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Yee EJ, Torphy RJ, Thielen ON, Easwaran L, Franklin O, Sugawara T, Bartsch C, Garduno N, McCarter MM, Ahrendt SA, Schulick RD, Del Chiaro M. Radiologic Occult Metastases in Pancreatic Cancer: Analysis of Risk Factors and Survival Outcomes in the Age of Contemporary Neoadjuvant Multi-agent Chemotherapy. Ann Surg Oncol 2024; 31:6127-6137. [PMID: 38780693 DOI: 10.1245/s10434-024-15443-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/25/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Radiologic occult metastatic disease (ROMD) in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo contemporary neoadjuvant chemotherapy (NAC) has not been well studied. This study sought to analyze the incidence, risk factors, and oncologic outcomes for patients who underwent the NAC approach for PDAC. METHODS A retrospective review analyzed a prospectively maintained database of patients who had potentially resectable PDAC treated with NAC and were offered pancreatectomy at our institution from 2011 to 2022. Multivariable regression analysis was performed to assess risk factors associated with ROMD. Kaplan-Meier curves with log-rank analyses were generated to estimate time-to-event end points. RESULTS The study enrolled 366 patients. Upfront and borderline resectable anatomic staging comprised 80% of the cohort, whereas 20% had locally advanced disease. The most common NAC regimen was FOLFIRINOX (n = 274, 75%). For 55 patients (15%) who harbored ROMD, the most common site was liver-only metastases (n = 33, 60%). The independent risk factors for ROMD were increasing CA19-9 levels during NAC (odds ratio [OR], 7.01; confidence interval [CI], 1.97-24.96; p = 0.008), indeterminate liver lesions (OR, 2.19; CI, 1.09-4.39; p = 0.028), and enlarged para-aortic lymph nodes (OR, 6.87; CI, 2.07-22.74; p = 0.002) on preoperative cross-sectional imaging. Receipt of palliative chemotherapy (p < 0.001) and eventual formal pancreatectomy (p = 0.04) were associated with survival benefit in the log-rank analysis. The median overall survival (OS) of the patients with ROMD was nearly 15 months from the initial diagnosis, with radiologic evidence of metastases occurring after a median of 2 months. CONCLUSIONS Radiologic occult metastatic disease remains a clinical challenge associated with poor outcomes for patients who have PDAC treated with multi-agent NAC.
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Affiliation(s)
- Elliott J Yee
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert J Torphy
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Otto N Thielen
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lavanya Easwaran
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Oskar Franklin
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Toshitaka Sugawara
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Christan Bartsch
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Garduno
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin M McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven A Ahrendt
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marco Del Chiaro
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA.
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Sun BJ, Daniel SK, Lee B. The Role of Prophylactic and Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Prevention of Peritoneal Metastases in Advanced Colorectal Cancer. J Clin Med 2023; 12:6443. [PMID: 37892582 PMCID: PMC10607874 DOI: 10.3390/jcm12206443] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/28/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a locoregional therapy that may be combined with cytoreductive surgery (CRS) to treat patients with colorectal cancer and peritoneal metastases (PM). In recent years, three randomized controlled trials (RCTs) have investigated the role of prophylactic or adjuvant HIPEC in preventing the development of PM in patients with high-risk colorectal cancer: PROPHYLOCHIP and COLOPEC evaluated adjuvant HIPEC, and HIPECT4 studied concurrent HIPEC and CRS. Although PROPHYLOCHIP and COLOPEC were negative trials, a great deal may be learned from their methodology, outcome measures, and patient selection criteria. HIPECT4 is the first RCT to show a clinical benefit of HIPEC in high-risk T4 colorectal cancer, demonstrating improved locoregional disease control with the addition of HIPEC to CRS with no increase in the rate of complications. This review critically examines the strengths and limitations of each major trial and discusses their potential impact on the practice of HIPEC. Several additional ongoing clinical trials also seek to investigate the role of HIPEC in preventing PM in advanced colorectal cancer.
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Affiliation(s)
| | | | - Byrne Lee
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (B.J.S.); (S.K.D.)
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Javed AA, Young RWC, Habib JR, Kinny-Köster B, Cohen SM, Fishman EK, Wolfgang CL. Cinematic Rendering: Novel Tool for Improving Pancreatic Cancer Surgical Planning. Curr Probl Diagn Radiol 2022; 51:878-883. [PMID: 35595587 DOI: 10.1067/j.cpradiol.2022.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/24/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2023]
Abstract
Pancreatic ductal adenocarcinoma is the third-leading cause of all cancer-related deaths in the US. While 20% of patients have resectable disease at diagnosis, improved control of systemic disease using effective chemotherapeutic regimens allows for aggressive operations involving complex vascular resection and reconstruction. A pancreas protocol computed tomography (PPCT) is the gold standard imaging modality in determining local resectability (degree of tumor-vessel involvement), however, it is limited by the inter-operator variability. While post-processing-3D-rendering helps, it does not allow for real-time dynamic assessment of resectability. A recent development in post-process-rendering called cinematic rendering (CR) overcomes this by utilizing advanced light modeling to generate photorealistic 3D images with enhanced details. Cinematic rendering allows for nuanced visualization of areas of interest. Our preliminary experience, as one of the first centers to incorporate the routine use of CR, has proven very useful in surgical planning. For local determination of resectability, vascular mapping allows for accurate assessment of major arteries and the portovenous system. For the portovenous anatomy it assists in determining the optimal surgical approach (extent of resection, appropriate technique for reconstruction, and need for mesocaval shunting). For arterial anatomy, vessel encasement either represents dissectible involvement via periadventitial dissection or true vessel invasion that is unresectable. CR could potentially provide superior ability than traditional PPCT to discern between the two. Additionally, CR allows for better 3D visualization of arterial anatomic variants which, if not appreciated preoperatively, increases risk of intraoperative ischemia and postoperative complications. Lastly, CR could help avoid unnecessary surgery by enhanced identification of occult metastatic disease that is metastatic disease that is otherwise not appreciated on a standard PPCT.
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Affiliation(s)
- Ammar A Javed
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD; Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Robert W C Young
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Joseph R Habib
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Benedict Kinny-Köster
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD; Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Steven M Cohen
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Elliot K Fishman
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Lee SE, Han SS, Kang CM, Kwon W, Paik KY, Song KB, Yang JD, Chung JC, Jeong CY, Kim SW. Korean Surgical Practice Guideline for Pancreatic Cancer 2021: A summary of evidence-based surgical approaches. Ann Hepatobiliary Pancreat Surg 2022; 26:1-16. [PMID: 35220285 PMCID: PMC8901981 DOI: 10.14701/ahbps.22-009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related deaths in Korea. Despite the increasing incidence and high mortality rate of pancreatic cancer, there are no appropriate surgical practice guidelines for the current domestic medical situation. To enable standardization of management and facilitate improvements in surgical outcome, a total of 10 pancreatic surgical experts who are members of Korean Association of Hepato-Biliary-Pancreatic Surgery have developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. This is an English version of the Korean Surgical Practice Guideline for Pancreatic Cancer 2021. This guideline includes 13 surgical questions and 15 statements. Due to the lack of high-level evidence, strong recommendation is almost impossible. However, we believe that this guideline will help surgeons understand the current status of evidence and suggest what to investigate further to establish more solid recommendations in the future.
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Affiliation(s)
- Seung Eun Lee
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sung-Sik Han
- Department of Surgery, National Cancer Center, Goyang, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Yeol Paik
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Do Yang
- Department of Surgery, Jeonbuk National University Medical School, Jeonju, Korea
| | - Jun Chul Chung
- Department of Surgery, Soon Chun Hyang University School of Medicine, Cheonan, Korea
| | - Chi-Young Jeong
- Department of Surgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sun-Whe Kim
- Department of Surgery, National Cancer Center, Goyang, Korea
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Iyengar S, Nevala-Plagemann C, Garrido-Laguna I. Updates on adjuvant and neoadjuvant treatment strategies for surgically resectable and borderline resectable pancreatic ductal adenocarcinoma. Ther Adv Med Oncol 2021; 13:17588359211045861. [PMID: 34552668 PMCID: PMC8450613 DOI: 10.1177/17588359211045861] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/25/2021] [Indexed: 01/05/2023] Open
Abstract
Pancreatic cancer is the third leading cause of cancer-related mortality in the US. Outcomes for patients with pancreatic cancer are poor as curative approaches are only available to the minority of patients who have localized tumors for which surgery may be an option. The past decade has established fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) as the new standard of care following resection for fit patients with resectable pancreatic tumors. However, most patients will relapse and a large number of patients treated with upfront resection are unable to receive or complete adjuvant chemotherapy. There is therefore considerable interest in neoadjuvant treatment strategies for patients with resectable and borderline resectable pancreatic cancer as a way to provide early systemic treatment of micrometastatic disease, facilitate lymph node downstaging, and increase the likelihood of negative resection margins (R0). This review will focus on key aspects of completed trials evaluating adjuvant therapy in resectable pancreatic cancer and will provide an overview of emerging evidence supporting the use of neoadjuvant treatment strategies for both resectable and borderline resectable pancreatic cancer.
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Affiliation(s)
- Siddharth Iyengar
- Department of Internal Medicine, University of Utah School of Medicine, 50 Medical Dr N, Salt Lake City, UT 84132-0002, USA
| | | | - Ignacio Garrido-Laguna
- Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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8
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Noda Y, Goshima S, Takai Y, Kawai N, Kawada H, Tanahashi Y, Matsuo M. Detection of pancreatic ductal adenocarcinoma and liver metastases: comparison of Gd-EOB-DTPA-enhanced MR imaging vs. extracellular contrast materials. Abdom Radiol (NY) 2020; 45:2459-2468. [PMID: 32248260 DOI: 10.1007/s00261-020-02511-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To compare the detectability of pancreatic ductal adenocarcinoma (PDAC) and liver metastases between Gd-EOB-DTPA- and extracellular contrast materials (ECCMs) contrast-enhanced MR imaging contrast. METHODS Two hundred seventy-two patients with suspected pancreatic disease underwent Gd-EOB-DTPA-enhanced MR imaging (EOB group, n = 79) or ECCMs-enhanced MR imaging (ECCM group, n = 193). The ECCM group were administered the following contrast agents: Gd-DTPA (n = 158), Gd-BT-DO3A (n = 28), Gd-DOTA (n = 5), and Gd-DTPA-BMA (n = 2). Signal intensities of pancreatic parenchyma, paraspinal muscle, PDAC (if present), and background noise were measured. The signal intensity ratio (SIR) of the pancreas and tumor-to-pancreas contrast-to-noise ratio (CNR) were also calculated. If present, the conspicuity of PDAC was evaluated with the arterial dominant phase images. Liver metastases, if present, were also evaluated for all sequences. Qualitative and quantitative imaging parameters were compared between EOB and ECCM groups. RESULTS SIR of the pancreas (P < 0.001) and CNR (P = 0.0037) were significantly lower in EOB group when compared with the ECCM group. However, the sensitivity (97.1% vs. 93.5%, P = 0.42) and specificity (100.0% vs. 99.2%, P = 1.00) for detecting PDAC were not significant between EOB and ECCM groups. The EOB group showed a significantly greater sensitivity for detecting liver metastases compared with the ECCM group (95.0% vs 84.5%, P = 0.04) when evaluating on a lesion-by-lesion basis. CONCLUSION Gd-EOB-DTPA-enhanced MR imaging performed similarly to ECCMs-enhanced MR imaging in detecting PDAC but had better sensitivity in detecting liver metastases.
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Liu X, Fu Y, Chen Q, Wu J, Gao W, Jiang K, Miao Y, Wei J. Predictors of distant metastasis on exploration in patients with potentially resectable pancreatic cancer. BMC Gastroenterol 2018; 18:168. [PMID: 30400836 PMCID: PMC6220565 DOI: 10.1186/s12876-018-0891-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/23/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patients with potentially resectable pancreatic ductal adenocarcinoma (PDAC) are frequently found to be unresectable on exploration due to small distant metastasis. This study was to investigate predictors of small distant metastasis in patients with potentially resectable PDAC. METHODS Patients who underwent surgical exploration for potentially resectable PDAC from 2013 to 2014 were reviewed retrospectively and divided into two groups according to whether distant metastases were encountered on exploration. Then, univariate and multivariate logistic regression analyses were used to identify predictors of distant metastasis. A scoring system to predict distant metastasis of PDAC on exploration was constructed based on the regression coefficient of a multivariate logistic regression model. RESULTS A total of 235 patients were included in this study. Mean age of the study population was 61.7 ± 10.4 years old. Upon exploration, distant metastases were found intraoperatively in 62 (26.4%) patients, while the remaining 173 were free of distant metastases. Multivariate logistic regression analysis identified that age ≤ 62 years old (p < 0.001), male sex (p = 0.011), tumor size ≥4.0 cm (p < 0.001), alanine aminotransferase level (ALT) < 125 U/L (p < 0.001), and carbohydrate antigen (CA19-9) level ≥ 385 U/mL (p < 0.001) were independent risk factors for occult distant metastasis of PDAC. A preoperative scoring system (0-8 points) for distant metastasis on exploration was constructed using these five factors. The receiver operating characteristic curves showed that the area under the curve of this score was 0.85. A score of 6 points was suggested to be the optimal cut-off value, and the sensitivity and specificity were 85% and 69%, respectively. CONCLUSIONS Distant metastasis is still frequently encountered on exploration for patients with potentially resectable PDAC. Younger age, male sex, larger tumor size, low ALT level and high CA19-9 level are independent predictors of unexpected distant metastasis on exploration.
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Affiliation(s)
- Xinchun Liu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China.,Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Yue Fu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China.,Department of Gastrointestinal Surgery, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Qiuyang Chen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China.,Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China.,Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Wentao Gao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China.,Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China.,Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China. .,Pancreas Institute, Nanjing Medical University, Nanjing, China.
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, China. .,Pancreas Institute, Nanjing Medical University, Nanjing, China.
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de Jesus VHF, da Costa Junior WL, de Miranda Marques TMD, Diniz AL, de Castro Ribeiro HS, de Godoy AL, de Farias IC, Coimbra FJF. Role of staging laparoscopy in the management of Pancreatic Duct Carcinoma (PDAC): Single-center experience from a tertiary hospital in Brazil. J Surg Oncol 2018; 117:819-828. [PMID: 29509968 DOI: 10.1002/jso.25024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/02/2018] [Accepted: 01/25/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Proper staging is critical to the management of pancreatic ductal carcinoma (PDAC). Laparoscopy has been used to stage patients without gross metastatic disease with variable success. OBJECTIVES We aimed to identify the frequency of patients diagnosed by laparoscopy with occult metastatic disease. Also, we looked for variables related to a higher chance of occult metastasis. METHODS Patients with PDAC submitted to staging laparoscopy either immediately before pancreatectomy or as a separate procedure between January 2010 and December 2016 were included. None presented gross metastatic disease at initial staging. We used logistic regression to search for variables associated with metastatic disease. RESULTS The study population consisted of 63 patients. Among all patients, nine (16.7%) had occult metastases at laparoscopy. Unresectable tumor (Odds ratio = 18.0, P = 0.03), increasing tumor size (Odds ratio = 1.36, P = 0.01), and abdominal pain (Odds ratio = 5.6, P = 0.04) significantly predicted the risk of occult metastases in univariate analysis. In multivariate analysis, only tumor size predicted the risk of occult metastases. CONCLUSION Laparoscopy remains a valuable tool in PDAC staging. Patients with either large or unresectable tumors, or presenting with abdominal pain present the highest risk for occult intra-abdominal metastases.
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Affiliation(s)
| | | | | | | | | | - André Luis de Godoy
- Abdominal Surgery Department-A.C. Camargo Cancer Center, São Paulo, SP, Brazil
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Sahakyan MA, Kim SC, Kleive D, Kazaryan AM, Song KB, Ignjatovic D, Buanes T, Røsok BI, Labori KJ, Edwin B. Laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: Long-term oncologic outcomes after standard resection. Surgery 2017; 162:802-811. [PMID: 28756944 DOI: 10.1016/j.surg.2017.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Surgical resection is the only curative option in patients with pancreatic ductal adenocarcinoma. Little is known about the oncologic outcomes of laparoscopic distal pancreatectomy. This bi-institutional study aimed to examine the long-term oncologic results of standard laparoscopic distal pancreatectomy in a large cohort of patients with pancreatic ductal adenocarcinoma. METHODS From January 2002 to March 2016, 207 patients underwent standard laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma at Oslo University Hospital-Rikshospitalet (Oslo, Norway) and Asan Medical Centre (Seoul, Republic of Korea). After the exclusion criteria were applied (distant metastases at operation, conversion to an open operation, loss to follow-up), 186 patients were eligible for the analysis. Perioperative and oncologic variables were analyzed for association with recurrence and survival. RESULTS Median overall and recurrence-free survivals were 32 and 16 months, while 5-year overall and recurrence-free survival rates were estimated to be 38.2% and 35.9%, respectively. Ninety-six (52%) patients developed recurrence: 56 (30%) extrapancreatic, 27 (15%) locoregional, and 13 (7%) combined locoregional and extrapancreatic. Thirty-seven (19.9%) patients had early recurrence (within 6 months of operation). In the multivariable analysis, tumor size >3 cm and no adjuvant chemotherapy were associated with early recurrence (P = .017 and P = .015, respectively). The Cox regression model showed that tumor size >3 cm and lymphovascular invasion were independent predictors of decreased recurrence-free and overall survival. CONCLUSION Standard laparoscopic distal pancreatectomy is associated with satisfactory long-term oncologic outcomes in patients with pancreatic ductal adenocarcinoma. Several risk factors, such as tumor size >3 cm, no adjuvant chemotherapy, and lymphovascular invasion, are linked to poor prognosis after standard laparoscopic distal pancreatectomy.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
| | - Song Cheol Kim
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Dyre Kleive
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Ki Byung Song
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Trond Buanes
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Bård I Røsok
- Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Knut Jørgen Labori
- Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
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Reply to the letter to the editor regarding "The diagnostic advantage of EOB-MR imaging over CT in the detection of liver metastasis in patients with potentially resectable pancreatic cancer: Methodological issues". Pancreatology 2017; 17:650. [PMID: 28693975 DOI: 10.1016/j.pan.2017.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 12/11/2022]
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Ito T, Sugiura T, Okamura Y, Yamamoto Y, Ashida R, Aramaki T, Endo M, Uesaka K. The diagnostic advantage of EOB-MR imaging over CT in the detection of liver metastasis in patients with potentially resectable pancreatic cancer. Pancreatology 2017; 17:451-456. [PMID: 28298257 DOI: 10.1016/j.pan.2017.03.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 02/12/2017] [Accepted: 03/05/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver metastases (LMs) are sometimes diagnosed intraoperatively, even when multidetector-row computed tomography (MDCT) reveals no LM in the staging of pancreatic cancer (PC). Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MR imaging) may have a role to play in the detection of LM. METHODS The present study included a total of 201 patients who underwent an EOB-MR imaging examination before undergoing surgical resection for pancreatic cancer that was determined to be radiologically-resectable by MDCT. Intrahepatic lesions that were considered suspected to be liver metastases following an EOB-MR imaging examination were defined as possible lesions (PLs). All PLs were evaluated by a pathological examination or through close follow-up examinations. The diagnostic ability of EOB-MR imaging was assessed. The predictive factors for liver metastasis were evaluated. RESULTS Thirty-seven PLs were noted in 17 patients: 31 PLs were true LMs, and six were benign lesions (3 hemangiomas and 3 abscesses). Nine LMs were newly detected during surgery and were not detected by preoperative EOB-MR imaging. The diagnostic ability of EOB-MR imaging was as follows: sensitivity, 77.5%; specificity, 94.7%; positive predictive value, 83.8%; negative predictive value, 92.3%; and accuracy, 90.2%. A multivariate analysis revealed that the presence of PL on EOB-MR imaging was the only independent risk factor for intraoperative liver metastasis (P < 0.001). CONCLUSION EOB-MR imaging was useful in detecting tiny liver metastases from pancreatic cancer in cases that were determined to be radiologically resectable by MDCT.
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Affiliation(s)
- Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Takeshi Aramaki
- Division of Diagnostic Radiology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Masahiro Endo
- Division of Diagnostic Radiology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
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Xu W, Jiang B, Yin X. Clinical data combined with radiological imaging improves the accuracy of TNM staging of pancreatic body and tail adenocarcinoma. Patient Prefer Adherence 2017; 11:1711-1721. [PMID: 29042755 PMCID: PMC5634375 DOI: 10.2147/ppa.s139938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Pancreatic body and tail adenocarcinoma (PBTA) remains one of the deadliest cancers, and current radiological modalities still have limitations on the staging of PBTA. Improving PBTA staging will contribute to the management of this disease. PATIENTS AND METHODS Clinicopathological characteristics of 91 surgically treated PBTA patients were retrospectively retrieved. Clinical data associated with postoperative tumor staging (pTNM) were assessed using ordinal logistic regression model. Discriminant analysis was performed using function formula based on multivariate analysis results; further cross-validation was conducted by Bootstrap methods. RESULTS Multivariate analysis showed that carbohydrate antigen 19-9 ≥955.0 U/L, albumin, and alkaline phosphatase/total bilirubin ratio were independent factors contributing to improved accuracy of pTNM staging. Discriminant analysis exhibited better performance and showed that the probability of accurate prediction of pTNM stage was 90.6% and the probability of cross-validation was 85.9%. After excluding patients with preoperative diagnosis of stage IV disease, the probability of accurate prediction of pTNM stage was 86.1% and the probability of cross-validation was 75.0%. CONCLUSION The combination of imaging and clinical data has higher accuracy in staging PBTA than radiological data alone. A model proposed in this study will improve the management of PBTA.
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Affiliation(s)
- Wei Xu
- Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, Changsha, China
| | - Bo Jiang
- Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, Changsha, China
- Correspondence: Bo Jiang, Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, No 61 West Jiefang Road, Changsha 410005, China, Tel +86 130 1728 6395, Fax +86 731 8227 8012, Email
| | - Xinmin Yin
- Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, Changsha, China
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Karabicak I, Satoi S, Yanagimoto H, Yamamoto T, Hirooka S, Yamaki S, Kosaka H, Inoue K, Matsui Y, Kon M. Risk factors for latent distant organ metastasis detected by staging laparoscopy in patients with radiologically defined locally advanced pancreatic ductal adenocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:750-755. [PMID: 27794194 DOI: 10.1002/jhbp.408] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/25/2016] [Indexed: 01/29/2023]
Abstract
OBJECTIVES We aimed to identify risk factors for latent distant organ metastasis in patients with radiographically defined locally advanced (RDLA) pancreatic ductal adenocarcinoma (PDAC). METHODS RDLA disease was defined as unresectable disease without distant organ metastasis based on resectability status by NCCN guidelines. Between January 2005 and November 2015, 110 consecutive patients underwent staging laparoscopy to rule out latent distant metastasis. Univariate and multivariate analyses were performed to identify risk factors for latent distant organ metastasis or peritoneal metastasis (PM), defined as peritoneal dissemination and/or positive peritoneal lavage cytology (PPC). RESULTS Latent distant organ metastasis was diagnosed by staging laparoscopy in 62 patients. PPC was found in 23%, peritoneal dissemination in 19%, and liver metastasis in 15%. Univariate analysis showed tumor location, preoperative CA 19-9 level and tumor size, and multivariate analysis revealed tumor size >55 mm and CA 19-9 level >60 IU/ml as risk factors for latent distant metastasis. Multivariate analysis showed pancreas body-tail tumors and tumor size >42 mm as risk factors for PM; 65.4% of pancreas body-tail tumors >42 mm had PM. CONCLUSIONS Patients with large pancreas body-tail tumors and high CA 19-9 level are at greater risk for latent distant organ metastasis or PM, and should undergo staging laparoscopy routinely for accurate diagnosis (UMIN000023125).
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Affiliation(s)
- Ilhan Karabicak
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Masanori Kon
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan
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Karabicak I. Letter to the Editor: Objective Assessment of Surgical Restaging after Concurrent Chemoradiation for Locally Advanced Pancreatic Cancer. J Korean Med Sci 2016; 31:1503-4. [PMID: 27510398 PMCID: PMC4974196 DOI: 10.3346/jkms.2016.31.9.1503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ilhan Karabicak
- Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Department of General Surgery, Ondokuz Mayis University Medical Faculty, Samsun, Turkey.
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Allen VB, Gurusamy KS, Takwoingi Y, Kalia A, Davidson BR. Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2016; 7:CD009323. [PMID: 27383694 PMCID: PMC6458011 DOI: 10.1002/14651858.cd009323.pub3] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer. OBJECTIVES To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016). SELECTION CRITERIA We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone. MAIN RESULTS We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone. AUTHORS' CONCLUSIONS Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.
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Affiliation(s)
- Victoria B Allen
- Oxford University Hospitals NHS TrustOxford University Clinical Academic Graduate SchoolJohn Radcliffe HospitalOxfordUKOX3 9DU
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
| | | | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
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21
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Satoi S, Yanagimoto H, Yamamoto T, Toyokawa H, Hirooka S, Yamaki S, Opendro SS, Inoue K, Michiura T, Ryota H, Matsui Y, Kon M. A clinical role of staging laparoscopy in patients with radiographically defined locally advanced pancreatic ductal adenocarcinoma. World J Surg Oncol 2016; 14:14. [PMID: 26791083 PMCID: PMC4721110 DOI: 10.1186/s12957-016-0767-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/11/2016] [Indexed: 01/05/2023] Open
Abstract
Background The aim of current study is to verify usefulness of staging laparoscopy (stag-lap) for patient’s selection and to find prognostic factors in patients with radiographically defined locally advanced (RD-LA) pancreatic ductal adenocarcinoma (PDAC). Methods The LA disease was defined as an unresectable disease without distant organ metastasis based on resectability status of NCCN guideline in this study. Stag-lap was performed in 67 patients with RD-LA (2007–2012) which were divided into 4 groups according to metastatic site: group CY (peritoneal fluid or washing cytology positive and without any distant organ metastasis); group P (peritoneal dissemination); group L (liver metastasis); group LA (peritoneal fluid or washing cytology negative and without any distant organ metastasis). Clinical backgrounds, survival curves, and prognostic factors were investigated. Results There were 16 patients in CY group (24 %), 13 patients in P group (19 %), 10 patients in L group (15 %), and 28 patients in LA group (42 %). Median survival time was 13 months in CY group and 11 months in LA group, which was significantly better than 7 months in P group, respectively (p < 0.05). The rate of emergence of ascites in LA was significantly better than in CY or P groups (p < 0.05). Multivariate analysis showed that the presence of partial response and administration of second-line chemotherapy were significantly independent prognostic factors. Conclusions The majority of PDAC patients with RD-LA had occult distant organ metastasis. Clinical features and survival curves were different depending on the site of occult distant organ metastasis. Administration of second-line chemotherapy and responsiveness to chemotherapy were associated with favorable prognosis. Staging laparoscopy should be routinely performed in patients with RD-LA PDAC (UMIN000019936).
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Affiliation(s)
- Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Hideyoshi Toyokawa
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Singh Sapam Opendro
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Taku Michiura
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Hironori Ryota
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
| | - Masanori Kon
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.
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De Rosa A, Cameron IC, Gomez D. Indications for staging laparoscopy in pancreatic cancer. HPB (Oxford) 2016; 18:13-20. [PMID: 26776846 PMCID: PMC4750228 DOI: 10.1016/j.hpb.2015.10.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/26/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND To identify indications for staging laparoscopy (SL) in patients with resectable pancreatic cancer, and suggest a pre-operative algorithm for staging these patients. METHODS Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords 'pancreatic cancer', 'resectability', 'staging', 'laparoscopy', and 'Whipple's procedure'. RESULTS Twenty four studies were identified which fulfilled the inclusion criteria. Of the published data, the most reliable surrogate markers for selecting patients for SL to predict unresectability in patients with CT defined resectable pancreatic cancer were CA 19.9 and tumour size. Although there are studies suggesting a role for tumour location, CEA levels, and clinical findings such as weight loss and jaundice, there is currently not enough evidence for these variables to predict resectability. Based on the current data, patients with a CT suggestive of resectable disease and (1) CA 19.9 ≥150 U/mL; or (2) tumour size >3 cm should be considered for SL. CONCLUSION The role of laparoscopy in the staging of pancreatic cancer patients remains controversial. Potential predictors of unresectability to select patients for SL include CA 19.9 levels and tumour size.
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Affiliation(s)
- Antonella De Rosa
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Iain C Cameron
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Dhanwant Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
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Schwarz L, Katz MHG. Diagnosis and Management of Borderline Resectable Pancreatic Adenocarcinoma. Hematol Oncol Clin North Am 2015; 29:727-40. [PMID: 26226907 DOI: 10.1016/j.hoc.2015.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Borderline resectable pancreatic cancer represents a subcategory of advanced cancer that is typically defined by limited involvement of the major mesenteric vasculature. Such involvement is associated with a high likelihood of microscopically incomplete resection if surgery is used as the primary therapeutic modality. Increasing data support the role of neoadjuvant therapy as part of multimodality management but there is no uniformly accepted standard of care. This review discusses, based on recent literature and the experience of the Pancreatic Tumor Study Group at The University of Texas MD Anderson Cancer Center, the classification, definition, diagnosis, and management of borderline resectable pancreatic cancer.
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Affiliation(s)
- Lilian Schwarz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, 17th Floor, Houston, TX 77030, USA
| | - Matthew Harold G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, 17th Floor, Houston, TX 77030, USA.
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Zanini N, Lombardi R, Masetti M, Giordano M, Landolfo G, Jovine E. Surgery for isolated liver metastases from pancreatic cancer. Updates Surg 2015; 67:19-25. [PMID: 25702263 DOI: 10.1007/s13304-015-0283-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 02/05/2015] [Indexed: 12/16/2022]
Abstract
The resection of liver metastases from pancreatic ductal adenocarcinoma has been discouraged because it is commonly thought that it does not improve survival. However, the role of potential prognostic factors is unclear, and universally accepted strategies have not been proposed. Between 2003 and 2014, 15 patients with isolated synchronous or metachronous metastases from pancreatic cancer underwent liver resection in our department. The role of potential prognostic factors was analyzed to predict survival. One right hepatectomy, 1 bisegmentectomy and 13 wedge resections were performed. Eleven patients underwent simultaneous pancreatic and liver resection for synchronous disease. The median overall survival (OS) was 9.1 months (95% CI 8.6-9.7). The only potential prognostic factor that significatively affected survival was the timing of metastases (metachronous vs. synchronous). Median OS in patients with metachronous disease was 11.4 months (95% CI 0-25.1) vs. 8.3 months (95% CI 6.9-9.7), p = 0.038. Surgery for liver metastases from pancreatic cancer is not suggested for most patients. If resection is considered, timing of metastatic disease could be a prognostic factor for survival after surgery.
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Affiliation(s)
- Nicola Zanini
- Department of Surgery, Maggiore Hospital, Bologna, Italy,
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25
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Jayakrishnan TT, Nadeem H, Groeschl RT, George B, Thomas JP, Ritch PS, Christians KK, Tsai S, Evans DB, Pappas SG, Gamblin TC, Turaga KK. Diagnostic laparoscopy should be performed before definitive resection for pancreatic cancer: a financial argument. HPB (Oxford) 2015; 17:131-9. [PMID: 25123702 PMCID: PMC4299387 DOI: 10.1111/hpb.12325] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 07/02/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT). METHODS Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50,000/quality-adjusted life year). RESULTS Base case costs were US$34,921 for ExLap and US$33,442 for DL in SF patients, and US$39,633 for ExLap and US$39,713 for DL in NAT patients. Routine DL is the dominant (preferred) strategy in both treatment types: it allows for cost reductions of US$10,695/QALM in SF and US$4158/QALM in NAT patients. CONCLUSIONS The present analysis supports the cost-effectiveness of routine DL before curative resection in pancreatic cancer patients treated with either SF or NAT.
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Affiliation(s)
- Thejus T Jayakrishnan
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
| | - Hasan Nadeem
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
| | - Ryan T Groeschl
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
| | - Ben George
- Division of Medical Oncology, Medical College of WisconsinMilwaukee, WI, USA
| | - James P Thomas
- Division of Medical Oncology, Medical College of WisconsinMilwaukee, WI, USA
| | - Paul S Ritch
- Division of Medical Oncology, Medical College of WisconsinMilwaukee, WI, USA
| | - Kathleen K Christians
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
| | - Susan Tsai
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
| | - Sam G Pappas
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical CenterMaywood, IL, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
| | - Kiran K Turaga
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, WI, USA
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Katz MHG, Crane CH, Varadhachary G. Management of borderline resectable pancreatic cancer. Semin Radiat Oncol 2014; 24:105-12. [PMID: 24635867 DOI: 10.1016/j.semradonc.2013.11.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Borderline resectable pancreatic cancers are those that, although technically resectable, are at high risk for margin-positive resection following surgery de novo. Generally, such cancers are characterized by localized primary tumors that involve the mesenteric vasculature to a limited degree and that may require venous or hepatic arterial resection at pancreatectomy. In this article, we review diagnosis and staging algorithms, pretreatment strategies, and multidisciplinary treatment protocols for patients with this stage of disease. The rationale for and results following treatment with neoadjuvant chemotherapy and chemoradiation and subsequent surgical resection of the primary tumor are described in detail and existing data are reviewed.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Gauri Varadhachary
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Kikuchi H, Kamiya K, Hiramatsu Y, Miyazaki S, Yamamoto M, Ohta M, Baba S, Konno H. Laparoscopic narrow-band imaging for the diagnosis of peritoneal metastasis in gastric cancer. Ann Surg Oncol 2014; 21:3954-62. [PMID: 24859934 DOI: 10.1245/s10434-014-3781-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Staging laparoscopy (SL) is often used to diagnose peritoneal metastasis in patients with advanced gastric cancer, but accurate detection of metastasis can be difficult. We evaluated the usefulness of laparoscopic narrow-band imaging (NBI) versus conventional laparoscopic white-light imaging (WLI) for the diagnosis of peritoneal metastasis. METHODS We excised 37 white nodules from the parietal peritoneum of 26 patients with gastric cancer and suspected peritoneal metastasis. The WLI and NBI findings were compared with the pathological findings. All the peritoneal lesions examined were observed as white nodules on WLI. Intranodular vessels were evaluated by WLI and NBI for (1) vessel dilatation, (2) vessel tortuousness, (3) vessel heterogeneity, and (4) brown spots. RESULTS Each individual abnormal finding had a diagnostic accuracy of less than 79 % with or without NBI. Detection of any one abnormal finding had a sensitivity, specificity, and accuracy of 47.8, 85.7, and 62.2 %, respectively, on WLI and 91.3, 71.4, and 83.8 %, respectively, on NBI, for detection of peritoneal metastasis. Detection of any one abnormal finding on NBI plus clear demarcation of the nodule on WLI had a sensitivity of 91.3 %, specificity of 92.9 %, and accuracy of 91.9 % for detection of peritoneal metastasis. Pathological examination showed that a brown spot detected on NBI correlated with dilated vessels around cancer cells. Vascular endothelial growth factor was expressed in 76.2 % of peritoneal metastases. CONCLUSIONS NBI was more sensitive for the detection of dilated vessels than WLI. NBI could be a useful tool for the diagnosis of peritoneal metastasis during SL.
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Affiliation(s)
- Hirotoshi Kikuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan,
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28
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Abstract
OPINION STATEMENT Borderline resectable pancreatic adenocarcinoma represents a subset of localized cancers that are at high risk for a margin-positive resection and early treatment failure when resected de novo. Although several different anatomic definitions for this disease stage exist, there is agreement that some degree of reconstructible mesenteric vessel involvement by the tumor is the critical anatomic feature that positions borderline resectable between anatomically resectable and unresectable (locally advanced) tumors in the spectrum of localized disease. Consensus also exists that such cancers should be treated with neoadjuvant chemotherapy and/or chemoradiation before resection; although the optimal algorithm is unknown, systemic chemotherapy followed by chemoradiation is a rational approach. Although gemcitabine-based systemic chemotherapy with either 5-FU or gemcitabine-based chemoradiation regimens has been used to date, newer regimens, including FOLFIRINOX, should be evaluated on protocol. Delivery of neoadjuvant therapy necessitates durable biliary decompression for as many as 6 months in many patients with cancers of the pancreatic head. Patients with no evidence of metastatic disease following neoadjuvant therapy should be brought to the operating room for pancreatectomy, at which time resection of the superior mesenteric/portal vein and/or hepatic artery should be performed when necessary to achieve a margin-negative resection. Following completion of multimodality therapy, patients with borderline resectable pancreatic cancer can expect a duration of survival as favorable as that of patients who initially present with resectable tumors. Coordination among a multidisciplinary team of physicians is necessary to maximize these complex patients' short- and long-term oncologic outcomes.
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Allen VB, Gurusamy KS, Takwoingi Y, Kalia A, Davidson BR. Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2013:CD009323. [PMID: 24272022 DOI: 10.1002/14651858.cd009323.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). There has been no systematic review or meta-analysis assessing the role of diagnostic laparoscopy in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer. OBJECTIVES To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer. SEARCH METHODS We searched the Cochrane Register of Diagnostic Test Accuracy Studies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 13 September 2012), and Science Citation Index Expanded (from 1980 to 13 September 2012). SELECTION CRITERIA We included diagnostic accuracy studies of diagnostic laparoscopy in patients with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies. DATA COLLECTION AND ANALYSIS Two authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. Therefore, the sensitivities were meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in patients who had a negative laparoscopy (post-test probability for patients with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone. MAIN RESULTS Fifteen studies with a total of 1015 patients were included in the meta-analysis. Only one study including 52 patients had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 40.3% (that is 40 out of 100 patients who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 68.7% (95% CI 54.3% to 80.2%). Assuming a pre-test probability of 40.3%, the post-test probability of unresectable disease for patients with a negative test result was 0.17 (95% CI 0.12 to 0.24). This indicates that if a patient is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 17% probability that their cancer will be unresectable compared to a 40% probability for those receiving CT alone.A subgroup analysis of patients with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40% for those receiving CT alone. AUTHORS' CONCLUSIONS Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in patients with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 23 unnecessary laparotomies in 100 patients in whom resection of cancer with curative intent is planned.
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Affiliation(s)
- Victoria B Allen
- University College London, Royal Free Campus, Pond Street, London, UK, NW3 2QG
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von Breitenbuch P, Jeiter T, Schreml S, Glockzin G, Agha A, Piso P, Schlitt HJ. Autofluorescent imaging in patients with peritoneal carcinomatosis. Surg Innov 2013; 21:187-93. [PMID: 23843158 DOI: 10.1177/1553350613495114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Autofluorescence imaging (AFI) is mainly used to detect (pre)cancerous colorectal and pulmonal lesions. This is the first report establishing the feasibility of AFI in patients with peritoneal carcinomatosis (PC). METHODS This is a prospective analysis of 10 patients undergoing conventional white-light laparoscopy (WL) and AFI for PC of different gastrointestinal tumors and 1 ovarian cancer. Before taking biopsies, suspicious peritoneal lesions were first detected by WL and then investigated by AFI. The intraoperative findings were photographed and then correlated with histological results. RESULTS Conventional WL and AFI evaluation was successful in all patients. A total of 38 biopsies were taken. The neoplasm detection rate under WL was 66% and increased to 86% when using AFI. The positive tumor detection rate was slightly higher in low AF lesions (83 vs 88%) and higher in tumor nodules (94%) than in flat peritoneal lesions (75%). For tumor nodules, the sensitivity was 94%, and the specificity was 100%. For flat lesions, the sensitivity was 75% and specificity 50%. CONCLUSIONS We demonstrate the feasibility and effectiveness of AFI in patients with PC.
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Do patient- and tumor-related factors predict the peritoneal spread of pancreatic adenocarcinoma? Surg Today 2013; 44:260-3. [PMID: 23494067 DOI: 10.1007/s00595-013-0546-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 12/11/2012] [Indexed: 12/21/2022]
Abstract
PURPOSE In pancreatic cancer, the presence of peritoneal carcinomatosis (PC) precludes the possibility of a surgical cure, irrespective of the resectability of the primary tumor. However, peritoneal spread cannot be reliably detected radiographically during preoperative tumor staging. METHODS The pancreatic adenocarcinoma database of the Tübingen Comprehensive Cancer Center included 29 patients in whom PC was incidentally detected during the surgery. These patients were retrospectively compared for patient- and tumor-related factors with 29 randomly selected patients without PC who underwent curative resection. RESULTS Clinical jaundice and diarrhea were more frequently present in patients without PC. The CA 19-9 levels were significantly higher in patients with PC compared to those in patients without PC. No other differences were observed in the patient- or tumor-related factors between the two groups. CONCLUSION In pancreatic cancer patients, markedly elevated CA 19-9 levels may serve as surrogate marker for peritoneal dissemination, irrespective of the local resectability of the tumor. In such patients, laparoscopy should be considered as an additional staging tool to rule out peritoneal carcinomatosis.
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The role of diagnostic laparoscopy in detecting minimal peritoneal metastatic deposits in patients with pancreatic cancer scheduled for curative resection. Surg Laparosc Endosc Percutan Tech 2012; 22:358-60. [PMID: 22874688 DOI: 10.1097/sle.0b013e318259f172] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pancreatic cancer (PC) is an aggressive disease usually diagnosed at an advanced stage. Modern computed tomography can define the subgroup of operable patients. However, minimal peritoneal deposits can be undetected even by modern computed tomography protocols. AIM To diagnose those patients who are not operable because of a peritoneal spread using diagnostic laparoscopy (DL), thus avoiding unnecessary laparotomies. METHODS A retrospective study was conducted on 52 consecutive patients with PC scheduled for curative pancreatic surgery. RESULTS Out of 52 patients who underwent DL, peritoneal spread was diagnosed in 5 patients and these patients were denied surgery. Laparoscopy did not detect 2 other patients with peritoneal spread. CONCLUSIONS Although the added value of DL in patients with PC is small (around 10% in our series), considering the minimal morbidity and costs attributed to this procedure, we believe that it should be adopted as a routine approach.
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Tran Cao HS, Kaushal S, Menen RS, Metildi CA, Lee C, Snyder CS, Talamini MA, Hoffman RM, Bouvet M. Submillimeter-resolution fluorescence laparoscopy of pancreatic cancer in a carcinomatosis mouse model visualizes metastases not seen with standard laparoscopy. J Laparoendosc Adv Surg Tech A 2011; 21:485-9. [PMID: 21699431 DOI: 10.1089/lap.2011.0181] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Staging laparoscopy can visualize peritoneal and liver metastases in pancreatic cancer otherwise undetectable by preoperative imaging. However, false-negative rates may be as high as 18%-26%. The aim of the present study was to improve detection of metastatic pancreatic cancer with the use of fluorescence laparoscopy (FL) in a nude-mouse model with the tumors expressing green fluorescent protein (GFP). METHODS The carcinomatosis mouse model of human pancreatic cancer was established by intraperitoneal injections of green fluorescent protein-expressing MiaPaca-2 human pancreatic cancer cells into 6-week-old female athymic mice. Two weeks later, mice underwent diagnostic laparoscopy. Laparoscopy was performed first under standard brightfield lighting, followed by fluorescent lighting. The number of metastatic foci identified within the four quadrants of the peritoneal cavity was recorded. After laparoscopy, the animals were sacrificed, opened, and imaged with the OV-100 Small Animal Imaging system as a positive control to identify metastasis. Tumors were collected and processed for histologic review. RESULTS FL enabled visualization of pancreatic cancer metastatic foci not visualized with standard brightfield laparoscopy (BL). Under FL, in 1 representative mouse, 26 separate micrometastatic lesions were identified. In contrast, only very large tumors were seen using BL. Use of the OV-100 images, as positive controls, confirmed the presence of tumor foci. FL thus allowed identification and exact localization of submillimeter tumor foci. Such small-sized tumor foci were not distinguished from surrounding tissue under BL. All malignant lesions were histologically confirmed. CONCLUSIONS The use of FL enables the identification of tumor foci that cannot be seen with standard laparoscopy. The technology described in this report has important potential for the clinical development of FL.
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Affiliation(s)
- Hop S Tran Cao
- Department of Surgery, University of California, San Diego, San Diego, California, USA
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Gillen S, Kleeff J, Kranzfelder M, Shrikhande SV, Friess H, Feussner H. Natural orifice transluminal endoscopic surgery in pancreatic diseases. World J Gastroenterol 2010; 16:3859-64. [PMID: 20712045 PMCID: PMC2923758 DOI: 10.3748/wjg.v16.i31.3859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diagnostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.
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