Multidisciplinary considerations for patients with cancer of the pancreas or biliary tract

Multidisciplinary approach to tumors of the pancreas and biliary tree

Tumors of the pancreas and biliary tree remain formidable challenges to patients and clinicians. These tumors elude early detection, rapidly spread locally and systemically, and frequently recur despite apparently complete resection. Cystic tumors of the pancreas, however, may represent a subset of patients who do not uniformly require aggressive resection, and a thoughtful, evidence-based approach to work-up allows for the rational application of surgical therapy. Increasing evidence supports treating patients who have pancreaticobiliary disease in a multidisciplinary setting.

Gemcitabine and cisplatin for inoperable and/or metastatic biliary tree carcinomas: a multicenter phase II study of the Gruppo Oncologico dell'Italia Meridionale (GOIM)

BACKGROUND

The aim of the study was to test the clinical efficacy and toxicity profile of gemcitabine (GEM) in combination with cisplatin (CDDP) in a series of patients affected by unresectable and/or metastatic biliary tree carcinoma (BTC) previously untreated with chemotherapy.

PATIENTS AND METHODS

Overall 38 consecutive patients who satisfied eligibility criteria (10 with gall-bladder carcinoma and 28 with bile duct carcinoma) were included in this phase II study. Median age was 61 years with median PS 1. Treatment included GEM 1000 mg/m(2)/week as 30 min i.v. on days 1 and 8, and CDDP 75-80 mg/m(2) on day 1 with adequate hydration protocol and forced diuresis. Treatment was repeated every 3 weeks for three cycles before first re-evaluation of disease status.

RESULTS

According to an intent-to-treat analysis a complete response (CR) was achieved in 1 patient (3%) with duration of 8 months. A partial response (PR) was recorded in 11 cases (29%; 95% CI 6% to 48%) with a median duration of 6.4 months (range 5-11 months) for an overall response rate (ORR) of 32%. Stable disease (SD) was seen in eight cases (21%), while the remaining 18 patients showed progressive disease (PD). Tumor growth control rate was 53%. Objective responses were recorded at loco-regional disease, liver and nodal metastases. Lung and peritoneal metastases did not respond. Time-to-progression was 4 months (range 2-11 months) and median overall survival was 8+ months (range 2-15 months). Side-effects were mild with few cases of grade 4 hematological toxicity. Transient and reversible liver toxicity was recorded in nearly one-quarter of patients. Infection without severe grade 4 neutropenia was observed in three cases. In no case was chemotherapy withdrawn for toxicity.

CONCLUSION

The GEM/CDDP regimen is active against advanced and/or metastatic BTC with a favourable toxicity profile. This regimen represents a reasonable therapeutic choice for palliation of advanced BTC. Inferences concerning overall survival are difficult to draw due to the phase II nature of the study.

Traitement de la sténose biliaire par prothèse métallique

A patient presented with a cholangiocarcinoma of the common bile duct; it was initially considered unresectable leading to the placement of the metallic stent whose upper end extended beyond the convergence of the hepatic ducts. The metallic biliary stent became obstructed and so encrusted as to be unremovable; the patient required a left hepatectomy with resection of the stent and the biliary convergence in addition to a pancreatoduodenectomy in order to resect his primary lesion This difficult situation emphasizes that, whenever there is doubt as to the resectability of a biliary lesion, the decision to place a metallic stent should be the fruit of a thorough medico-surgical discussion; where there is any doubt, a plastic stent which is more easily removable should be placed.

Imaging for the diagnosis and staging of periampullary carcinomas

Multiple imaging modalities are available for investigating patients with a suspected periampullary neoplasm. The relative utility of each imaging modality is discussed regarding its role in diagnosis and staging. A general imaging approach to patients with a distal biliary obstruction also is presented.

Gallbladder cancer in northern Jordan

BACKGROUND AND AIM

To highlight the epidemiological, clinical, and pathological features of gallbladder cancer in Jordan as a model for the Middle East. Only scattered reports are available from this region.

METHODS

The histopathological reports and the hospital records for all cholecystectomies performed at Princess Basma Teaching Hospital between 1994-2000 were retrospectively reviewed to identify all patients with gallbladder carcinoma. All the histological slides for the cancer group were reviewed and reclassified by a single pathologist.

RESULTS

Of 4502 cholecystectomies performed, 33 cases (0.73%) of gallbladder carcinoma were found. The mean age was 61.4 years (range 39-80 years). The male : female ratio was 1 : 3.7. Biliary colic and/or acute cholecystitis were the main presentations. Gallstones were present in 88% (29/33) of the patients. The spectrum of histological subtypes was similar to other series. Only three cases were diagnosed preoperatively, making the incidence of incidental gallbladder cancer 0.66% (30/4502). Simple cholecystectomy was performed for 13 patients. The remaining 20 patients underwent cholecystectomy and portal lymphadenectomy with (five cases) or without (15 cases) extrahepatic resection of the bile ducts. The mean follow up was 22 months (SD +/- 18.95 months; range 1-96 months). The 2-year survival rates for stages I, II, III, and IV were 100%, 42.9%, 10.8%, and 0%, respectively (P = 0.0013).

CONCLUSIONS

The importance of a high index of suspicion when dealing with cholelithiasis in elderly patients, particularly with large sized stones, cannot be over-emphasized. Proper gross inspection in the theater should be a routine procedure performed by all surgeons. Routine ultrasound for suspected gallbladder stones should always be performed under the supervision of senior radiologists.