A clinical algorithm for the assessment of pancreatic lesions: utilization of 16- and 64-section multidetector CT and endoscopic ultrasound

Endoscopic ultrasound (EUS) and the management of pancreatic cancer

Pancreatic cancer is one of the leading causes of cancer-related mortality in western countries. Early diagnosis of pancreatic cancers plays a key role in the management by identification of patients who are surgical candidates. The advancement in the radiological imaging and interventional endoscopy (including endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography and endoscopic enteral stenting techniques) has a significant impact in the diagnostic evaluation, staging and treatment of pancreatic cancer. The multidisciplinary involvement of radiology, gastroenterology, medical oncology and surgical oncology is central to the management of patients with pancreatic cancers. This review aims to highlight the diagnostic and therapeutic role of EUS in the management of patients with pancreatic malignancy, especially pancreatic ductal adenocarcinoma.

Comparative analysis and assessment of diagnostic accuracy of 256 slice CT and endoscopic ultrasound in evaluation of pancreatic masses

CONTEXT

Pancreatic masses are routinely encountered on imaging and often present as a diagnostic dilemma. These masses range from benign inflammatory masses, requiring no intervention to malignant masses, which carry grave prognosis and hence require aggressive management.

AIMS

Compare the diagnostic accuracy of 256 multislice CT and endoscopic ultrasound (EUS) in characterization and assessment of resectability of pancreatic masses and compare the multidetector computed tomography (MDCT) and EUS findings with histopathological findings.

SETTINGS AND DESIGN

Prospective study.

SUBJECTS AND METHODS

36 patients with pancreatic masses were included who underwent dual phase CT using pancreatic protocol and EUS using 5-13 MHz transducer. Fine needle aspiration cytology (FNAC) was done wherever feasible. Parameters regarding tumor size, location, imaging morphology, and vessel involvement were recorded. Findings were compared with histopathological/operative diagnosis/clinical follow-up.

STATISTICAL ANALYSIS USED

Descriptive statistics with percentages and proportions and Chi-square test.

RESULTS

Multidetector computed tomography (MDCT) and EUS established diagnosis consistent with tissue diagnosis in 30 (83%) and 22 (61%) patients, respectively. However, the best results were obtained with the combined use of MDCT and EUS. The number of patients categorized as inconclusive by MDCT were lower compared to EUS. Assessing resectability for pancreatic adenocarcinoma, MDCT showed specificity and positive predictive value (PPV) of 100% compared to EUS, which had specificity and PPV of 75% and 92.3%, respectively. MDCT is the first-line imaging modality in detection, characterization of pancreatic masses, and assessment of resectability in malignant neoplasms. EUS is beneficial in the detection of masses <2 cm in size causing pancreatic contour deformity on CT, for guiding FNAC. MDCT and EUS with EUS-guided FNA are complementary not competitive tools in preoperative imaging of pancreatic masses.

PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer

BACKGROUND

Pancreatic cancer diagnosis and staging can be difficult in 10-20% of patients. Positron emission tomography (PET)/computed tomography (CT) adds precise anatomical localisation to functional data. The use of PET/CT may add further value to the diagnosis and staging of pancreatic cancer.

OBJECTIVE

To determine the incremental diagnostic accuracy and impact of PET/CT in addition to standard diagnostic work-up in patients with suspected pancreatic cancer.

DESIGN

A multicentre prospective diagnostic accuracy and clinical value study of PET/CT in suspected pancreatic malignancy.

PARTICIPANTS

Patients with suspected pancreatic malignancy.

INTERVENTIONS

All patients to undergo PET/CT following standard diagnostic work-up.

MAIN OUTCOME MEASURES

The primary outcome was the incremental diagnostic value of PET/CT in addition to standard diagnostic work-up with multidetector computed tomography (MDCT). Secondary outcomes were (1) changes in patients' diagnosis, staging and management as a result of PET/CT; (2) changes in the costs and effectiveness of patient management as a result of PET/CT; (3) the incremental diagnostic value of PET/CT in chronic pancreatitis; (4) the identification of groups of patients who would benefit most from PET/CT; and (5) the incremental diagnostic value of PET/CT in other pancreatic tumours.

RESULTS

Between 2011 and 2013, 589 patients with suspected pancreatic cancer underwent MDCT and PET/CT, with 550 patients having complete data and in-range PET/CT. Sensitivity and specificity for the diagnosis of pancreatic cancer were 88.5% and 70.6%, respectively, for MDCT and 92.7% and 75.8%, respectively, for PET/CT. The maximum standardised uptake value (SUVmax.) for a pancreatic cancer diagnosis was 7.5. PET/CT demonstrated a significant improvement in relative sensitivity (p = 0.01) and specificity (p = 0.023) compared with MDCT. Incremental likelihood ratios demonstrated that PET/CT significantly improved diagnostic accuracy in all scenarios (p < 0.0002). PET/CT correctly changed the staging of pancreatic cancer in 56 patients (p = 0.001). PET/CT influenced management in 250 (45%) patients. PET/CT stopped resection in 58 (20%) patients who were due to have surgery. The benefit of PET/CT was limited in patients with chronic pancreatitis or other pancreatic tumours. PET/CT was associated with a gain in quality-adjusted life-years of 0.0157 (95% confidence interval -0.0101 to 0.0430). In the base-case model PET/CT was seen to dominate MDCT alone and is thus highly likely to be cost-effective for the UK NHS. PET/CT was seen to be most cost-effective for the subgroup of patients with suspected pancreatic cancer who were thought to be resectable.

CONCLUSION

PET/CT provided a significant incremental diagnostic benefit in the diagnosis of pancreatic cancer and significantly influenced the staging and management of patients. PET/CT had limited utility in chronic pancreatitis and other pancreatic tumours. PET/CT is likely to be cost-effective at current reimbursement rates for PET/CT to the UK NHS. This was not a randomised controlled trial and therefore we do not have any information from patients who would have undergone MDCT only for comparison. In addition, there were issues in estimating costs for PET/CT. Future work should evaluate the role of PET/CT in intraductal papillary mucinous neoplasm and prognosis and response to therapy in patients with pancreatic cancer.

STUDY REGISTRATION

Current Controlled Trials ISRCTN73852054 and UKCRN 8166.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Power Doppler endoscopic ultrasound for the assessment of pancreatic neuroendocrine tumors

OBJECTIVE

Pancreatic neuroendocrine tumors (PNET) represent rare, heterogeneous tumors with clinical, imaging and treatment particularities. The aim of this study was to assess the role of power Doppler endoscopic ultrasound (EUS) in the diagnosis and characterization of PNET.

METHODS

All consecutive patients with PNET assessed by power Doppler EUS in the Research Centre of Gastroenterology and Hepatology Craiova, Romania, in the past 51 months were included in the study. All EUS examinations were performed initially in gray-scale mode, followed by power Doppler mode examinations, before and after contrast-enhancement. Each recorded EUS movie was further subjected to post-processing using a computer-enhanced dynamic analysis using a special plug-in which permitted assessment of vascularity index (EUS-VI).

RESULTS

Based on the analysis of all consecutive malignant focal pancreatic masses diagnosed in the study period, a total number of 131 consecutive patients were included: 14 patients with pancreatic neuroendocrine tumors and 117 patients with pancreatic adenocarcinoma. The sensitivity of the pre-contrast EUS-VI for the diagnosis of PNET was 71.43%, similar to EUS-FNA. After contrast enhancement, the EUS-VI is also higher in PNET (27.07%) as compared to pancreatic adenocarcinoma where it was significantly lower 9.82% (P < 0.001). However, the sensitivity of EUS-VI after contrast enhancement for the diagnosis of PNET was 100%, higher than pre-contrast EUS-VI, with an acceptable specificity (79.49%) and better accuracy (81.68%).

CONCLUSION

Power Doppler EUS represents a useful method in the initial assessment of PNET. Using evaluation of vascularity through EUS-VI, the differentiation between PNET and pancreatic cancer could be possible, especially in the subgroup of patients where EUS-guided fine needle aspiration is falsely negative.

Preoperative differentiation between T1a and ≥T1b gallbladder cancer: combined interpretation of high-resolution ultrasound and multidetector-row computed tomography

OBJECTIVES

To determine the diagnostic value of combined interpretation of high-resolution ultrasound (HRUS) and multidetector-row computed tomography (MDCT) for preoperative differentiation between T1a and ≥T1b gallbladder (GB) cancer.

METHODS

Eighty-seven patients with pathologically confirmed GB cancers (T1a, n = 15; ≥T1b, n = 72), who preoperatively underwent both HRUS and MDCT, were included in this retrospective study. Two reviewers independently determined the T-stages of the GB cancers on HRUS and MDCT using a five-point confidence scale (5, definitely T1a; 1, definitely ≥T1b). For individual modality interpretation, the lesions with scores ≥4 were classified as T1a, and, for combined modality interpretation, the lesions with all scores ≥4 in both modalities were classified as T1a. The McNemar test was used to compare diagnostic performance.

RESULTS

The diagnostic accuracy of differentiation between T1a and ≥T1b GB cancer was higher using combined interpretation (90.8% and 88.5% for reviewers 1 and 2, respectively) than individual interpretation of HRUS (82.8% and 83.9%) or MDCT (74.7% and 82.8%) (P < 0.05, reviewer 1). Combined interpretations demonstrated 100% specificity for both reviewers, which was significantly higher than individual interpretations (P < 0.05, both reviewers).

CONCLUSIONS

Combined HRUS and MDCT interpretation may improve the diagnostic accuracy and specificity for differentiating between T1a and ≥T1b GB cancers.

KEY POINTS

• Differentiating between T1a and ≥T1b gallbladder cancer can help surgical planning. • HRUS and MDCT are useful for local staging of gallbladder cancer. • HRUS and MDCT may be synergistic for T-staging of gallbladder cancer.

A review of pancreatic cyst fluid analysis in the differential diagnosis of pancreatic cyst lesions

Diagnosis and management of pancreatic cyst lesions is challenging as there is currently no investigation that offers both high diagnostic sensitivity and high specificity for the identification of potentially malignant lesions. Accurate classification of these lesions is vital in order to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of lesions that are malignant/pre-malignant. Pancreatic cyst fluid analysis has an important role in diagnosis, although all currently available investigations based on fluid analysis have significant limitations. Cytological analysis can reveal features that are specific for a certain class of cyst, but offers limited sensitivity in detecting malignant/pre-malignant cysts. Measurement of tumour markers, particularly carcinoembryonic antigen can also be informative. Concentrations of cyst fluid carcinoembryonic antigen tend to be higher in malignant/pre-malignant cysts, although there is a wide overlap between the various classes of cyst. A number of studies have suggested that diagnostic carcinoembryonic antigen cut-offs can be chosen that provide a high degree of specificity but limited sensitivity. Studies of the analytical validity of tumour marker assays in pancreatic cyst fluid analysis have highlighted discrepancies in some fluid specimens, which require further investigation. DNA analysis also has a role. In particular, K-Ras-2 mutational analysis appears to provide high specificity for detection of malignant/pre-malignant lesions. A number of diagnostic algorithms have been published, integrating use of available investigations in order to achieve the optimum discrimination of benign and potentially malignant cysts. Research into new biochemical markers and optimal use of available pancreatic cyst fluid analyses is ongoing.

Current status on the diagnosis and evaluation of pancreatic tumor in Asia with particular emphasis on the role of endoscopic ultrasound

In Asia, the incidence of pancreatic cancer in some countries has been increasing. Owing to most cases being diagnosed late, prognosis for pancreatic cancer remains dismal. It is clear that the future for pancreatic cancer lies in early detection. While the possible presence of pancreatic masses is often first raised by non-invasive abdominal imaging, such as computerized tomography and magnetic resonance imaging, smaller lesions and locoregional lymph node metastases are often not detectable by these means. Endoscopic ultrasonography (EUS) offers a higher sensitivity (93-100%) for detection of small potentially curable pancreatic masses than other existing imaging modalities. It is also recommended for the evaluation of portal vein confluence, portal vein, celiac axis, and superior mesentric artery origin, and exclusion of resectability. Due to the closer proximity of EUS to the target structure, and lower rate of needle tract seeding, EUS-guided fine-needle aspiration of pancreatic mass is considered the most suitable tissue acquisition technique. Lastly, EUS also enables the performance of endoscopic interventions. Its performance can be further enhanced with newer techniques, including contrast-enhanced ultrasound and elastrography. It is anticipated that in the near future, molecular technologies may make it possible to detect microscopic amounts of cancer in tissue or blood, predict relapse and survival after therapy, as well as determine optimal therapy.

The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease

Pancreatic and biliary disease continues to have a significant impact on the workload of the National Health Service (NHS), for which there exists a multimodality approach to investigation and diagnosis. Endoscopic ultrasound (EUS) is fast becoming a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but also because of its valuable role as a problem-solving tool and ever-improving ability in an interventional capacity. We provide a comprehensive review of the benefits of EUS in everyday clinical practice.

Imaging investigation of pancreatic cystic lesions and proposal for therapeutic guidelines

AIM: To propose a diagnostic algorithm for preoperatively predicting the need for surgical intervention.

METHODS: The study included 56 patients (27 men and 29 women) with a final diagnosis of cystic pancreatic lesions. The following materials were used: ultrasonic equipment with 3.5 and 7 MHz linear, convex and biopsical transducers. Multidetector computed tomography (MDCT) investigations were performed using a 16-slice scanner. Images were obtained following the oral administration of 200 mL water and 100 mL intravenous iopamidol (300 mg/mL) administered by pump injector at a rate of 3 mL/s (40 and 60 s post-injection, respectively) using 0.5 mm detectors, reconstructed at 1 mm (pancreatic phase) or 2 mm (portal venous phase) increments. The table feed was 10 mm per rotation. Images were acquired in the pancreatic and portal venous phases of contrast enhancement. The “Chiba” needles 18, 20, 22, 23 G and an automatic aspiration system were used in conjunction with the following methods of guiding the interventional procedures: (1)“free-hand” biopsy and puncture method under ultrasound (US) or computed tomography (CT) control; (2) guiding method using biopsical transducer.

RESULTS: All 56 patients in this study underwent at least two cuts imaging survey methods, such as US, CT or magnetic resonance imaging (MRI). The most common preoperative diagnostic examination was US scan - 56 patients (100%). MDCT studies were conducted in 49 (87.50%) and MRI in 13 (23.21%). More than half of patients surveyed (37) underwent some type of interventional procedure: 25-fine-needle aspiration and 29-fine needle aspiration biopsy (FNAB), as part of the examination. Thirty-four patients of all 56 patients underwent surgery because of histological evidence of malignancy after the FNAB for cystic lesions of the pancreas. Distal pancreatectomy with splenectomy was the most common operative approach in 13 patients, followed by Whipple resection in 11 and distal pancreatectomy without splenectomy in 7. Three patients were treated with total pancreatectomy due to the presence of a multifocal mucinous neoplasm. Comparing the diagnostic results of US examination with those of MDCT examination and histological verification true positive results were found in 31 patients, true negative in 11 patients, false positive in 5 and false negative in 9 patients. Accordingly we estimated the power of the diagnostic imaging methods for cystic lesions of the pancreas. A specificity of 68.75%, sensitivity of 79.48%, accuracy of 75.00%, positive predictive value of 86.11% and negative predictive value of 55% were obtained. The power increased after applying invasive procedures with immunohistochemical analysis of CEA and P-53 (Fig. 4). In 15 patients with cytological feature of malignant tumour cells, the tumour markers were positive. In our opinion the higher the percentage of reacting cells the higher the percent of malignancy. In patients with clear symptoms and/or clear imaging features of malignant or premalignant cystic neoplasm, the need for surgery was confirmed by histological verification in 34 (60.71%) of cases.

CONCLUSION: By using the proposed algorithm, cystic mucinous tumors of the pancreas were detected and proper operative interventions would have been rendered with fewer diagnostic examinations.

Direct histological processing of EUS biopsies enables rapid molecular biomarker analysis for interventional pancreatic cancer trials

OBJECTIVE

Current practice to diagnose pancreatic cancer is accomplished by endoscopic ultrasound guided fine needle aspiration (EUS-FNA) using a cytological approach. This method is time consuming and often fails to provide suitable specimens for modern molecular analyses. Here, we compare the cytological approach with direct formalin fixation of pancreatic EUS-FNA micro-cores and evaluate the potential to perform molecular biomarker analysis on these specimen.

METHODS

130 specimens obtained by EUS-FNA with a 22G needle were processed by the standard cytological approach and compared to a separate cohort of 130 specimens that were immediately formalin fixed to preserve micro-cores of tissue prior to routine histological processing.

RESULTS

We found that direct formalin fixation significantly shortened the time required for diagnosis from 3.6 days to 2.9 days (p<0.05) by reducing the average time (140 vs 33 min/case) and number of slides (9.65 vs 4.67 slides/case) for histopathological processing. Specificity and sensitivity yielded comparable results between the two approaches (82.3% vs 77% and 90.9% vs 100%). Importantly, EUS-FNA histology preserved the tumour tissue architecture with neoplastic glands embedded in stroma in 67.89% of diagnostic cases compared to 27.55% with the standard cytological approach (p < 0.001). Furthermore, micro-core samples were suitable for molecular studies including the immunohistochemical detection of intranuclear Hes1 in malignant cells, and the laser-capture microdissection-mediated measurement of Gli-1 mRNA in tumour stromal myofibroblasts.

CONCLUSIONS

Direct formalin fixation of pancreatic EUS-FNA micro-cores demonstrates superiority regarding diagnostic delay, costs, and specimen suitability for molecular studies. We advocate this approach for future investigational trials in pancreatic cancer patients.

A multidisciplinary survey on controversies in the use of EUS-guided FNA: assessing perspectives of surgeons, oncologists and gastroenterologists

BACKGROUND

EUS-guided FNA can help diagnose and differentiate between various pancreatic and other lesions.The aim of this study was to compare approaches among involved/relevant physicians to the controversies surrounding the use of FNA in EUS.

METHODS

A five-case survey was developed, piloted, and validated. It was collected from a total of 101 physicians, who were all either gastroenterologists (GIs), surgeons or oncologists. The survey compared the management strategies chosen by members of these relevant disciplines regarding EUS-guided FNA.

RESULTS

For CT operable T2NOM0 pancreatic tumors the research demonstrated variance as to whether to undertake EUS-guided FNA, at p < 0.05. For inoperable pancreatic tumors 66.7% of oncologists, 62.2% of surgeons and 79.1% of GIs opted for FNA (p < 0.05). For cystic pancreatic lesions, oncologists were more likely to send patients to surgery without FNA. For stable simple pancreatic cysts (23 mm), most physicians (66.67%) did not recommend FNA. For a submucosal gastric 19 mm lesion, 63.2% of surgeons recommended FNA, vs. 90.0% of oncologists (p < 0.05).

CONCLUSIONS

Controversies as to ideal application of EUS-FNA persist. Optimal guidelines should reflect the needs and concerns of the multidisciplinary team who treat patients who need EUS-FNA. Multi-specialty meetings assembled to manage patients with these disorders may be enlightening and may help develop consensus.

Cystic pancreatic lesions: current evidence for diagnosis and treatment

Pancreatic cystic neoplasms are detected at an increasing frequency due to an increased use and quality of abdominal imaging. There are well known differential diagnostic difficulties concerning these lesions. The aim is to review current literature on the diagnostic options and the following treatment for cystic lesions in the pancreas focusing on serous cystadenomas, primary mucinous neoplasm of the pancreas and mucinous cystadenocarcinomas, as well as intraductal papillary mucinous neoplasms, starting with excluding pseudocysts. A conservative approach is feasible in patients with a clinical presentation suggestive of an asymptomatic serous cystadenoma. Surgical management, as well as follow-up, is discussed for each of the types of neoplastic lesions, including an uncharacterized cyst, based on patient data, symptoms, serum analysis, cyst fluid analysis and morphological features. Aspects for future diagnostics and management of these neoplasia are commented upon.

Endoscopic ultrasound in the assessment of solid and cystic pancreatic lesions

Pancreatic masses can be solid or cystic, benign or malignant. Rapid and accurate diagnosis is essential for optimal management. Clinical presentation and radiological appearance are often inadequate for a definitive diagnosis. Endoscopic ultrasound allows more detailed assessment of the pancreas than traditional imaging techniques.

Relative accuracy of CT and MRI in the differentiation of benign from malignant pancreatic cystic lesions

AIMS

To assess the diagnostic accuracies of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) for differentiating benign from malignant lesions and suggesting the specific diagnoses for pancreatic cystic lesions, and to assess whether review of both MDCT and MRI is beneficial.

MATERIALS AND METHODS

Patients with various neoplastic and non-neoplastic pancreatic cystic lesions that were identifiable by biopsy or surgery, who underwent both MRI and MDCT (n=63), were retrospectively reviewed by three reviewers. The likelihood of malignancy was recorded on a five-point scale, and a specific diagnosis was given. ROC analysis was performed and the sensitivity, specificity for the characterization of malignancy, and the accuracy of specific diagnoses were calculated.

RESULTS

MDCT and MRI yielded comparable results for the characterization of malignancy (Az: 0.639, 0.735, 0.806 for MDCT and 0.732, 0.753, 0.792 for MRI, for each reviewer). The accuracies of specific diagnosis based on MDCT or MRI were 61.9 versus 55.6% for reviewer 1; 76.2 versus 76.2% for reviewer 2; and 65.1 versus 61.9% for reviewer 3. There was a trend toward better prediction of malignancy (Az: 0.787, 0.745, 0.849 for each reviewer), and better accuracy in suggesting a specific diagnosis (77.8, 73, and 73% for each reviewer) for MDCT+MRI over MDCT or MRI alone, although it was statistically significant for one reviewer in the comparison of MDCT versus MDCT+MRI for the prediction of malignancy, and MRI versus MDCT for suggesting a specific diagnosis.

CONCLUSIONS

MDCT and MRI have equivalent accuracy for characterizing pancreatic cystic lesions as benign or malignant, and suggesting a specific diagnosis. Combined review of MDCT and MRI was not significantly better but may have the potential to improve diagnostic accuracy in equivocal cases.

Comparison of MRI and endoscopic ultrasound in the characterization of pancreatic cystic lesions

OBJECTIVE

The purpose of this study was to compare the diagnostic performance of MRI and endoscopic ultrasound (EUS) for the characterization of cystic pancreatic lesions and prediction of malignancy.

MATERIALS AND METHODS

Fifty patients (24 women and 26 men; average age, 57 years) underwent both MRI and EUS. All pancreatic lesions (21 cystic and 29 solid lesions) were proven by histopathologic analysis. Two radiologists retrospectively examined MR images, and a single gastroenterologist reviewed EUS images. The MRI and EUS characterizations of morphologic features of the cystic lesions and predictions of malignancy were evaluated. The prediction of malignancy was done by receiver operating characteristic (ROC) curve analysis.

RESULTS

There was no difference between the ability of MRI and EUS to correctly classify lesions as cystic or solid (accuracy, 90-98% vs 88%; p > 0.05). There was no difference between the sensitivity of MRI and EUS for the characterization of septa (94.4% for MRI vs 77.8% for EUS), mural nodule (66.7-58.3% for MRI vs 58.3% for EUS), main pancreatic duct dilatation (92.9-85.7% for MRI vs 85.7% for EUS), and communication with main pancreatic duct (100% for MRI vs 88.9% for EUS). The area under ROC curve values for predicting malignancy showed no statistical significance (0.755-0.774 for MRI vs 0.769 for EUS; p > 0.894).

CONCLUSION

MRI and EUS are comparable in the characterization of cystic pancreatic lesions and prediction of malignancy.

Quality improvement for pancreatic cancer care: is regionalization a feasible and effective mechanism?

Variability exists in the quality of pancreatic cancer care provided in the United States. High-volume centers have been shown to have improved outcomes for pancreatectomy. Regionalization of pancreatic cancer care to high-volume centers has the potential to improve care and outcomes. Practical limitations such as overloading currently available high-volume centers, extending patient travel times, sharing patients within a multipayer health system, and incorporating patient preferences must be addressed for regionalization to become a reality. The benefits and limitations of regionalization of pancreatic cancer care are discussed in this review. To improve the overall quality of pancreatic cancer care at all hospitals in the United States, a combination of referral of patients with pancreatic cancer to high- and moderate-volume hospitals in conjunction with specific quality-improvement efforts at those institutions is proposed.

Pancreatic cancer: incidence, treatment and survival trends--1175 cases in Calvados (France) from 1978 to 2002

AIM

To assess the trends in incidence, therapeutic modalities and survival of pancreatic cancer between 1978 and 2002 in a well-defined population, as recorded in the Calvados digestive cancer registry database.

PATIENTS AND METHODS

All patients living in Calvados with a diagnosis of pancreatic cancer were registered. Clinical data and treatment modalities were prospectively recorded. This 25-year database was divided into five 5-year periods. Data were compared using log-rank tests and the Cox model.

RESULTS

A total of 1175 cases of pancreatic cancer (617 men, 558 women) were registered. Its incidence increased with an average annual coefficient of +2.8% in men and +5.1% in women. Therapeutic modalities changed over the five time periods: surgical resection increased from 6.8 to 13.4% (median survival 15 months) while radiation therapy and/or chemotherapy also increased from 5.5 to 13.2%. Palliative surgery decreased from 54.6 to 32.0% and favored interventional endoscopic techniques. Postoperative mortality decreased significantly. Survival increased significantly over the five time periods, although the median survival time remained stable (4 months).

CONCLUSION

From 1978 to 2002, pancreatic cancer incidence increased in Calvados (France). Therapeutic modalities changed, with endoscopic treatments preferred over palliative surgery. The improvement in survival could be explained by the decrease in postoperative mortality.