Diagnostic approach to pancreatic cancer

Endoscopic Palliation of Pancreatic Cancer

OPINION STATEMENT

Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.

Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction

AIM

To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS).

METHODS

This was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified.

RESULTS

Among the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications.

CONCLUSION

Limited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

Higher quality of life after metal stent placement compared with plastic stent placement for malignant extrahepatic bile duct obstruction: a randomized controlled trial

OBJECTIVE

For palliation of extrahepatic bile duct obstruction, self-expandable metal stents (SEMS) are superior to plastic stents in terms of stent patency and occurrence of stent dysfunction. We assessed health-related quality of life (HRQoL) after stent placement to investigate whether this also results in a difference in HRQoL between patients treated with a plastic stent or SEMS.

PATIENTS AND METHODS

This randomized multicenter trial included 219 patients who were randomized to receive plastic stent (n=73) or SEMS [uncovered (n=75) and covered (n=71); n=146] placement. HRQoL was assessed with two general questionnaires (EQ-5D-3L and QLQ-C30) and one disease-specific questionnaire (PAN-26). Scores were analyzed using linear mixed model regression and included all patients with baseline and at least one follow-up measurement.

RESULTS

HRQoL data were available in 140 of 219 patients (64%); 71 patients (32%) declined participation and in eight patients (4%) only baseline questionnaires were available. On the QLQ-C30, the interaction between follow-up time and type of stent was significantly different on two of five functional scales [physical functioning (P=0.004) and emotional functioning (P=0.01)] in favor of patients with a SEMS. In addition, patients with SEMS reported significantly less frequent symptoms of fatigue (P=0.01), loss of appetite (P=0.02), and nausea and vomiting (0.04) over time. The EQ-VAS score decreased with time in both treatment groups, indicating a statistically significant decrease in HRQoL over time.

CONCLUSION

In patients with inoperable malignant extrahepatic bile duct obstruction, SEMS placement results in better scores for general and disease-specific HRQoL over time compared with plastic stent placement.

Cost Efficacy of Metal Stents for Palliation of Extrahepatic Bile Duct Obstruction in a Randomized Controlled Trial

BACKGROUND & AIMS

Endoscopic stents are placed for palliation of extrahepatic bile duct obstruction. Although self-expandable metal stents (SEMS) remain patent longer than plastic stents, they are more expensive. We aimed to evaluate which type of stent (plastic, uncovered SEMS [uSEMS], or partially covered SEMS [pcSEMS]) is the most effective and we assessed costs.

METHODS

We performed a multicenter randomized trial in 219 patients at 18 hospitals in The Netherlands from February 2008 through February 2013. Patients were assigned randomly for placement of a plastic stent (n = 73), uSEMS (n = 75), or pcSEMS (n = 71) during endoscopic retrograde cholangiopancreatography. Patients were followed up for up to 1 year. Researchers were not blinded to groups. The main study end points included functional stent time and costs.

RESULTS

The mean functional stent times were 172 days for plastic stents, 288 days for uSEMS, and 299 days for pcSEMS (P < .005 for uSEMS and pcSEMS vs plastic). The initial placement of plastic stents (€1042 or $1106) cost significantly less than placement of SEMS (€1973 or $2094) (P = .001). However, the total cost per patient at the end of the follow-up period did not differ significantly between plastic stents (€7320 or $7770) and SEMS (€6932 or $7356) (P = .61). Furthermore, in patients with short survival times (≤3 mo) or metastatic disease, the total cost per patient did not differ between plastic stents and SEMS. No differences in costs were found between pcSEMS and uSEMS.

CONCLUSIONS

Although placement of SEMS (uncovered or partially covered) for palliation of extrahepatic bile duct obstruction initially is more expensive than placement of plastic stents, SEMS have longer functional time. The total costs after 1 year do not differ significantly with stent type. Dutch Clinical Trial Registration no: NTR1361.

Clinical, laboratory biomarkers and imaging findings of pancreatic adenocarcinoma in Iran

BACKGROUND

Pancreatic cancer has a high mortality rate because it is usually diagnosed late. Since little is known about this cancer in Iran, with the aim of improving this knowledge deficiency, we evaluated clinical, laboratory biomarkers, imaging findings and treatment modalities in Iranian patients with pancreatic adenocarcinoma.

MATERIALS AND METHODS

131 cases of pancreatic adenocarcinoma in 2010-2013 were obtained from the Taleghani Hospital Record Department. Cases confirmed by histopathology from CT-guided biopsy, EUS-FNA and surgery examination were included. We excluded those with incomplete medical records.

RESULTS

The study included 131 subjects between 24 and 97 years of age and a mean age of 63 ± 13.4 years. Eighty (61.1%) were male and 51 (38.9%) female. Previous history included diabetes mellitus in 36 (27.5%), alcohol drinking in 5 (3.9%), smoker in 28 (21.4%) and opium addiction in 13 (10%) . The common presenting history included weight loss in 79 (60.3%), abdominal pain in 77 (58.8%), fever in 11 (8.4%), nausea in 30 (22.9%), jaundice in 72 (55%), pruritus in 52 (39.7) and anemia in 33 (25.2%) . CA19-9 levels with cut offs of 50, 100 and 200 U/ml were increased in 81%, 72% and 66% of patients, respectively. Tumor staging was: stage I, 3 (2.3%); stage II, 10 (7.6%); stage III, 58 (44.3%); and stage IV, 60 (45.8%). From 45 patients, 17 received ERCP inserted metallic stents and 22 plastic stents, the remaining 6 failed that PTC was done. Whipple surgery and chemotherapy were conducted for 10 and 29 patients, respectively.

CONCLUSIONS

This disease affected older people and there was a male preponderance. The commonest risk factors were diabetes mellitus, smoking and cholelithiasis. The majority of patients presented with loss of appetite, loss of weight, jaundice, abdominal pain and discomfort. Almost all presented at late stages of the disease so that curative surgery was impossible. Also chemotherapy was only performed in a few patients as a neoadjuant treatment.

Predictors of malignancy in patients with suspicious or indeterminate cytology on pancreatic endoscopic ultrasound-guided fine-needle aspiration: a multivariate model

OBJECTIVE

The aim of this study was to evaluate predictors of malignancy in pancreatic lesions with suspicious or indeterminate endoscopic ultrasound fine-needle aspiration (EUS-FNA) cytology.

METHODS

Suspicious/indeterminate EUS-FNA cytology was identified from our database. Stable imaging, benign pathology, or survival for 12 months after EUS-FNA was considered benign. Diagnosis of malignancy was based on positive pathology, local invasion/metastasis on imaging, or death within 12 months from cancer-associated causes. Univariate analysis was performed to compare variables between benign and malignant lesions. Multivariate analysis (covariates: age [<70 or ≥70], appearance [solid/cystic], size [<20 or ≥20 mm], and serum CA19-9 [<40 or ≥40]) was performed using binary logistic regression.

RESULTS

There were 81 patients with suspicious or indeterminate cytology. Final diagnosis was cancer in 55 (67.9%) of 81 (adenocarcinoma in 40/81 [49.4%], "other neoplasms" in 15/81 [18.5%]) and benign in 26 (32.1%) of 81. Univariate analysis revealed a difference in age, lesion size, solid/cystic characteristics, and serum CA 19-9 between benign and malignant lesions. Only elevated serum CA 19-9 was independently associated with a diagnosis of malignancy on multivariate analysis.

CONCLUSIONS

Age, lesion size, and solid/cystic characteristics on EUS were not independently associated with cancer. Pancreatic lesions with suspicious/indeterminate cytology and elevated serum CA 19-9 should be considered as concerning for a malignant diagnosis.

Utility of contrast-enhanced FDG-PET/CT in the clinical management of pancreatic cancer: impact on diagnosis, staging, evaluation of treatment response, and detection of recurrence

OBJECTIVES

Fluorodeoxyglucose (FDG)-positron emission tomography/contrast-enhanced computed tomography (PET/CE-CT) involving whole-body scanning first by non-CE-CT and FDG-PET followed by CE-CT has been used for detailed examination of pancreatic lesions. We evaluated PET/CE-CT images with regard to differential diagnosis, staging, treatment response, and postoperative recurrence in pancreatic cancer.

METHODS

Positron emission tomography/CE-CT was conducted in 108 patients with pancreatic cancer and in 41 patients with other pancreatic tumor diseases.

RESULTS

The maximum standardized uptake value (SUV(max)) overlapped in benign and malignant cases, suggesting that differential diagnosis of pancreatic tumors based on the SUV(max) is difficult. In the evaluation of staging in 31 resectable pancreatic cancer by PET/CE-CT, the diagnostic accuracy rate was more than 80% for most factors concerning local invasion and 94% for distant metastasis but only 42% for lymph node metastasis. Significant positive correlations were found between the SUV(max) and tumor size/markers, suggesting that SUV(max) may be a useful indicator for the treatment response. Regarding the diagnosis of the postoperative recurrence, PET/CE-CT correctly detected local recurrence in all the 11 cases of recurrence, whereas abdominal CE-CT detected only 7 of 11 cases, suggesting that PET/CE-CT is superior in this context.

CONCLUSIONS

Positron emission tomography/CE-CT is useful for the clinical management of pancreatic cancer.

Endoscopic sphincterotomy associated cholangitis in patients receiving proximal biliary self-expanding metal stents

BACKGROUND

Endoscopic biliary stent placement during the procedure of endoscopic retrograde cholangiopancreatography (ERCP) is preferred to provide biliary drainage for unresectable malignant biliary obstruction. There is considerable controversy over the use of endoscopic sphincterotomy (ES) prior to stent placement. This study aimed to determine whether ES before intraductal self-expanding metal stent (SEMS) placement affects the clinical outcome and complications in patients with proximal malignant obstructive biliary diseases.

METHODS

In a prospective randomized controlled trial, 82 patients with inoperable malignant biliary strictures were randomly assigned to biliary stenting groups with or without ES. Resolution of jaundice and the incidence of complications including acute cholangitis, pancreatitis and stent occlusion within 6 months were evaluated.

RESULTS

SEMSs were successfully deployed in all patients, resulting in clinical and biochemical improvement of obstructive symptoms in both groups. The incidence of cholangitis was higher in the ES group than in the non-ES group (58.5% vs 31.7%, P=0.015). The interval between stent placement and the first acute cholangitis was much shorter in the ES group than in the non-ES group (P=0.024). The use of ES increased the incidence of cholangitis (P=0.004, risk ratio, 8.196). The rate of post-ERCP pancreatitis after stent placement was greater in the non-ES group than in the ES group (31.7% vs 9.8%, P=0.014). No significant differences were found in the rate of restenosis and the mortality rate between the two groups.

CONCLUSIONS

ES prior to intraductal SEMS placement was associated with an increased incidence of acute cholangitis. ES should be carefully evaluated prior to its use in patients with proximal malignant obstructive biliary diseases.

Pancreatic cancer in Universiti Sains Malaysia Hospital: a retrospective review of years 2001-2008

Pancreatic cancer is usually detected late and has a high mortality rate. Since little is known about this cancer in Malaysia, a review of all cases admitted to Universiti Sains Malaysia Hospital was conducted to identify the epidemiological distribution and assess survival. A list of pancreatic cancer patients in 2001-2008 was obtained from the Hospital Record Department. Only cases confirmed by radio-imaging or histo-pathology examination were included. We excluded those with incomplete medical records. Kaplan-Meier and Cox proportional hazard approaches were used for data analysis. Only 56 cases were included with a mean (SD) age of 49.6 (16.0) years, with 60.7% males and 82.1% of Malay ethnicity. Previous history included cholelithiasis in 23.2%, diabetes mellitus in 16.1%, previous laparotomy in 10.7%, chronic pancreatitis in 7.1%, alcohol drinking in 5.4% and positive family history in 3.6%. The common presenting history included 67.9% loss of appetite, 66.1% loss of weight, 58.9% jaundice and 46.4% abdominal pain. Tumour staging was: 21.5% stage l, 17.8% stage ll, 3.6% stage lll and 57.1% stage lV. The median (95% CI) survival time was 3.4 (0.5, 6.3) months and significant prognostic factors were duration of symptoms (HR 0.97; 95% CI: 0.95, 0.99; p value 0.013), ascites (HR 2.64; 95% CI: 1.28, 5.44; p value 0.008) and Whipple surgery (HR 4.20; 95% CI: 2.27, 7.76; p value <0.001). The history of presenting complaints was short and the majority presented at late stages of the disease, thus the median survival time was very poor.

CT diagnosis of recurrence after pancreatic cancer: Is there a pattern?

AIM: To investigate predilection sites of recurrence of pancreatic cancer by computed tomography (CT) in follow-up after surgery.

METHODS: Seventy seven patients with recurrence after pancreatic cancer surgery were retrospectively identified. The operative technique, R-status, T-stage and development of tumor markers were evaluated. Two radiologists analyzed CT scans with consensus readings. Location of local recurrence, lymph node recurrence and organ metastases were noted. Surgery and progression of findings on follow-up CT were considered as reference standard.

RESULTS: The mean follow-up interval was 3.9 ± 1.8 mo, with a mean relapse-free interval of 12.9 ± 10.4 mo. The predominant site of recurrence was local (65%), followed by lymph node (17%), liver metastasis (11%) and peritoneal carcinosis (7%). Local recurrence emerged at the superior mesenteric artery (n = 28), the hepatic artery (n = 8), in an area defined by the surrounding vessels: celiac trunk, portal vein, inferior vena cava (n = 22), and in a space limited by the mesenteric artery, portal vein and inferior vena cava (n = 17). Lymph node recurrence occurred in the mesenteric root and left lateral to the aorta. Recurrence was confirmed by surgery (n = 22) and follow-up CT (n = 55). Tumor markers [carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA)] increased in accordance with signs of recurrence in most cases (86% CA19-9; 79.2% CEA).

CONCLUSION: Specific changes of local and lymph node recurrence can be found in the course of the cardinal peripancreatic vessels. The superior mesenteric artery is the leading structure for recurrence.

Mortality in patients undergoing covered self-expandable metal stent revisions in malignant biliary stricture: does pathology matter?

BACKGROUND AND AIMS

Partially covered metal stents have been extensively used for palliation of obstructive jaundice in malignant distal biliary strictures and can be removed in cases of malfunction or need for tissue diagnosis. We investigated independent predictors of mortality in patients undergoing partially covered metal stents revision (i.e., removal and replacement).

METHODS

Patients with a distal malignant biliary obstruction palliated with a partially covered metal stent were followed-up prospectively over 5 years until malfunction or death. All patients who required removal of their partially covered metal stents were captured in a specific database. Multivariate analysis was performed on non-surgical patients to assess for independent predictors of death using known risk factors including type of malignancy (adenocarcinoma versus all others), age greater than 55, gender, and exposure to adjuvant chemotherapy and/or radiotherapy.

RESULTS

Forty-two patients (28 men, mean age of 62±12 years) underwent partially covered metal stents removal. Of these, biliary drainage was achieved in 38 patients by placement of a new partially covered metal stent (n=32) or plastic stent (n=6). The remaining 4 patients did not undergo stent replacement because of refusal (2), resolution of obstruction (1) and unrelated death (1). Long-term follow-up post removal in patients who were not surgical candidates (n=31) was 35 weeks (95% CI 28-40), with a survival rate of 29% at 10 months. Logistic regression analysis in the 31 patients with unresectable disease showed that a histologic diagnosis of adenocarcinoma was associated with increased mortality post partially covered metal stents revision.

CONCLUSIONS

Partially covered metal stents revision should be undertaken especially when dealing with a non-adenocarcinoma type cancer.

Bridge to surgery using partially covered self-expandable metal stents (PCMS) in malignant biliary stricture: an acceptable paradigm?

BACKGROUND AND AIM

Partially covered self-expanding metal stents (PCMS) have been extensively used for palliation of malignant distal biliary stricture. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS and subsequently referred for surgery in our institution.

METHODS

Our prospectively established pancreaticobiliary database was retrospectively analyzed to retrieve all patients with malignant biliary stricture who underwent PCMS placement and subsequently went for curative surgical attempt at our institution. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of postoperative hospitalization, and postoperative follow-up were recorded.

RESULTS

27 patients (21 men; median age 66 years, range 39-82 years) received PCMS. Indications for placement included biliary stricture related to pancreatic cancer (n=23) or other malignancies (n=4). Median time between stenting and surgery was 32 days (range 6-569 days). Median time of hospitalization post surgery was 7 days (1-40 days). All patients underwent exploratory laparoscopy, followed in 9 (33.3%) by Whipple procedure with uneventful removal of the PCMS. Eighteen patients (66.6%) had their attempted curative resection terminated early due to intraoperative evidence of metastatic spread, with 8 (30%) patients undergoing peritoneal or liver metastasis biopsy. PCMS were left in place in those 18 patients. Complications related to PCMS in the bridge-to-surgery period included migration (n=2, 7.4%) and tissue overgrowth (n=1, 3.4%), all of them managed by endoscopic removal and replacement with PCMS. Median follow-up post surgery was 210 days (range 9-1,642 days).

CONCLUSION

PCMS are an appropriate BTS option. For resectable patients, PCMS results in biliary drainage and allows for neoadjuvant treatment without portending subsequent curative resection (Whipple). For unresectable patients, long-term biliary drainage is provided by PCMS.

Significance of perivascular soft tissue around the common hepatic and proximal superior mesenteric arteries arising after pancreaticoduodenectomy: evaluation with serial MDCT studies

PURPOSE

To evaluate the interval change of perivascular soft tissue (PVST) around the common hepatic and proximal superior mesenteric arteries arising after pancreaticoduodenectomy (PD) and to compare the difference between post operative change (benign PVST) and recurrence (malignant PVST).

MATERIALS AND METHODS

Serial multidetector CT (MDCT) studies in 44 patients who underwent PD for periampullary carcinomas were retrospectively reviewed (Group A). The incidence and interval change of PVST were evaluated and compared to control group (Group B, 21 patients with PD for benign diseases).

RESULTS

PVST was seen in all the 44 patients in Group A, and it was noted in 12 of 21 (57.1%) patients in Group B. Thirteen of 44 (29.5%) patients showed interval enlargement of PVST (malignant PVST), and 12 of 13 developed within 2 years after PD. There was higher incidence of malignant PVST in patients with lymph node metastasis (p < 0.01) and those with pancreas head carcinoma (p < 0.05).

CONCLUSION

PVST is common after PD regardless of whether patients had malignant or benign diseases. PVST should be monitored for at least 2 years to distinguish recurrence from post operative change. Patients with lymph node metastasis and pancreas head carcinoma had a higher incidence of malignant PVST.

Endoscopic ultrasound guided fine needle aspiration of solid pancreatic lesions: Performance and outcomes

BACKGROUND AND AIM

We report our single-centre experience with endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of solid pancreatic lesions with regard to clinical utility, diagnostic accuracy and safety.

METHODS

We prospectively reviewed data on 100 consecutive EUS-FNA procedures performed in 93 patients (54 men, mean age 60.6 +/- 12.9 years) for evaluation of solid pancreatic lesions. Final diagnosis was based on a composite standard: histologic evidence at surgery, or non-equivocal malignant cytology on FNA and follow-up. The operating characteristics of EUS-FNA were determined.

RESULTS

The location of the lesions was pancreatic head in 73% of cases, the body in 20% and the tail in 7%. Mean lesion size was 35.1 +/- 12.9 mm. The final diagnosis revealed malignancy in 87 cases, including adenocarcinomas (80.5%), neuroendocrine tumours (11.5%), lymphomas (3.4%) and other types (4.6%). The FNA findings were: 82% interpreted as malignant cytology, 1% as suspicious for neoplasia, 1% as atypical, 7% as benign process and 9% as non-diagnostic. No false-positive results were observed. There was a false-negative rate of 5%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 94.3%, 100%, 100%, 72.2% and 95%, respectively. In 23 (88.5%) of 26 aspirated lymph nodes malignancy was found. Minor complications occurred in two patients.

CONCLUSIONS

Our experience confirms that EUS-FNA in patients with suspected solid pancreatic lesions is safe and has a high diagnostic accuracy. This technique should be considered the preferred test when a cytological diagnosis of a pancreatic mass lesion is required.

Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial

BACKGROUND

Most patients with malignant common bile duct strictures are suited only for palliation of jaundice by placement of a polyethylene (PE) stent using an endoscopic retrograde cholangiographic technique. Occlusion of these stents occurs after 3 to 4 months, whereas uncovered self-expanding metal stents (SEMS) remain open twice as long. The initial higher cost of the latter might be balanced by a decreased need for repeat intervention.

OBJECTIVE

To compare the patency of 10F PE stents and covered 30F steel SEMS (Wallstent; Boston Scientific Nordic AB, Helsingborg, Sweden).

DESIGN

Single-center, prospective, randomized, controlled trial.

SETTING

General hospital in Stockholm, Sweden, which has a catchment area of 0.6 million people.

PATIENTS

Non-referred, unresectable malignant common bile duct strictures.

INTERVENTIONS

Endoscopic retrograde cholangiography with plastic stents or covered SEMS.

MAIN OUTCOME MEASUREMENTS

Time to stent failure, requiring a new stent.

LIMITATIONS

Similar setting and patients, and costs in Scandinavia.

RESULTS

Fifty-one and 49 patients were allocated to the PE stent and SEMS groups, respectively. Fifty-six patients died without stent failure within 10 months (median, 2.6 months). Twenty-two PE stent and 9 SEMS patients (P = .009) developed failure after a median of 1.1 and 3.5 months, respectively (P = .007). Median patency times were 1.8 and 3.6 months in the PE and SEMS groups, respectively (P = .002). Median survival was 4.5 months; in 35 patients with distant metastases, the median survival was 2.5 months (P = .002)(PE group, 1.9 months).

CONCLUSIONS

The more-effective SEMS are recommended in unresectable patients with malignant common bile duct strictures, who survive a median of 4.5 months. Less costly plastic stents are preferable in the one third of patients who have distant metastases. In our study, the cost was equal.

Comparison of endoscopic ultrasound and computed tomography for the preoperative evaluation of pancreatic cancer: a systematic review

BACKGROUND & AIMS

It is uncertain whether computed tomography (CT) or endoscopic ultrasound (EUS) is superior for the detection, staging, and resectability of pancreatic cancer. We therefore performed a systematic literature review to determine which test is more accurate.

METHODS

We identified relevant studies from MEDLINE (1986-2004) and evaluated study quality, which was measured on the basis of guidelines for assessing studies of diagnostic tests. Quantitative outcomes data were abstracted from the studies.

RESULTS

Eleven studies with 678 patients satisfied inclusion criteria. Nine studies assessed tumor detection, all of which concluded that the sensitivity of EUS was superior to CT. Four of 5 studies that assessed tumor staging accuracy and 5 of 8 that assessed nodal staging accuracy concluded that EUS was superior to CT. Among the 4 studies that assessed resectability, 2 showed no difference between EUS and CT, and 1 favored each modality. Three of 11 studies met all but one of the quality criteria. The most important and frequent study limitations were lack of a consecutive series of patients and biased patient selection for surgery. Quantitative comparisons among studies were precluded by differences in tumor staging classifications, surgical selection, CT and EUS techniques, and reporting of operating characteristics.

CONCLUSIONS

The published literature comparing EUS and CT for preoperative assessment of pancreatic cancer is heterogeneous in study design, quality, and results. All studies have methodologic limitations that potentially affect validity. Prospective studies with state-of-the-art imaging are needed to further define the role of each test.

¿Cuáles son los principales errors que cometemos los cirujanos en el tratamiento del cáncer de páncreas?

The present review identifies two major conceptual errors. Therapeutic nihilism, which should be discounted in view of the results currently achieved by surgery, and noncentralization, since better results have been demonstrated, both in terms of morbidity and mortality and in survival, in high-volume centers than in low volume centers. The present review also identifies errors in management, the most important of which are: undervaluing the medical record, which is of great utility and continues to be the pillar on which the entire diagnostic process is based; the systematic use of preoperative biliary drainage, which used to be considered mandatory but should be used highly selectively in patients with severe jaundice or biliary tract infections, and viewing preoperative imaging tests as unreliable, when current radiological techniques, particularly helical computed tomography (CT), are highly reliable in establishing tumor resectability and consequently they should be used in all treatment planning. Moreover, because radiological tests are highly reliable, laparoscopic staging has lost diagnostic value; obtaining a preoperative histological diagnosis, which is not mandatory except when neoadjuvant therapy is planned or when tumors requiring nonsurgical treatment are suspected; undervaluing the use of surgical palliation, since this technique provides better long-term results than nonsurgical palliation, and consequently still plays a role in patients with good general health status and prolonged life expectancy; systematically performing gastrojejunostomy with bilio-enteric bypass, as this procedure should only be performed in tumors of the uncus or when there is imminent biliary or gastroduodenal obstruction; the use of supraradical surgical techniques such as regional, total or extensive pancreatectomy, since these techniques do not prolong survival after resection. Furthermore, the use of vascular resections would only be justified if resection with disease-free margins could be performed; undervaluing close postoperative monitoring within specialized units since this is the key to reducing morbidity and mortality rates in this type of surgery; and lastly when an intraoperative pancreatic incidentaloma is present, performing diagnostic maneuvers such as biopsy or pancreatic mobilization, since these procedures hamper subsequent radiological interpretation and possible surgical intervention.

Detection of recurrent pancreatic cancer: comparison of FDG-PET with CT/MRI

OBJECTIVE

To determine the value of fluorine-18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) for the detection of recurrent pancreatic cancer in comparison to computed tomography (CT) and magnetic resonance imaging (MRI).

METHODS

Thirty-one patients with suspected recurrence after surgery were included. Inclusion criteria were sudden weight loss, pain or increased CA 19-9 levels. FDG-PET was performed in all patients. After visual analysis, maximal standardized uptake values (SUVmax) were determined by placing regions of interest on the pancreas bed. Additionally, all patients underwent contrast-enhanced multidetector CT (n = 14) or MR (n = 17) imaging. Positive findings at FDG-PET or CT/MRI were compared to follow-up.

RESULTS

All patients relapsed. Of 25 patients with local recurrences upon follow-up, initial imaging suggested relapse in 23 patients. Of these, FDG-PET detected 96% (22/23) and CT/MRI 39% (9/23). Local SUVmax ranged from 2.26 to 16.9 (mean, 6.06). Among 12 liver metastases, FDG-PET detected 42% (5/12). CT/MRI detected 92% (11/12) correctly. Moreover, 7/9 abdominal lesions were malignant upon follow-up of which FDG-PET detected 7/7 and CT/MR detected none. Additionally, FDG-PET detected extra-abdominal metastases in 2 patients.

CONCLUSION

In patients suspected of pancreatic cancer relapse; FDG-PET reliably detected local recurrences, whereas CT/MRI was more sensitive for the detection of hepatic metastases. Furthermore, FDG-PET proved to be advantageous for the detection of nonlocoregional and extra-abdominal recurrences.

Splenic rupture: a rare presentation of pancreatic carcinoma

CONTEXT

Splenic rupture secondary to solid malignancy is an infrequent complication that usually occurs late in the progression of a previously diagnosed cancer. In rare instances, splenic rupture precipitates the discovery of an unsuspected pancreatic carcinoma. We report 2 cases of adenocarcinoma of the pancreas in which the patients presented with splenic rupture.

OBJECTIVES

To review the clinicopathologic features of splenic rupture due to pancreatic carcinoma and to increase awareness of malignancy as a possible etiology for atraumatic splenic rupture.

DESIGN

We reviewed the clinical and pathologic data from 2 patients. A literature search was conducted to identify previous reports of splenic rupture associated with pancreatic cancer. We summarized the characteristics of the earlier cases and compared them with those of our patients.

RESULTS

We found only 4 previous reports of splenic rupture preceding the diagnosis of pancreatic cancer. In 3 of these cases, the pancreatic carcinoma grossly invaded the spleen at the time of resection. In contrast, malignancy was not suspected as the etiology of the rupture in our patients until histologic examination of the resected spleen revealed carcinoma.

CONCLUSION

Splenic rupture is an unusual presentation of cancer of the pancreas, and to our knowledge only 4 cases have been reported previously in the literature. Although an underlying malignancy is relatively rare, spleens resected for atraumatic rupture should be carefully examined for possible neoplastic etiologies.

Pancreatic neoplasms

Patients who present with signs and symptoms suggesting a pancreatic neoplasm typically undergo initial imaging with transabdominal ultrasound or CT. When a pancreatic mass or fullness is identified, it may represent an inflammatory mass, benign process, or malignancy. Endoscopic ultrasound (EUS) is performed commonly to further characterize the lesion, obtain a tissue diagnosis, and for staging. This article reviews the role of EUS for the diagnosis and staging of pancreatic tumors.

Comparison of ThinPrep and conventional preparations in pancreatic fine-needle aspiration biopsy

Use of ThinPrep preparation for fine-needle aspiration biopsy (FNA) is gaining popularity. However, there may be a difference in the morphology and the operating characteristics between ThinPrep and conventional methods. The objective of this study was to compare the accuracy of the two methods and to address the pitfalls of ThinPrep preparation in pancreatic FNA. A computer search identified 67 pancreatic FNAs with both conventional smears and ThinPrep preparation during a 19-mo period. These cases, obtained under endoscopic ultrasound-guidance, consisted of 47 malignant neoplasms (44 ductal carcinomas, two mucinous neoplasms, and one islet cell tumor) and 20 benign lesions. Direct smears were prepared first and the remaining material was then put into PreservCyt Solution for ThinPrep slides. All slides were reviewed and the cytologic diagnoses were correlated with histologic and clinical follow-up. Five conventional and 16 ThinPrep specimens were unsatisfactory due to insufficient cellularity. These cases were excluded from the analysis. Among the 62 cases evaluated by conventional preparation, 77% (34) were diagnosed as positive and 14% (seven) atypical/suspicious by conventional smears. For the 51 ThinPrep specimens, 58% (22) were interpreted as positive and 31% (12) atypical/suspicious. The sensitivity, specificity, and accuracy of diagnosing a malignancy were 77%, 100%, and 84% for conventional smears and 58%, 100%, and 67% for ThinPrep preparation, respectively. There were no false positives with either method. However, three benign lesions were interpreted as atypical/suspicious with ThinPrep preparation because of the presence of single atypical cells with distinct nucleoli. One of the two mucinous neoplasms was incorrectly diagnosed with ThinPrep preparation because of lack of mucin. The diagnostic accuracy of pancreatic FNA using ThinPrep is inferior to that of conventional smears. This may be partly due to the use of split sample technique resulting in scant cellularity in ThinPrep preparation and partly due to the differences in morphology between the two preparations. Therefore, the current morphologic criteria may need modification for ThinPrep preparation in pancreatic FNA.

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Surgery and cancer of the pancreas: will common sense become common practice?

Pancreatic cancer is a systemic disease for most patients. Operations with the intent to cure may be done safely (mortality, < 3%) with shorter hospital stays. Surgery has been minimally effective as a long-term cure. Endoscopic palliation of jaundice is becoming standard practice. Common sense dictates a defined and clear role for surgery (i.e., strict patient selection criteria). Surgery is of great value for small, localized lesions; of clear value as palliative therapy when nonoperative measures fail; and perhaps best applied after neoadjuvant chemoradiotherapy. Surgery is just part of the armamentarium available to treat pancreatic cancer. Novel systemic therapies, including chemotherapy, immunotherapy, and so-called targeted therapies, are becoming increasingly valuable in the management of this systemic disease and are discussed in detail in other articles in this issue.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Idiopathic acute recurrent pancreatitis

Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.

Pancreatic cancer: the bigger picture

Despite accurate diagnosis, better radiologic techniques, and safer surgery, long-term survival after surgical therapy for pancreatic cancer is disappointing. Median survival following pancreaticoduodenal resection is 12 to 15 months independent of surgical expertise, hospital size, or technical factors. Subsets of favorable tumors and longer survival times after surgery have been defined and include: small tumor size and low-grade lesions, tumor-free margins, and absence of nodal, venous, or perineural invasion; however, long-term survivors of pancreatic cancer may have none of these favorable features, and their tumors commonly manifest the most adverse tumor prognostic features. The converse that small-sized, histologically favorable tumors result in long-term survivors, also is not true. Five-year survival rates average 5% or less after all resections. In a large series in which 118 pancreatic resections were performed in 684 evaluated patients over a 6-year period, there were 12 5-year survivors, 5 of whom died in the sixth year. A report of 10-year survivors after surgery numbered 13 patients. The best actual 5-year survival rate was reported by Trede et al. Of the 37, 5-year survivors from a cohort of 118 patients, more than half died of cancer. This far exceeds any other actual survival rate and may be explained by a smaller tumor size. Farnell et al reported a 5-year survival rate difference (i.e., actuarial survival) in a subset of 174 resected patients with adenocarcinoma without perineural or duodenal invasion and with negative nodes (23% versus 6.8%), respectively. An impressive, large series of 616 patients with resected adenocarcinoma of the pancreas who underwent PDR (85%), distal pancreatectomy (9%), and total pancreatectomy (6%), has been reported. The mortality rate was 2.1%, and postoperative complications occurred in 30%. The five-year survival rate was 15%. The author's best result was observed among 20 initially "unresectable" patients who were treated with chemoradiation therapy, followed by tumor extirpation. Among the 18 surgical survivors there are seven five-year survivors, three of whom are in their tenth year of survival. They are discussed in the article by Cooperman et al ("Long-term Follow-up...") elsewhere in this issue.