Diagnostic workup of patients with suspected pancreatic carcinoma: the University of California-Los Angeles approach

Utilization of preoperative endoscopic ultrasound for pancreatic adenocarcinoma

BACKGROUND

Endoscopic ultrasound (EUS) is used for pancreatic adenocarcinoma staging and obtaining a tissue diagnosis. The objective was to determine patterns of preoperative EUS and the impact on downstream treatment.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database was used to identify patients with pancreatic adenocarcinoma. The staging period was the first staging procedure within 6 months of surgery until surgery. Logistic regression was used to determine factors associated with preoperative EUS. The main outcome was EUS in the staging period, with secondary outcomes including number of staging tests and time to surgery.

RESULTS

2782 patients were included, 56% were treated at an academic hospital (n = 1563). 1204 patients underwent EUS (43.3%). The factors most associated with receipt of EUS were: earlier year of diagnosis, SEER area, and a NCI or academic hospital (all p < 0.0001). EUS was associated with a longer time to surgery (17.8 days; p < 0.0001), and a higher number of staging tests (40 tests/100 patients; p < 0.0001).

CONCLUSIONS

Factors most associated with receipt of EUS are geographic, temporal, and institutional, rather than clinical/disease factors. EUS is associated with a longer time to surgery and more preoperative testing, and additional study is needed to determine if EUS is overused.

Patients with pancreatic adenocarcinoma benefit from staging laparoscopy

BACKGROUND

Unnecessary laparotomy in patients with advanced pancreatic cancer may both compromise the quality of life and delay the initiation of more appropriate therapy. Very often, peritoneal small liver metastases and true local status cannot be fully determined without surgery. Laparoscopy may spare laparotomy and decrease morbidity for patients with nonresectable advanced disease. The aim of this study was to determine the impact of laparoscopy in patients with potentially resectable adenocarcinoma of the pancreas.

MATERIALS AND METHODS

We reviewed the records of patients undergoing pancreatic surgery at the University of Nebraska Medical Center from October 2001 to April 2005. A total of 59 patients were included in the study. All patients were staged radiographically with a high resolution helical computed tomography scan and their tumors were considered resectable. Thirty-seven patients underwent staging laparoscopy while 22 proceeded directly to laparotomy.

RESULTS

Of the 37 patients who underwent laparoscopic staging, 9 (24.3%) were detected to have metastatic disease or advanced tumor; the remaining 28 (75.7%) patients with negative laparoscopy proceeded to laparotomy. Of those, 24 patients (85.7%) underwent pancreatic resection with curative intent, while 4 patients had metastatic or locally advanced disease at subsequent laparotomy which was missed on staging laparoscopy (false negative rate of 14.3%). Of the 22 patients who proceeded directly to laparotomy, 16 (72.7%) received curative Whipple resection and 6 (27.3%) were found to have advanced disease and received bypass procedures or biopsy alone.

CONCLUSION

These findings suggest that staging laparoscopy is beneficial in a significant proportion of patients deemed resectable by routine noninvasive preoperative studies. We plan to add intraoperative laparoscopic ultrasound to our staging protocol in order to decrease the false negative rate.

Surgical management of early-stage pancreatic cancer

BACKGROUND

Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease.

METHODS

The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided.

RESULTS

Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre- vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens.

CONCLUSIONS

Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately.

Influence of different dietary fat intake on liver metastasis and hepatic lipid peroxidation in BOP-induced pancreatic cancer in Syrian hamsters

OBJECTIVES

Effects of polyunsaturated fatty acids (PUFA) on carcinogenesis are discussed controversially. Thus, tumor growth seems to be influenced by type and composition of fat dietary; however, the pathomechanism is still unknown. Therefore, we investigated the impact of different PUFAs on liver metastasis and hepatic lipid peroxidation in a solid model of ductal pancreatic cancer in Syrian hamsters.

METHODS

90 male hamsters were randomized into 6 groups (n = 15). Accordingly groups 2, 4 and 6 received 10 mg N-nitrosobis-2-oxopropylamine (BOP)/kg body weight weekly by subcutaneous injection for 12 weeks in order to induce ductal pancreatic cancer, while groups 1, 3 and 5 were treated with 0.5 ml 0.9% sodium chloride. All hamsters received a standard fat diet (SFD) rich in n-6 PUFA for 16 weeks (2.9% fat). Afterwards, groups 1 and 2 had free access to SFD, while groups 3 and 4 were given a diet enriched with n-3, n-6 and n-9 PUFA (SMOF) and groups 5 and 6 were fed a diet high in n-3 PUFA (FISH-OIL). After 32 weeks all hamsters were sacrificed in order to determine incidence of pancreatic carcinoma and liver metastasis. Furthermore hepatic activities of glutathionperoxidase (GSH-Px) and superoxiddismutase (SOD) as well as levels of lipidperoxidation were analyzed intra- and extrametastatically.

RESULTS

The incidence of liver metastasis was decreased in the FISH-OIL tumor group compared to the SFD and SMOF groups. However, GSH-Px activity was not influenced by different diets. Extrametastatic hepatic SOD activity did not differ between all groups, while intrametastatic hepatic SOD activity in the SFD-BOP group was increased. In the FISH-OIL-BOP and the SMOF-BOP group intrametastatic SOD activity was lower than in non-metastatic hepatic tissue. Furthermore levels of hepatic lipid peroxidation were decreased in the tumor groups treated with fish oil and SMOF compared to the SFD group. Comparing intra- and extrametastatic TBARS concentration there was no difference in the SFD-BOP and the SMOF-BOP groups, while in the FISH-OIL-BOP group intrametastatic TBARS concentration was increased.

CONCLUSION

Conclusively, fish oil reduced the incidence of liver metastasis in experimental ductal pancreatic cancer. Maybe this effect is caused by an increase of intrametastatic hepatic lipid peroxidation.

Nodular fasciitis: an unexpected finding on computed tomography and positron emission tomography

Nodular fasciitis is an uncommon lesion that is also designated as a pseudosarcomatous, self-limiting reactive process. We describe a 40-year-old woman with a nodular fasciitis that was detected by computed tomography (CT), positron emission tomography (PET) with 18F-fluorodeoxyglucose (18-FDG), and histology while she was being examined for upper abdominal pain.

Diagnostic laparoscopy

Diagnostic laparoscopy began in a surgical unit in a developing country in 1972. The developers of this technique aimed to hasten diagnosis, reduce patient distress, and improve bed utilization in an overcrowded teaching hospital wherein simple investigations such as x-rays took weeks to materialize. Over a period of 18 years reaching to 1990, 3,200 diagnostic laparoscopies were performed on adults under local anesthesia with no mortality, a complication rate of 0.09%, an 84% diagnosis rate, and 74% undergoing histologic biopsies targeting a wide spectrum of pathology. The equipment cost spread out over the 3,200 patients works out to 30 rupees (0.60 dollar) per patient. With the availability of noninvasive diagnostic aids such as ultrasound, computed tomography, and magnetic resonance imaging used US, CT, MRI under the control of target biopsy, the role of diagnostic laparoscopy has altered. Since 1990, clinicians have had the sophistication of the video camera and the pneumoperitoneum insufflator. Diagnostic laparoscopy is used for the evaluation of liver and peritoneal pathology, abdominal tuberculosis, malignancy, acute abdomen, and abdominal trauma. It often is a prelude to laparoscopic treatment of the underlying pathology, specifically in cases of acute appendicitis.

K-ras gene mutation in the diagnosis of ultrasound guided fine-needle biopsy of pancreatic masses

AIM: To investigate the utility of K-ras mutation analysis of ultrasound guided fine-needle aspirate biopsy of pancreatic masses.

METHODS: Sixty-six ultrasound guided fine-needle biopsies were evaluated by cytology, histology and K-ras mutation. The mutation at codon 12 of the K-ras oncogene was detected by artificial restriction fragment length polymorphisms using BstN I approach.

RESULTS: The presence of malignant cells was reported in 40 of 54 pancreatic carcinomas and K-ras mutations were detected in 45 of the 54 FNABs of pancreatic carcinomas. The sensitivity of cytology and K-ras mutation were 74% and 83%, respectively. The speciality of cytology and K-ras mutation were both 100%. The sensitivity and speciality of K-ras mutation combined with cytology were 83% and 100%, respectively.

CONCLUSION: High diagnostic accuracy with acceptable discomfort of FNAB make it useful in diagnosis of pancreatic carcinoma. Ultrasound guided fine-needle biopsy is a safe and feasible method for diagnosing pancreatic cancer. Pancreatic carcinoma has the highest K-ras mutation rate among all solid tumors. The mutation rate of K-ras is about 80%-100%. The usage of mutation of codon 12 of K-ras oncogene combined with cytology is a good alternative for evaluation of pancreatic masses.

Effects of Celebrex and Zyflo on BOP-induced pancreatic cancer in Syrian hamsters

BACKGROUND/AIMS

Selective inhibition of eicosanoid synthesis decreases inflammation, however, it is still unknown whether oxidative stress and carcinogenesis might be influenced in ductal pancreatic ductal cancer as well.

METHODS

120 male hamsters were randomized into 8 groups (n = 15). While control group 1-4 received 0.5 ml normal saline s.c. weekly for 16 weeks, groups 5-8 were injected 10 mg BOP/kg body weight to induce pancreatic cancer. After establishment of pancreatic cancer, groups 1 and 5 received no therapy, groups 2 and 6 were fed 7 mg Celebrex daily, groups 3 and 7 were given 28 mg Zyflo and groups 4 and 8 received Celebrex and Zyflo orally daily in weeks 17-32. In week 33, all animals were sacrificed, macroscopic size of pancreatic carcinomas was measured, incidence of pancreatic cancer was analyzed histopathologically and activities of antioxidative enzymes and concentration of products of lipid peroxidation in tumor-free and pancreatic intratumoral tissue were determined.

RESULTS

Incidence and size of macroscopic pancreatic carcinomas were decreased by single therapy with Zyflo as well as combined therapy (Zyflo + Celebrex). Activities of antioxidative enzymes were increased and the concentration of products of lipid peroxidation was decreased in tumor-free pancreas. On the other hand, lipid peroxidation was increased in pancreatic tumors.

CONCLUSION

Zyflo alone or in combination with Celebrex reduce tumor growth in pancreatic cancer and thus might be a new therapeutic option in advanced pancreatic cancer.

Pancreatic cancer: cost-effectiveness of imaging technologies for assessing resectability

PURPOSE

To evaluate the cost-effectiveness of imaging strategies for the assessment of resectability in patients with pancreatic cancer.

MATERIALS AND METHODS

A decision model was developed to calculate costs and benefits (survival) accruing to hypothetical cohorts of patients with known or suspected pancreatic cancer. Results are presented as cost per life-year gained under various scenarios and assumptions of diagnostic test characteristics, surgical mortality, disease characteristics, and costs.

RESULTS

With best estimates for all data inputs, the strategy of computed tomography (CT) followed by laparoscopy and laparoscopic ultrasonography (US) had an incremental cost-effectiveness ratio of $87,502 per life-year gained, compared with best supportive care. This strategy was significantly more cost-effective than CT followed by magnetic resonance (MR) imaging and was significantly less expensive than other imaging strategies while providing a statistically and clinically insignificant difference in life-year gains. A strategy involving no imaging (immediate surgery) was more expensive but less effective than all imaging strategies. A hypothetical perfect test with cost equal to that of CT followed by MR had an incremental cost-effectiveness ratio of $64,401 per life-year gained, compared to best supportive care.

CONCLUSION

Most available imaging tests for assessing resectability of pancreatic cancer do not differ in effectiveness, but a strategy of CT, laparoscopy, and laparoscopic US would consistently result in significantly lower costs than other imaging tests under a wide range of scenarios.

The Mayo clinic approach to the surgical treatment of adenocarcinoma of the pancreas

Ductal carcinoma of the pancreas remains a challenging problem for gastrointestinal surgeons. Significant progress has been made in diagnosis, preoperative staging, and safety of surgery; however, long-term survival after resection is unusual, and cure is rare. That said, the authors maintain their aggressive posture regarding this disease, recognizing that resection offers the only potential for cure. The authors' approach such patients in the most efficient and least invasive manner possible, relying primarily on triple phase helical abdominal CT for clinical diagnosis and staging, reserving ERCP and EUS for diagnostic dilemmas. In fit candidates with potentially resectable lesions, the authors eschew pre- or intraoperative biopsy, angiography, or endoscopic stenting and use preliminary limited staging laparoscopy selectively. Surgical palliation is chosen for fit patients who, at exploration for potentially curative resection, are found to have occult distant metastases or locally unresectable disease. Radical pancreatoduodenectomy can be performed with a mortality rate of 3% or less, and although morbidity remains significant, most can be managed with conservative measures. Quality of life after pancreatoduodenectomy is good and, if not, is generally a manifestation of recurrence rather than physiologic alterations inherent to the procedure. Adjuvant chemoradiation is standard therapy after resection, recommended for those with locally unresectable disease but used selectively for those with distant metastasis. Survival after potentially curative resection has remained disappointing. Whether extended lymphadenectomy or neoadjuvant chemoradiation improves survival has not been determined. Clearly, methods for earlier diagnosis of pancreatic cancer and more effective adjuvant therapies are sorely needed.

Diagnostic and interventional laparoscopy and intraoperative ultrasonography in the management of pancreatic disease

The laparoscopic management of pancreatic disorders has evolved dramatically from its inception in 1911 and its rediscovery in the 1970s. Although investigators once proclaimed that "it seems unlikely that laparoscopy will have any more than an extremely limited use in the investigation of pancreatic disorders," laparoscopy and LUS now have a well-recognized role in the staging of pancreatic cancer and an increasing part in the management of benign pancreatic disease at many institutions. Although the appropriate role of LS and LUS is debatable, the development and refinement of laparoscopic techniques and instrumentation and the improvement of noninvasive diagnostic modalities will provide new data, increase the rate of resection at laparotomy, and allow surgeons to treat a broader range of pancreatic disease by minimally invasive methods. The value of LS and LUS for benign and malignant pancreatic disorders has been clearly demonstrated, but the inevitable issues of hospital resource, operative expertise, and surgical philosophy will ultimately determine the role of laparoscopy and LUS in clinical practice.

The impact of laparoscopic biopsy of pancreatic lymph nodes with helium and carbon dioxide on port site and liver metastasis in BOP-induced pancreatic cancer in hamster

The influence of pancreatic biopsy during laparoscopy with carbon dioxide (CO2) and helium on the incidence of port site and liver metastasis in pancreatic carcinoma is still unknown. Ductal adenocarcinoma of the pancreas was induced in Syrian hamsters (n = 30) by injection of N-nitrosobis-2-oxopropylamin (BOP, 10 mg/kg body weight/week) for 12 weeks. In week 13, hamsters were randomized in 3 groups (n = 10): While in group 1 (gr. 1) a laparotomy and biopsy of pancreatic lymph nodes was performed, gr. 2 and gr. 3 underwent a laparoscopic biopsy either with CO2 or helium. Therefore, one trocar was located in the left (biopsy) and the right abdominal wall (camera). In the 18th week all animals were sacrificed and the incidence of abdominal wall, port site and liver metastases was histologically determined. While there were abdominal wall metastases after laparotomy in 10% (n = 1), we observed trocar metastases in the CO2 group in 20% (n = 2). However, there were no trocar metastases in the helium group. The incidence of liver metastasis did not differ between the laparotomy and the helium group (20% vs 30%), but was increased in the CO2 group (60%). Laparoscopic biopsy of pancreatic lymph nodes with CO2 increased the incidence of port site and liver metastases in pancreatic cancer. The helium group was equal to the laparotomy group in this respect. Thus, staging laparoscopy with helium might become an alternative to explorative laparotomy in pancreatic cancer.

Laparoscopy in the staging of pancreatic cancer

BACKGROUND

Over the past decade, laparoscopy has emerged as a popular method of detecting extrapancreatic metastatic disease in patients presumed to have localized pancreatic cancer.

METHODS AND RESULTS

The English language literature on laparoscopic staging of pancreatic cancer was reviewed. Interpretation of this literature on staging laparoscopy is difficult because (1) there has been inconsistent use of high-quality computed tomography (CT) in prospective studies, (2) many studies have included patients with locally advanced disease, and (3) the R0/R1/R2 resection rates among patients staged by laparoscopy have not been reported, making it impossible to correlate laparoscopic findings with the R0 resection rate. Laparoscopy may prevent unnecessary laparotomy in a proportion of CT-staged patients presumed to have resectable pancreatic cancer. However, routine laparoscopy is performed on patients judged to have resectable disease by high-quality CT, this fraction of patients is between 4 and 13 per cent.

CONCLUSION

When state-of-the-art CT is available, the routine use of staging laparoscopy may not be easily justified from the data in the recent literature. Selective use of laparoscopy may be more appropriate and will probably be a more cost-effective staging approach. Criteria are presented for the selective use of laparoscopy in the staging of patients with localized pancreatic cancer.

Detection of pancreatic metastases by EUS-guided fine-needle aspiration

BACKGROUND

Metastases to the pancreas are usually found incidentally. Tissue diagnosis is imperative because imaging alone is incapable of differentiating them from primary pancreatic tumors. This study tested whether it is possible to differentiate metastases from other focal pancreatic lesions by using EUS-guided fine-needle aspiration (EUS-FNA) for cytodiagnosis.

METHODS

One hundred fourteen consecutive patients (mean age 61 years) with focal pancreatic masses, detected on CT, underwent EUS-FNA by using a linear-array echoendoscope and 22-gauge needles.

RESULTS

Adequate specimens were obtained from 112 lesions. Carcinomas were identified in 68 cases (60.7%), 56 (50%) of pancreatic origin and 12 (10.7%) from distant primary tumors. The metastases were all located in the head and body of the pancreas and measured 1.8 to 4.0 cm. The echo-texture was heterogeneous or hypoechoic in all cases and resembled that of primary tumors. Six of the 12 patients with metastatic disease had a prior diagnosis of cancer (breast, 3; renal cell, 2; salivary gland, 1), 4 of them with a recurrence and 2 with a second carcinoma metastasizing to the pancreas. Six patients without a prior diagnosis of cancer had metastases from renal cell, colonic, ovarian, and esophageal carcinomas; one metastasis was from an unknown primary and another was from a malignant lymphoma. These findings influenced the therapeutic strategy in 8 patients who underwent nonsurgical palliation. There were no complications.

CONCLUSIONS

Pancreatic metastasis is an important cause of focal pancreatic lesions, but the EUS features are not diagnostic. Simultaneous EUS-FNA allows cytodiagnosis and can have a decisive influence on the selection of appropriate therapeutic strategies.

Modern imaging methods versus clinical assessment in the evaluation of hospital in-patients with suspected pancreatic disease

OBJECTIVE

Various modern imaging procedures such as endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT), and endoscopic ultrasonography (EUS) have been shown to be highly accurate in the diagnosis of specific disorders of the pancreas. However, prior information often causes bias in the interpretation of these results. Little information is available concerning the value of these examinations in the primary and differential diagnosis of suspected pancreatic disease-particularly in comparison with clinical evaluation, including laboratory tests and transabdominal ultrasound (TUS).

METHODS

Clinical and imaging information (EUS, ERCP, and CT) was collected for 184 inpatients who were referred over a 5-yr period for evaluation of suspected pancreatic disease. On the basis of patient history, laboratory tests, and the results of routine TUS, one gastroenterologist, who was unaware of any of the other procedures or the final diagnosis, made a presumptive clinical diagnosis. CT and ERCP images and EUS videotapes were then analyzed by three different and independent examiners, who had the same clinical information except for the TUS results, but were completely blinded to the results of the other examinations and the patients' diagnoses. The final diagnoses were obtained by surgery, histology, and cytology, plus a follow-up of at least 1 yr (mean 35 months) in all noncancer cases.

RESULTS

The final diagnoses were: normal pancreas (n = 36), chronic pancreatitis without a focal inflammatory mass (n = 53) or with a focal inflammatory mass (n = 18), and pancreatic malignancy (n = 77). Clinical evaluation, including ultrasonography, achieved a sensitivity for pancreatic disease of 94% but a specificity of only 35%. The figures for the sensitivity and specificity of the three imaging procedures were 93% and 94%, respectively, for EUS; 89% and 92% for ERCP; and 91% and 78% for CT (p < 0.05 for the specificity of clinical assessment vs all three imaging tests, p > 0.05 for comparison of the three imaging procedures). In the differential diagnosis between cancer and chronic pancreatitis as well as between malignant and inflammatory tumors, there was no difference among clinical assessment and the three imaging tests.

CONCLUSIONS

In a group of patients with a high suspicion of pancreatic disease, little additional sensitivity in the diagnosis of pancreatic disease is provided by sophisticated imaging procedures such as EUS, ERCP, and CT, in comparison with clinical assessment including laboratory values and TUS. However, the specificity can be substantially improved. To confirm the diagnosis, one of the three examinations is needed, depending on the suspected disease and local expertise. The imaging procedures should be performed in a stepwise fashion for specific purposes, such as exclusion of pancreatic disease and the planning of treatment in chronic pancreatitis and pancreatic cancer.

Endosonography-guided, fine-needle aspiration cytology extending the indication for organ-preserving pancreatic surgery

OBJECTIVE

Organ preserving pancreatic resections are considered whenever malignant disease is ruled out. In tumors of low malignant potential such as cystadenomas and neuroendocrine tumors, the diagnosis is rarely established preoperatively. We studied the feasibility of cytodiagnosis using endosonography-guided fine-needle aspiration in determining the operative approach.

METHODS

A total of 78 patients (16 female, 62 male; mean age 61.4 yr, range 31-82 yr) with focal pancreatic lesions underwent EUS-FNA. Final diagnosis was confirmed by histology, cytology, or clinical follow up (>9 months). Patients with tumors of low malignant potential were managed by customized pancreatic resections.

RESULTS

Final diagnosis was malignant tumors in 36 patients, tumors of low malignant potential in nine (six, neuroendocrine, two, borderline mucinous cystadenomas, one, borderline adenocarcinoma), and benign in 31 (two inadequate smears). No complications occurred. With six false-negative and no false-positive results, the accuracy, sensitivity, specificity, and positive and negative predictive values were 92%, 84%, 100%, 100%, and 86%, respectively. Five patients with low malignant tumors underwent duodenum-preserving pancreatic head resection, three mid segment resection, and one pylorus-preserving pancreatoduodenectomy.

CONCLUSIONS

EUS-FNA is useful in the preoperative cytodiagnosis of pancreatic tumors of low malignant potential. It extends the indication for organ-preserving pancreatic resections and avoids the unnecessary sacrifice of adjacent organs.

Validity of the hospital discharge diagnosis in epidemiologic studies of biliopancreatic pathology. PANKRAS II Study Group

BACKGROUND

The aim was to analyse the magnitude, direction and predictors of change in the main hospital discharge diagnosis (HDD) after a clinical expert review, among patients included in a multicentre molecular epidemiologic study of biliopancreatic diseases.

METHODS

A total of 602 patients with a suspicion diagnosis of pancreas cancer (PC), cancer of the extrahepatic biliary system (CEBS) or benign biliopancreatic pathologies (BPP) were prospectively recruited at five general hospitals. A structured form was used to collect information from medical records. A panel of experts revised all diagnostic information and established the main clinicopathological diagnosis (CPD) by consensus.

RESULTS

Of the 204 cases with a HDD of PC, 176 (86%) were deemed to have a CPD of PC, eight of CEBS, twelve a neoplasm of different origin, four BPP and four syndromic diagnoses. Thus, 28 cases (14%) were false positives. Of the 129 patients with a HDD of CEBS, 15 (12%) were false positives. Nine of the 396 cases with a HDD of non-PC (2%) had a CPD of PC (false negatives), whilst 14 of 471 patients with a HDD of non-CEBS (3%) were deemed to have CEBS. Overall, sensitivity and specificity of HDD for PC were, respectively, 95 and 93%, and for CEBS, 89 and 97%. Cytohistological confirmation and laparotomy were independent predictors of diagnostic change.

CONCLUSIONS

Validity of the HDD was high, but its association with some clinical variables suggests that sole reliance on HDD can significantly bias results, and highlights the need to review all HDDs. Alternatively, only patients at high risk of misdiagnosis could be reviewed: primarily, those lacking a cytohistological diagnosis or a laparotomy. No exclusions appear warranted solely on the basis of age, gender or tumour spread.

American gastroenterological association medical position statement: epidemiology, diagnosis, and treatment of pancreatic ductal adenocarcinoma

This document presents the official recommendations of the American Gastroenterological Association (AGA) on the Epidemiology, Diagnosis, and Treatment of Pancreatic Ductal Adenocarcinoma. It was approved by the Clinical Practice and Practice Economics Committee in March 1999 and by the AGA Governing Board in May 1999.

AGA technical review on the epidemiology, diagnosis, and treatment of pancreatic ductal adenocarcinoma. American Gastroenterological Association

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee in March 1999 and by the AGA Governing Board in May 1999.

Diagnosis of pancreatic cancer by detecting telomerase activity in pancreatic juice: comparison with K-ras mutations

OBJECTIVE

Telomerase activity is reported to be specific and very frequent in human malignancy. K-ras mutations are also very frequently detected in pancreatic cancer, but their specificity for pancreatic cancer is controversial. We examined the telomerase activity and K-ras mutations in pancreatic juice from patients with pancreatic disease.

METHODS

Pancreatic juice was obtained endoscopically at endoscopic retrograde pancreatography from 10 patients with pancreatic cancer, three with chronic pancreatitis, and three with a normal pancreas. The telomerase activity in pancreatic juice was assayed by telomeric repeat amplification protocol. K-ras mutations in exon 1 codon 12 were examined by the two-step polymerase chain reaction combined with restriction enzyme digestion, followed by single-strand conformation polymorphism analysis and direct sequencing.

RESULTS

Telomerase activity of >5.0 was detected in eight of 10 (80%) subjects with pancreatic cancer, but in none with chronic pancreatitis or normal pancreas. K-ras mutations were detected not only in eight of 10 (80%) subjects with pancreatic cancer but also in two of three with chronic pancreatitis and in one of three with a normal pancreas.

CONCLUSIONS

It was shown that the detection of telomerase activity in pancreatic juice is a more useful diagnostic tool for pancreatic cancer than that of K-ras mutations.

Pancreatic surgery

According to epidemiologic studies, the incidence of acute and chronic pancreatitis and carcinoma of the pancreas are increasing worldwide. This is the result not only of improved diagnostic methods introduced in the last decades (eg, contrast-enhanced computed tomography, "all-in-one" magnetic resonance imaging, single-photon emission computed tomography, and endoscopic retrograde cholangiopancreatography) but also of changes in the environment and nutritional behavior. Once a specific diagnosis has been made, the first-choice interventions in acute and chronic inflammatory pancreatic diseases are predominantly organ-and organ function-preserving surgical procedures. In pancreatic cancer, extended radical surgery and multimodal therapies seem to offer the most benefit. This article provides an overview of recently published articles focusing on surgical treatment options in acute and chronic pancreatitis and carcinoma of the pancreas.

Combined chemoradiotherapy for unresectable pancreatic cancer

This study was undertaken to evaluate the efficacy of a regimen of combined chemoradiotherapy in patients with unresectable adenocarcinoma of the pancreas. An analysis was undertaken on 27 patients from January 1992 to May 1996. Patients had a median age of 70 years (range, 40-78) and Eastern Cooperative Oncology Group Performance Status of 0-2. Eighteen patients had locoregional disease (T2-T3, N0-N1, M0), and nine had metastatic disease. Chemotherapy consisted of four cycles of 5-fluorouracil 1 gm/m2/day as a continuous infusion over 110 hours, streptozotocin 300 mg/m2/day over 30 minutes on days 2-4, and cisplatin 100 mg/m2 over 2 hours on day 4 only, followed by a maintenance regimen of 5-fluorouracil and leucovorin every 2 weeks. The radiotherapy was administered as a split course concurrently with chemotherapy to a total dose of 6000 cGy. Toxicity was frequent, but there were no treatment-related deaths. Grade III and IV toxicity was primarily limited to myelosuppression, stomatitis, and gastrointestinal side effects. Fifteen patients (56%) were able to complete either three or four cycles of chemoradiotherapy. All patients were evaluable for toxicity, response, and survival. Nine patients (33%) had an objective response (four complete response 5 partial response), two remained stable, and 16 (59%) had disease progression. Median survival for the entire group was 19 weeks (2-139), and the median survival for overall responders was 56 weeks (15-139). No patient with localized disease underwent subsequent surgical resection. The authors conclude that those patients who are able to tolerate the entire treatment regimen may achieve a useful prolongation of time to tumor progression.

Major vascular resection as part of pancreaticoduodenectomy for cancer: radiologic, intraoperative, and pathologic analysis

Intraoperative assessment is inaccurate in defining the relationship of a pancreatic head neoplasm to adjacent vascular structures. We evaluated the ability of preoperative contrast-enhanced CT to predict the need for vascular resection during pancreaticoduodenectomy and examined the resected vessels for histologic evidence of tumor invasion. During a 7-year period, 63 patients underwent pancreaticoduodenectomy with en bloc resection of adjacent vascular structures for a presumed pancreatic head malignancy. Clinical, radiologic, operative, and pathologic data were reviewed and analyzed. Fifty-six patients underwent resection of the superior mesenteric-portal vein confluence, three patients required inferior vena cava resection, and the hepatic artery was resected and reconstructed in eight patients. The operative mortality rate was 1.6%, and the overall complication rate was 22%. CT predicted the need for resection of the superior mesenteric or portal veins in 84% of patients. Pathologic analysis revealed tumor invasion of the vein wall in 71% of resected specimens. Tumor invasion of vascular structures adjacent to the pancreas can be predicted with preoperative CT and should alert the surgeon that vascular resection may be required. Histologic evidence of tumor cell infiltration of vessel walls was present in the majority of the resected specimens.

Pancreas: does hyoscyamine butylbromide increase the diagnostic value of helical CT?

Among 50 patients referred for helical computed tomography (CT) of the pancreas, 24 randomly selected patients received 40 mg of hyoscyamine butylbromide to evaluate whether its administration improved image quality and diagnostic findings. Differences between the groups were not statistically significant. It was therefore concluded that hyoscyamine butylbromide does not contribute a diagnostic advantage at helical CT of the pancreas.

Intraductal carcinoma (carcinoma in situ) of the pancreas with microinvasion

We report a case of predominantly intraductal carcinoma of the pancreas with microscopic foci of invasive carcinoma in a patient with chronic pancreatitis. In this article, we discuss the pathologic and prognostic features of pancreatic carcinoma in situ. This entity is probably overlooked due to a number of reasons, including the fact that, in most cases, pancreatic ductal carcinomas are extensively infiltrative at the time of surgical removal; the atypical epithelial changes in the intraductal carcinoma had been overlooked in the presence or absence of an invasive component; epithelial changes may be missed due to insufficient sampling; and last, the differentiation with atypical epithelial hyperplasia is a subjective matter. Intraductal carcinoma of the pancreas is a distinct pathological entity with characteristic morphologic changes restricted to the ductal epithelium, bearing important prognostic implications.

Staging laparoscopy in the management of intra-abdominal malignancies

BACKGROUND

Laparoscopy in the evaluation of intra-abdominal malignancies has become a debated issue. Proponents have claimed that it increases resectability rates, whereas opponents suggest that many patients require laparotomy regardless of the laparoscopic findings. The purpose of this study was to compare outcomes in patients undergoing staging laparoscopy versus those who were managed by initial exploratory laparotomy.

METHODS

The medical records of all patients during an 18-month period who underwent surgical evaluation for upper gastrointestinal or hepatobiliary malignancies were reviewed. Forty-eight patients underwent staging laparoscopy (SL) initially; 80 patients underwent initial exploratory laparotomy (EL). Data obtained included type of cancer, laparoscopic findings, laparoscopic determination of resectability, laparoscopic procedures, open determination of resectability, open procedures, and length of stay (LOS). Statistical analysis was done by using Fisher exact test or the Mann-Whitney U test.

RESULTS

The malignancies of 75% of patients were deemed resectable by SL. Of these, 77.8% were resected. This compares to 56.3% resectability rate in the EL group (P = .025). SL findings in patients with unresectable malignancies were carcinomatosis (75%), liver metastasis (33.3%), and direct invasion (16.7%). In the 8 false-negative SLs, 75% were unresectable as a result of vascular invasion and 25% for other reasons. Findings in the EL group whose malignancies were unresectable were carcinomatosis (34.3%), direct invasion (22.6%), liver metastasis (42.9%), and vascular invasion only (17.1%). Therefore 82.9% of patients in the EL group could have been determined to have unresectable malignancy by SL. In the EL group 22.5% of the laparotomies were nontherapeutic, whereas 4.2% of patients in the SL group underwent nontherapeutic laparotomy. Average LOS for unresectable patients in the SL group was 0.5 days, with 75% discharged the same day of operation. This compares to 10.9 days in the EL group (P < .00001) and 7.6 days in the nontherapeutic EL group (P < .00001).

CONCLUSIONS

SL increases the resectability rate, decreases the nontherapeutic laparotomy rate, and decreases LOS in patients with unresectable disease. SL is poor at detecting unresectability as a result of vascular invasion only, but this accounts for less than one-fifth of patients. Laparoscopic sonography and palliation may further decrease the need for EL.