgery were high compared with those of other published series.
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Affiliation(s)
- S R Bramhall
- Academic Department of Surgery, University of Birmingham, City Hospital, UK
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242
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Hoffman JP, Weese JL, Solin LJ, Engstrom P, Agarwal P, Barber LW, Guttmann MC, Litwin S, Salazar H, Eisenberg BL. A pilot study of preoperative chemoradiation for patients with localized adenocarcinoma of the pancreas. Am J Surg 1995; 169:71-7; discussion 77-8. [PMID: 7818001 DOI: 10.1016/s0002-9610(99)80112-3] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND We hypothesized that delivering adjuvant radiotherapy (RT) preoperatively with chemotherapy might enhance local control of the cancer and patient tolerance for the intervention. METHODS Thirty-four patients with localized pancreatic cancer (24 head, 8 head and body, 2 body and tail) were treated during the past 6 years with an intramural protocol consisting of 5-fluorouracil (1,000 mg/m2 on days 2 to 5 and 29 to 32) and mitomycin-C (10 mg/m2 on day 2) given with preoperative external beam RT (median 5,040 cGy). Nine patients did not have surgery: 1 refused, 1 died of cholangitis, and 7 were noted to have distant (5) or unresectable local cancer (2) after RT. Of the 25 patients who underwent celiotomy, 11 had liver (8) or peritoneal (3) metastases and 3 had palliative pancreatectomies (2 with liver metastasectomy and 1 with hepatic artery and portal vein replacement). The remaining 11 patients (44% of the cohort with surgery, 32% of all patients) had potentially curative (PC) resections (5 total pancreatectomy, 5 Whipple, 1 distal pancreatectomy). Median tumor diameter by computed tomographic scan was 3.75 cm (range 3 to 5) for the 11 patients who received PC resections and 4.5 cm (range 3 to 7.5) for all patients. Of the 11 patients with PC resections, 8 had evidence of superior mesenteric, portal or splenic venous involvement and 4 had been deemed unresectable at previous celiotomies. RESULTS One patient developed respiratory failure and one died postoperatively, yielding a 9% rate of major morbidity and mortality. Median follow-up of the surviving patients with curative resection is 33 months (range 14 to 70). Their median survival from the time of tissue diagnosis is 45 months with a median disease-free survival of 27 months. The product limit estimate of 5-year survival is 40% (95% confidence bounds +29%, -30%). One patient had a microscopically positive resection margin, which was a falsely negative frozen section margin at the pancreatic neck. Two patients had positive regional lymph nodes. Five patients have been diagnosed with recurrent cancer. Only 1 has had a local/regional component to the recurrence. CONCLUSIONS Preoperative RT and chemotherapy followed by resection is well tolerated and safe for patients with locally advanced pancreatic cancer. This approach provides tumor free resection margins and offers prolonged survival to patients with truly localized pancreatic cancer.
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Affiliation(s)
- J P Hoffman
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111
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243
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Abstract
The management of patients with pancreatic carcinoma poses many problems. The diagnosis is usually made late, generally because the patients present late, but it is not unusual to find patients who have had many negative investigations for vague upper abdominal symptoms only to be diagnosed as having pancreatic carcinoma many months later. Staging the disease is equally difficult and often inaccurate. The results of treatment are to date discouraging even in those patients diagnosed early. But the outlook is not totally dismal; in recent years the results for surgical resection of pancreatic lesions have improved; adjuvant treatment may finally be having an effect, although small, on this relentless disease. The most notable inroad made in the management of pancreatic cancer in the last 10 years is the improvement in palliation due to the use of the endoprosthesis. In spite of the poor results we must continue to search actively for more accurate methods of diagnosis and better methods of treatment.
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Affiliation(s)
- D M Kelly
- Department of Surgery, King's College School of Medicine and Dentistry, King's College Hospital, London, U.K
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245
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Ishikawa O, Ohigashi H, Sasaki Y, Furukawa H, Kabuto T, Kameyama M, Nakamori S, Hiratsuka M, Imaoka S. Liver perfusion chemotherapy via both the hepatic artery and portal vein to prevent hepatic metastasis after extended pancreatectomy for adenocarcinoma of the pancreas. Am J Surg 1994; 168:361-4. [PMID: 7943597 DOI: 10.1016/s0002-9610(05)80167-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- O Ishikawa
- Department of Surgery, Center for Adult Diseases, Osaka, Japan
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246
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Cusack JC, Fuhrman GM, Lee JE, Evans DB. Managing unsuspected tumor invasion of the superior mesenteric-portal venous confluence during pancreaticoduodenectomy. Am J Surg 1994; 168:352-4. [PMID: 7943594 DOI: 10.1016/s0002-9610(05)80164-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Most surgeons believe that tumor invasion of the superior mesenteric-portal venous (SMPV) confluence is a contraindication to pancreaticoduodenectomy for adenocarcinoma of the pancreas or periampullary region. Traditional techniques for performing pancreaticoduodenectomy have emphasized the importance of establishing a tumor-free plane between the SMPV confluence and the neck of the pancreas. However, this maneuver does not reveal tumor invasion of the lateral wall of the superior mesenteric vein (SMV) until after gastric and pancreatic transection--a point at which the surgeon has committed to resection. This unexpected but not uncommon finding likely contributes to the high incidence of margin-positive resections and subsequent local tumor recurrence. We describe our technique for segmental resection of the SMPV confluence at the time of pancreaticoduodenectomy. Routine ligation of the splenic vein and primary anastomosis of the SMV and portal vein have been abandoned in favor of an interposition graft using internal jugular vein.
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Affiliation(s)
- J C Cusack
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030
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247
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Preservation of the pylorus during pancreaticoduodenectomy —Evolution and current indications. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/bf02391092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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248
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Abstract
OBJECTIVE The preoperative diagnostic strategy and operative technique for reoperative pancreaticoduodenectomy were outlined and operative mortality, perioperative morbidity, and early survival data in carefully selected patients undergoing reoperation for pancreatic cancer were analyzed. SUMMARY BACKGROUND DATA Many patients with localized, nonmetastatic cancer of the pancreas undergo exploratory surgery with limited preoperative assessment of resectability. Frequently, pancreaticoduodenectomy is not performed because cytologic or histologic proof of diagnosis is lacking, or tumor resectability is questioned. Many patients are denied reoperation and a potentially curative resection because of the unacceptable morbidity and mortality believed to accompany pancreaticoduodenectomy in the reoperative setting. METHODS Twenty-three patients who had undergone previous surgery for palliation or diagnosis of a pancreatic head mass were reoperated on after a standardized preoperative imaging evaluation consisting of chest radiography, computed tomography, and visceral angiography. A standardized operative technique was used on all patients, but was modified based on altered anatomy from the initial operation. RESULTS Based on preoperative imaging studies, 19 of the 23 patients believed to have resectable tumors underwent laparotomy for planned pancreaticoduodenectomy; resection was accomplished in 14 patients. Seven of the fourteen patients required extended resections that included the superior mesenteric vein, right colon, or both. There was no perioperative mortality, and early complications occurred in 3 of the 14 resected patients. Four patients underwent planned palliative procedures. Four of ten patients who underwent resection for adenocarcinoma are without evidence of disease at a median follow-up of 26 months. CONCLUSIONS Reoperative pancreaticoduodenectomy can be performed safely and may result in prolonged survival in carefully selected patients with resectable, localized pancreatic cancer.
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Affiliation(s)
- D S Tyler
- Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston
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249
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Zerbi A, Balzano G, Bottura R, Di Carlo V. Reliability of pancreatic cancer staging classifications. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1994; 15:13-8. [PMID: 8195639 DOI: 10.1007/bf02924383] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The prognostic value of UICC and JPS classifications was evaluated in a group of 74 patients undergoing resection for pancreatic carcinoma in the 1982-1992 period. The predictivity of peritoneal cytology and intraoperative liver biopsies was evaluated in a subgroup of 15 patients. Patient division by stage according, respectively, to UICC and JPS classifications was: stage I: 28 and 2 patients; stage II: 12 and 11 patients; stage III: 29 and 30 patients; stage IV: 5 and 31 patients. Median survival by UICC stages was: 17 months (m) in stage I, 10 m in stage II, 12 m in stage III, and 6 m in stage IV; by JPS stages it was 29 m in stage II, 14 m in stage III, and 7 m in stage IV. A radical resection was possible in 48 patients (65%); the survival was significantly worse in the nonradical resection group. The survival difference among UICC stages was not significant in a multivariate analysis with radicality, whereas among JPS stages a significant survival difference was found in both univariate and multivariate analysis. The tumor invasion of the retroperitoneal tissues and the presence of distant metastasis were indicators of a significantly worse prognosis. Lymph node involvement, tumor size, and serosal invasion had no significant effect on survival. Peritoneal cytology and liver biopsies did not provide further prognostic information.
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Affiliation(s)
- A Zerbi
- Department of Surgery, San Raffaele Hospital, University of Milan, Italy
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250
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Fuhrman GM, Charnsangavej C, Abbruzzese JL, Cleary KR, Martin RG, Fenoglio CJ, Evans DB. Thin-section contrast-enhanced computed tomography accurately predicts the resectability of malignant pancreatic neoplasms. Am J Surg 1994; 167:104-11; discussion 111-3. [PMID: 7906097 DOI: 10.1016/0002-9610(94)90060-4] [Citation(s) in RCA: 194] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- G M Fuhrman
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030
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