Pancreatic cancer in 1988. Possibilities and probabilities

Prognostic value of carcinoembryonic antigen and carbohydrate antigen 19-9 in periampullary cancer patients receiving pancreaticoduodenectomy

BACKGROUND

We assessed the use of serum concentrations of carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) measured during the preoperative diagnostic workup as prognostic factors for survival in patients with periampullary carcinoma.

METHODS

A retrospective review of patients diagnosed with periampullary carcinoma who underwent radical surgery was conducted. Factors related to the survival of periampullary carcinoma patients, including CA 19-9 and CEA, were analyzed.

RESULTS

The mean age of the 112 patients included in the results was 66.41 ± 10.513 years. In the study, the percentage of patients with elevated serum CA 19-9 and CEA concentrations was 65.2% and 24.1%, respectively. CA 19-9 concentrations were correlated with the tumor stage, pre-operative jaundice, and lymphovascular invasion, but CEA concentrations were not. The median overall survival was longer for the normal serum CA 19-9 group than the group with increased CA 19-9 (56 months vs. 25 months, p = 0.003); however, there was no statistically significant difference between the normal serum CEA group and the group with increased CEA (43 months vs. 25 months, p = 0.077). Independent factors related to overall survival were sex, age, stage, presence of jaundice, lymphovascular invasion, perineural invasion, margin status, and elevated serum CA 19-9 concentrations.

CONCLUSIONS

Periampullary carcinoma patients with elevated serum CA 19-9 concentrations at diagnosis are expected to have poor overall survival. CA 19-9 may be a useful marker for predicting prognosis in patients with periampullary carcinoma at the time of diagnosis.

Closed Loop Duodenal Obstruction Secondary to Pancreatic Carcinoma: A Case Report

BACKGROUND

Patients with pancreatic adenocarcinoma may develop into duodenal obstruction during the course of their disease. The diagnosis of obstruction can be generally achieved by means of imaging technologies.

Case and Outcome

We reported a rare case of pancreatic tumor with duodenal obstruction accompanied by obstructive symptoms, which was finally confirmed by laparotomy. A 68-year-old man was admitted to our department with a 3-day medical history of upper abdominal pain, nausea and vomiting. The diagnosis of duodenal obstruction was established by means of various imagings including computed tomography (CT) scan, gastroscopy and upper gastrointestinal imaging. Upper gastrointestinal imaging and magnetic resonance imaging (MRI) showed extrinsic tumor mass was noted at the second and third portion of the duodenum accompanied by duodenal obstruction and dilatation, respectively. Laparotomy confirmed a tumor mass arising from the head and uncinate process of pancreas, which had invaded the second and third portions of the duodenum and caused closed loop obstruction. A pancreaticoduodenectomy (Whipple procedure) was performed followed by therapeutic trade-off according to intraoperative exploration. Postoperative histopathology revealed pancreatic tumor only infiltrated duodenal wall, while resection margins of pancreas, common bile duct and duodenum were all negative. The patient was cured and discharged home 12 days after surgery.

CONCLUSION

The present case indicated radical operation in our study appeared to be the first choice treatment for patients with malignant duodenal obstruction.

The Role of Intraoperative Therapy by Electron Beam and Combination of Adjuvant Chemotherapy and External Radiotherapy in Carcinoma of the Pancreas

Aims and background

In the treatment of pancreatic carcinomas, one modality is intraoperative radiotherapy (IORT). A study was carried out to assess the feasibility of IORT alone or in a multimodality approach with postoperative adjuvant chemotherapy and external radiotherapy and to compare local control and survival of patients. Another objective of this retrospective study was to verify prognostic factors in resected patients treated with IORT.

Methods

From January 1985 through September 1992, 54 adenocarcinomas of the pancreas (unresectable and resected patients) were treated with IORT by electron beam at the San Raffaele Hospital and then analyzed. Comparison was also carried out between IORT-treated resected patients and a non-randomized control group of resected patients treated without IORT in the same period.

Results

In unresectable patients treated by laparotomy bypass and IORT, overall median survival was 6 months and 8 months in non-metastatic patients. Relief of severe pain present in 14 patients was observed in 85% within 12 days of IORT. As regards resected patients, the most important finding was that significantly better local control resulted from IORT. In fact, overall, local relapses were 25% in the IORT group and 55.8% in the non-IORT group (control group); instead, survival of the IORT group was not significantly longer than that of the control group. From a statistical analysis of resected patients treated with IORT and performed on prognostic factors on the basis of available data, survival was significantly influenced by tumor pathologic grading and diameter; postoperative adjuvant therapy was not a significant prognosis factor.

Conclusions

IORT has a role in local control of unresectable pancreatic carcinomas and in control of resultant severe pain. In resected patients, IORT is effective in decreasing local recurrences but has little impact on survival. To obtain more satisfactory results, new and more effective adjuvant therapies and better abdominal prophylaxis should be tested.

Efficacy of the prophylactic use of octreotide for the prevention of complications after pancreatic resection: An updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The use of octreotide prophylaxis in the prevention of complications after pancreatic resection remains controversial. The aim of this systematic review and meta-analysis was to evaluate the efficacy of octreotide prophylactic treatment to prevent complications after pancreatic resection.

METHODS

Five databases (PubMed, Medline, SinoMed, Embase, and Cochrane Library) were searched for eligible studies from 1980 to November 2016 with the limitation of human subjects and randomized controlled trials (RCTs). Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (Cochrane Collaboration, http://tech.cochrane.org/revman/download). Weighted mean differences (WMDs), risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration risk of bias tool was used to assess the risk of bias.

RESULTS

Twelve RCTs comprising 1902 patients were identified as eligible. The methodological quality of the trials ranged from low to moderate. A pooled analysis of effectiveness based on the data from each study revealed that octreotide could significantly reduce the rate of pancreatic fistula (PF) after pancreatic resection (RR = 0.75, 95% CI = 0.57-0.98, P = .04). The same findings were discovered in multicenter and European subgroups with a subgroup analysis; no obvious differences were noted in American, Asian, and single-center subgroup analyses. An equal effect was observed between the use or non-use of octreotide groups regarding mortality (RR = 1.24, 95% CI = 0.77-2.02, P = .38). Octreotide had no advantages in regards to mortality improvement. The total numbers of complications associated with the use or non-use of octreotide were similar (RR = 0.77, 95% CI = 0.58-1.03, P = .08). Among the high-risk group, octreotide was more effective in reducing complications (RR = 0.61, 95% CI = 0.46-0.82, P = .0009). Compared with the patients who did not receive prophylactic treatment, the patients who underwent pancreatic resection benefited from octreotide because it had better efficacy in preventing fluid collection and postoperative pancreatitis.

CONCLUSION

The prophylactic use of octreotide is suitable for preventing postoperative complications, especially PF and fluid collection as well as postoperative pancreatitis. However, no obvious differences were noted regarding mortality. In view of the clinical heterogeneity and varying definitions of PF, whether these conclusions are broadly applicable should be further determined in future studies.

Interventional Therapy for Pancreatic Cancer

BACKGROUND

Palliative therapy and primarily chemoradiotherapy are the mainstream treatments in patients with locally advanced or metastatic pancreatic cancer (PC). Conventional endoscopy and endoscopic ultrasound (EUS)-guided interventional therapy has emerged as an important procedure for PC management. In this review, the progress in conventional endoscopy and EUS for PC management is discussed.

SUMMARY

For local palliative therapy against PC, EUS-guided fine needle injection (FNI) could deliver different kinds of agents, such as radioactive seeds and fiducials. Although their feasibility and safety have been proven, the long-term efficiency of EUS-FNI is still not established. For pain, EUS-celiac plexus neurolysis (CPN) is effective. However, CPN can only relieve the pain to a limited degree, with short duration. Endoscopy-guided stent placement is the preferred strategy for biliary and duodenal obstruction. Plastic and metal stents are equally effective for the relief of obstructive jaundice. The functional times of metal stents are longer than those of a plastic stent.

KEY MESSAGE

For biliary obstruction, a metal stent is the first choice. The long-term efficiency of EUS-FNI still needs further study.

PRACTICAL IMPLICATIONS

Endoscopy and EUS-guided interventions have gradually become the mainstream method for local treatment of PC due to mini-invasiveness and real-time observation. PC is the second most common gastrointestinal malignancy and the sixth leading cause of cancer mortality in the United States, leading to about 4.0% of all cancer deaths [Siegel et al: CA Cancer J Clin 2014;64:9-29]. The only curative approach for patients with PC is surgical resection, but unfortunately 80-90% of patients have a surgically inoperable disease, with 53% having local metastases at the time of diagnosis [Weinberg et al: Oncology (Williston Park) 2015;29:809-820, 886]. Therefore, palliative therapy and primarily chemoradiotherapy are the mainstream of treatment in patients with locally advanced or metastatic PC. Although overall survival has improved from 6 to 8.5-11 months (some of them even survived for a year or more), the overall survival rate has not improved, and the 5-year survival is less than 4% [Weinberg et al: Oncology (Williston Park) 2015;29:809-820, 886; Greenlee et al: CA Cancer J Clin 2001;51:15-36; Zhang et al: Gastroenterol Res Pract 2016;2016:8962321]. Hence, it is crucial to develop more effective local treatment strategies for tumor tissue and symptom palliation. At present, endoscopy has gradually become the mainstream method for local treatment of gastrointestinal cancer due to mini-invasiveness and real-time observation. Conventional endoscopy can be used to manage the complication caused by PC, including endoscopic biliary stent placement for obstructive jaundice, and duodenal stent placement for duodenal obstruction. In addition, in those cases in whom obstructive jaundice failed to be relieved by endoscopic biliary stent placement, EUS-guided biliary drainage has emerged as an alternative procedure. Furthermore, antitumor agents can be delivered into tumor tissue or celiac plexus directly under interventional EUS guided to manage the tumor or the pain caused by the tumor. In this review, the progress in conventional endoscopy and EUS for PC management is discussed.

Changing trends in tissue acquisition in malignant pancreatic neoplasms

BACKGROUND AND AIM

To compare the frequency of use, hospital costs, and resource availability between endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), percutaneous, and surgical techniques for tissue acquisition in malignant pancreatic neoplasms.

METHODS

This is a retrospective claims analysis of Medicare patients undergoing biopsy of malignant pancreatic neoplasms over 5 years (2006-2010). The primary outcome measure was to compare the utilization of EUS, percutaneous techniques, and surgery for performing pancreatic biopsies. The secondary outcome measures were to compare treatment costs and variations in availability of resources between the three techniques over a 1-year period (2010).

RESULTS

Over 5 years, the use of EUS-FNA increased by 69.3% (7100 to 12 020) and the use of percutaneous biopsy by 1.8% (4480 to 4560) compared to decrease in surgical biopsy (720 to 420) by 41.7% (P < 0.0001). When compared to percutaneous and surgical biopsies ($9639 and $21 947, respectively) the median hospital cost/claim for EUS-FNA ($1794) was significantly lower (P < 0.0001). More EUS-FNA procedures were performed in urban and teaching hospitals compared to rural and non-teaching hospitals (P < 0.001).

CONCLUSIONS

Although EUS-FNA is increasingly performed and is less costly, and the rate of surgical biopsies has declined precipitously, the utilization of percutaneous techniques remains prevalent. Training and education are required to disseminate the use of EUS-FNA outside major teaching institutions or foster referral of patients to EUS centers because of implications for patient care and resource use.

Increased rates of duodenal obstruction in pancreatic cancer patients receiving modern medical management

BACKGROUND

Duodenal obstruction from pancreatic cancer historically occurs in 2-25 % of patients without surgery, but with new advances in chemotherapy and radiation therapy, the life expectancy of pancreatic cancer has increased.

AIM

The aim of the study was to determine the rate of development of duodenal obstruction requiring intervention in patients with pancreatic head adenocarcinoma who do not undergo surgical resection, but receive modern chemoradiation.

METHODS

It is a retrospective single center study. Inclusion criteria were patients with pancreatic cancer who underwent ERCP with metal biliary stent and then chemoradiation who subsequently developed symptomatic duodenal obstruction and underwent either metal duodenal stent placement or surgical duodenal bypass.

RESULTS

Twenty-four of 63 patients (38 %, 95 % CI 26-50 %) with unresectable pancreatic cancer and biliary stents who received chemotherapy and/or radiation therapy developed duodenal obstruction. The average length of time from diagnosis of pancreatic adenocarcinoma to development of outlet obstruction was 11.4 ± 4.9 months (range 1.5-40 months). Average length of time from development of duodenal obstruction to death was 4.8 ± 2.1 months (range 0.5-60 months). Average survival time from diagnosis to death was 16.6 ± 5.6 months (range 4.5-58 months).

CONCLUSION

Thirty-eight percent of patients with unresectable pancreatic head adenocarcinoma and metal biliary stents who receive chemotherapy and/or radiation therapy eventually develop symptomatic duodenal obstruction requiring duodenal stent or surgical bypass. This rate of duodenal obstruction is nearly twice that of previous reports using older oncologic therapy and will likely increase as patients survive longer with advances in medical therapy for pancreatic cancer.

Operative procedures for unresectable pancreatic cancer: does operative bypass decrease requirements for postoperative procedures and in-hospital days?

BACKGROUND

The optimal surgical management of patients found to have unresectable pancreatic cancer at open exploration remains unknown.

METHODS

Records of patients who underwent non-therapeutic laparotomy for pancreatic cancer during 2000-2009 and were followed until death at Memorial Sloan-Kettering Cancer Center, New York, were reviewed.

RESULTS

Over the 10-year study period, 157 patients underwent non-therapeutic laparotomy. Laparotomy alone was performed in 21% of patients; duodenal bypass, biliary bypass and double bypass were performed in 11%, 30% and 38% of patients, respectively. Complications occurred in 44 (28%) patients. Three (2%) patients died perioperatively. Postoperative interventions were required in 72 (46%) patients following exploration. The median number of inpatient days prior to death was 16 (interquartile range: 8-32 days). Proportions of patients requiring interventions were similar regardless of the procedure performed at the initial operation, as were the total number of inpatient days prior to death. Patients undergoing gastrojejunostomy required fewer postoperative duodenal stents and those undergoing operative biliary drainage required fewer postoperative biliary stents.

CONCLUSIONS

In this study, duodenal, biliary and double bypasses in unresectable patients were not associated with fewer invasive procedures following non-therapeutic laparotomy and did not appear to reduce the total number of inpatient hospital days prior to death. Continued effort to identify unresectability prior to operation is justified.

Assessing treatment effect in pancreatic cancer

CONTEXT

Pancreatic cancer is one of the most deadly forms of cancer (43,140 new cases per year; 36,800 deaths), and most people with pancreatic cancer do not survive past 5 years. New therapeutic regimens are constantly being evaluated in an attempt to reduce the rapid progression of this disease. Although some patients receive neoadjuvant therapy in an attempt to make a nonresectable or borderline-resectable tumor resectable, more patients with resectable disease are being enrolled in clinical trials that provide neoadjuvant therapy. This means more pancreatic resections must be evaluated for therapy effect. Histologic grading schemes for the assessment of posttherapy response have been described, but difficulties associated with determining the histologic features of treatment effect in pancreatic cancer have not been addressed.

OBJECTIVES

To critically review the diagnostic criteria for proposed grading schemes for pancreatic cancer treated with neoadjuvant chemoradiation therapy and to provide guidance to surgical pathologists who encounter treated pancreatic cancer resections.

DATA SOURCES

Published peer-reviewed literature and the personal experience of the authors.

CONCLUSIONS

Assessment of treatment effect in pancreatic cancer is difficult. Pathologists need to be aware that some histologic features of treatment effect overlap with histologic features seen in untreated pancreatic cancer, such as tumor cell anaplasia, necrosis, and fibrosis. Careful assessment of pancreatic resections, including detailed gross examination and thorough histologic sampling, is important in accurately assessing treatment effect and improving patient outcomes.

Outcomes comparing a pancreaticogastrostomy (PG) and a pancreaticojejunostomy (PJ) after a pancreaticoduodenectomy (PD)

BACKGROUND

The advantage of a pancreaticogastrostomy (PG) over a pancreaticojejunostomy (PJ) after a pancreaticoduodenectomy (PD) is not clear.

AIM

The aim of the present study was to compare the pancreatic fistula (PF, defined according to the International Study Group for Pancreatic Fistula classification) rate and other complications between both methods.

METHODS

Retrospective analysis of prospectively collected data of 424 [median: 65 years (17-83)] patients who underwent PG (239, 56.4%) and PJ (185, 43.6%) reconstruction between January 2005 and December 2009.

RESULTS

PF occurred in 55 (23.5%) in the PG and 30 (16.2%, P= 0.067) patients in the PJ group. Grade A PF occurred in 19 (7.9%), B in 22 (9.2%) and C in 14 (5.8%) in the PG compared with 5 (2.7%), 12 (6.5%) and in 13 (7.0%), respectively, in the PJ group. The median hospital was 10 days in both groups. The morbidity was higher in the PG group (108, 45.2 vs. 62, 33.5%, P= 0.015). However, there was no significant difference in the 90-day mortality between both groups (PG-17, 7.0% vs. PJ-16, 8.6%, P= 0.558).

CONCLUSION

There was no difference in the overall PF rate, hospital stay and overall mortality between PG and PJ reconstruction methods. However, the grade A PF rate was higher in the PG group.

Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010

Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.

Controversies in the management of borderline resectable proximal pancreatic adenocarcinoma with vascular involvement

Synchronous major vessel resection during pancreaticoduodenectomy (PD) for borderline resectable pancreatic adenocarcinoma remains controversial. In the 1970s, regional pancreatectomy advocated by Fortner was associated with unacceptably high morbidity and mortality rates, with no impact on long-term survival. With the establishment of a multidisciplinary approach, improvements in preoperative staging techniques, surgical expertise, and perioperative care reduced mortality rates and improved 5-year-survival rates are now achieved following resection in high-volume centres. Perioperative morbidity and mortality following PD with portal vein resection are comparable to standard PD, with reported 5-year-survival rates of up to 17%. Segmental resection and reconstruction of the common hepatic artery/proper hepatic artery (CHA/PHA) can be performed to achieve an R0 resection in selected patients with limited involvement of the CHA/PHA at the origin of the gastroduodenal artery (GDA). PD with concomitant major vessel resection for borderline resectable tumours should be performed when a margin-negative resection is anticipated at high-volume centres with expertise in complex pancreatic surgery. Where an incomplete (R1 or R2) resection is likely neoadjuvant treatment with systemic chemotherapy followed by chemoradiation as part of a clinical trial should be offered to all patients.

Use of octreotide for the prevention of pancreatic fistula after elective pancreatic surgery: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of octreotide in preventing postoperative pancreatic fistula. Pancreatic fistula is one of the most common complications after elective pancreatic surgery. Several clinical trials have evaluated the use of octreotide to prevent the development of pancreatic fistula after pancreatic surgery with conflicting recommendations.

METHODS

We undertook a meta-analysis of 7 identified randomized controlled trials, reporting comparisons between octreotide and a control. The primary outcome was the incidence of postoperative pancreatic fistula, and the secondary outcome was the postoperative mortality.

RESULTS

Seven studies, involving 1359 patients, met the inclusion criteria for this review. In these studies, sample sizes ranged from 75 to 252 patients. In total, 679 patients were given octreotide and 680 patients formed the control group. Perioperative octreotide is associated with a significant reduction in the incidence of pancreatic fistula after elective pancreatic surgery, with a relative risk of 0.59 (95% confidence interval 0.41-0.85, p = 0.004). However, this risk reduction was not associated with a significant difference in postoperative mortality (p > 0.05).

CONCLUSIONS

The review revealed that perioperative octreotide is associated with a significant reduction in the incidence of pancreatic fistula after elective pancreatic surgery. However, this risk reduction was not associated with a significant difference in postoperative mortality; further studies are warranted to confirm the results of this metaanalysis and to define which patient subgroups might benefit the most from prophylactic octreotide administration.

Predictive factors for complications after pancreaticoduodenectomy

BACKGROUND

Knowledge of the risk factors for complications following pancreaticoduodenectomy (PD) is sparse and there is not a consensus regarding the criteria to define the complications. The objective of this study was to determine the predictive risk factors for this surgery using the international study group definition.

PATIENTS AND METHODS

Between October 1999 and September 2005, data from 295 consecutive patients who underwent a PD in the Eastern Hepatobiliary Surgery Hospital were recorded prospectively. Medical records and specific charts from surgical procedures, histopathology reports, and intensive care units were continually scrutinized. Multivariable logistic regression analyses were used to estimate relative risks and their 95% confidence intervals.

RESULTS

Among 295 patients undergoing PD, 103 (34.9%) experienced at least one complication. Operations by low-volume surgeons (<50 PD surgeries across their lifetime) were followed by more abdominal complications (odds ratio [OR] 45.2). End-to-end pancreaticojejunostomy (PJ) resulted in more complications than end-to-side PJ (OR 2.7). Diabetes mellitus, increased estimated blood loss, and soft gland texture significantly increased the risks of abdominal complications. Systemic morbidity (OR 9.9) was the only independent predictive factor for mortality.

CONCLUSION

High-volume surgeons and end-to-side PJ greatly reduce the risk of abdominal complications in patients undergoing PD. The higher abdominal complications rate in patients with soft gland texture was similar to those found in previous reports. Moreover, PD should be performed with considerable attention in patients with diabetes mellitus.

Surgical palliation in patients with pancreatic cancer

BACKGROUND

The aim of palliative strategies in patients with pancreatic cancer is the relief of tumor-associated symptoms such as biliary and duodenal obstruction and tumor growth. Due to high mortality and morbidity rates of surgery, treatment of patients with advanced pancreatic cancer is mainly in the hand of gastroenterologists.

RATIONALE

In recent years, surgery of pancreatic cancer in specialized centres developed strongly, which makes it a viable option even in the treatment of advanced disease.

CONCLUSION

We advocate for an aggressive strategy in the treatment of pancreatic cancer with surgical exploration and tumor resection whenever possible.

¿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.

Phase I-II trial of twice-weekly gemcitabine and concomitant irradiation in patients undergoing pancreaticoduodenectomy with extended lymphadenectomy for locally advanced pancreatic cancer

PURPOSE

Define the maximum tolerated dose (MTD), tolerability, and efficacy of gemcitabine given concomitantly with radiotherapy in patients with locally advanced pancreatic cancer.

METHODS AND MATERIALS

Patients were required to have locally advanced T1-T3 resectable pancreatic cancer. Gemcitabine, given twice weekly before irradiation as a 30-min infusion, was tested at 3 dose levels: 20, 50, and 100 mg/m(2). The radiation dose was 50.4 Gy (ICRU) in 28 fractions. The targeted irradiation volume included the tumor, edema, and a 1-cm margin.

RESULTS

Twenty-eight of 34 patients was eligible for analysis of the treatment. The median age was 67 years (range 38-82). Six patients had T1, 9 had T2, and 19 had T3 diseases (AJCC). Dose-limiting toxicities were Grade 4, fatigue and nausea; Grade 3, thrombocytopenia, diarrhea, and infection. The MTD established was at the 50-mg/m(2) gemcitabine dose. A total of 21 of 28 patients underwent surgery: 18 had pancreaticoduodenectomy, 2 had total pancreatectomy, and 1 for palliative surgery. At the time of analysis, 13 of 28 (46%) were disease-free. The estimated median survival was 25 months and overall survival rate at 2 years (Kaplan-Meier) was 55%.

CONCLUSION

Gemcitabine 50 mg/m(2) given twice weekly with concomitant irradiation induces acceptable and manageable toxicity and might prolong survival.

Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial

BACKGROUND

Anastomotic failure is still a significant problem that affects the outcome of pancreaticoduodenectomy. There have been many techniques proposed for the reconstruction of pancreatic digestive continuity, but there have been few prospective and randomized studies that compare their efficacy.

METHODS

In the current work, 144 patients who underwent a pancreaticoduodenectomy with soft residual tissue were assigned randomly to receive either a duct-to-mucosa anastomosis (group A) or a 1-layer end-to-side pancreaticojejunostomy (group B).

RESULTS

The 2 treatment groups were found not to have any differences in regards to vital statistics, underlying disease, or operative techniques. The postoperative course was complicated in 54% of the 144 patients, with a comprehensive incidence of abdominal complications in 36% (group A, 35%; group B, 38%; P=not significant). The principal complication was pancreatic fistulas, which occurred in 14% of patients (group A, 13%; group B, 15%; P=not significant). Two patients (2%) required reoperation; the postoperative mortality rate was 1%.

CONCLUSION

The 2 methods that were studied revealed no significant difference the rate of complications.

Expression and diagnostic evaluation of the human tumor-associated antigen RCAS1 in pancreatic cancer

INTRODUCTION

Receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is one of the membrane molecules expressed on human cancer cells and is presumed to play a protective role for tumor cells against immune surveillance by inhibition of clonal expansion and induction of cell death in immunocytes.

AIMS

To address whether RCAS1 is expressed in pancreatic cancer and whether serologic diagnostic evaluation is useful compared with that of carbohydrate antigen 19-9 (CA19-9) and soluble Fas ligand.

METHODOLOGY

Immunohistochemical expression of RCAS1 was examined by staining with a 22-1-1 monoclonal antibody, and serum RCAS1 concentrations were determined by an enzyme-linked immunosorbent assay in 20 cases of ductal adenocarcinoma of the pancreas and other pancreatic diseases.

RESULTS

Immunohistochemically, RCAS1 detection occurred in 100% (20/20) of ductal adenocarcinoma of the pancreas cases, 100% (6/6) of intraductal papillary-mucinous adenoma of the pancreas cases, and 40% (2/5) of chronic pancreatitis cases. RCAS1 was found in the cytoplasm of cancer cells and ductal cells. Serum RCAS1 concentrations in patients with ductal adenocarcinoma of the pancreas were significantly higher than those in patients with chronic pancreatitis (p < 0.0001), acute pancreatitis (p < 0.005), and autoimmune pancreatitis (p < 0.001). RCAS1 concentrations in patients with intraductal papillary-mucinous adenoma of the pancreas were also significantly higher than those in patients with chronic pancreatitis (p < 0.05) and autoimmune pancreatitis (p < 0.05). Positive serum RCAS1 samples (concentration, > or = 10 U/mL) were found most often in cases of pancreatic neoplasm (80% [16/20], ductal adenocarcinoma of the pancreas; and 60% [3/5], intraductal papillary-mucinous adenoma of the pancreas). By contrast, in cases of pancreatic inflammatory diseases, raised concentrations occurred in 9.4% (3/32) of chronic pancreatitis cases, none (0/6) of acute pancreatitis cases, and none (0/8) of autoimmune pancreatitis cases. The sensitivity of CA19-9 for ductal adenocarcinoma of the pancreas was 75% and the specificity was 73.1% compared with chronic pancreatitis. On the other hand, the sensitivity of RCAS1 for ductal adenocarcinoma of the pancreas was 80% and the specificity was 96.2% compared with chronic pancreatitis. The specificity of RCAS1 for chronic pancreatitis was higher than that of CA19-9. Serum soluble Fas ligand concentrations were not considerably different among these patients.

CONCLUSIONS

RCAS1 was highly expressed in ductal adenocarcinoma of the pancreas, and serum RCAS1 concentrations in patients with ductal adenocarcinoma of the pancreas were significantly higher than those in patients with other inflammatory pancreatic diseases. Our results indicate that serum RCAS1 concentrations could be a new marker in screening procedures for pancreatic cancer.

Power Doppler ultrasonography for the assessment of vascular invasion by pancreatic cancer

AIM

To investigate the diagnostic accuracy of power Doppler ultrasonography (US) in assessing the vascular invasion by pancreatic cancer.

METHODS

A prospective study of 40 consecutive patients with pancreatic cancer (head 35, body 5) was performed. All patients underwent surgery. The relationships between tumor and each vessel were classified into four types according to the closest circumferential contact of the tumor with the vessel. A type 0 indicated no contact; type 1 indicated less than one third contact; type 2 indicated one third to 99% contact, and type 3 indicated encasement. Vascular invasion was diagnosed in types 2 and 3. The diagnostic accuracy was evaluated in the portal vein and in the splanchnic arteries (celiac artery, common hepatic artery, and superior mesenteric artery). The power Doppler US findings were confirmed by the operative findings. The results of power Doppler US were compared with those of CT scan and angiography.

RESULTS

Portal vein invasion was confirmed in resected specimens in 23 cases and by operative findings in 5 cases. For the diagnosis of portal vein invasion, sensitivity, specificity, and overall accuracy of power Doppler US were, respectively, 79.3, 90.9, and 82.5%. The respective values were 79.3, 100, and 85% for CT and 72.4, 81.8, and 75% for angiography. For the diagnosis of arterial invasion, sensitivity, specificity, and overall accuracy of power Doppler US were 80, 92, and 90%, respectively. The corresponding values were 47, 88, and 73% for CT and 47, 100, and 80% for angiography.

CONCLUSION

Power Doppler US proved to be useful for the diagnosis of vascular invasion by pancreatic cancer.

Unique K-ras mutational pattern in pancreatic adenocarcinoma from Taiwanese patients

To assess the prevalence and spectrum of K-ras mutations in Taiwanese patients with pancreatic adenocarcinoma, we analyzed 20 patients of ductal adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy. The study included K-ras mutations that were detected using DNA direct sequencing analysis of the polymerase chain reaction products and confirmed by reverse sequencing primers. The results showed that K-ras codon 12 mutation was detected in 90% of the cancer tissues (18/20). Moreover, the results from direct sequencing indicated that missense mutations were found to be a GGT to GTT in 94.5% of the cases (17/18) and a GGT to TTT in 5.5% of the cases (1/18). All cases with K-ras codon 12 mutations were found to be G to T transversion. However, no alterations were found at codons 13 and 61. From these findings, the high prevalence of K-ras codon 12 mutation in pancreatic adenocarcinoma and the predominant G to T transversion with the preferential substitution of glycine with valine might indicate an unusual sensitivity and specificity of this codon in genetic alterations for pancreatic carcinogenesis. The strikingly high mutational rate and the unique mutational spectrum of K-ras codon 12 in Taiwanese pancreatic adenocarcinoma can provide us with more information about the alternative diagnostic and therapeutic strategies in Taiwan.

Optimising the treatment of upper gastrointestinal fistulae

A three stage strategy is generally employed in the management of gastrointestinal fistulae which can form due to surgery, disease, or trauma. The condition is investigated leading to diagnosis, conservative treatment is initiated to stabilise the patient, followed by specific surgical treatment measures in complicated cases, or in the absence of spontaneous closure. Conservative management of fistulae is based on parenteral nutrition and bowel rest, as well as on control of infection, electrolytic disturbances, and local care of the fistula tract. Surgical treatment may be required although generally only in particularly serious cases. Somatostatin-14 has been used in addition to parenteral nutrition to further reduce the volume and enzymatic activity of the fluid output through the fistula tract, generally with good results. The majority of reports have shown a beneficial effect, and randomised studies have demonstrated a reduction in closure time and morbidity. However, due to a combination of the seriousness and rarity of the condition and the difficulties inherent in trial design, data from large scale, double blind, randomised, controlled studies investigating the use of pharmacotherapy in the treatment of established gastrointestinal fistulae are lacking. Nevertheless, preliminary data from initial trials suggest that somatostatin-14 and its analogue octreotide considerably improve the conservative treatment of gastrointestinal fistulae in the absence of distal obstruction. In addition, reduction of the concentration of caustic enzymes in the discharge will benefit both wound healing and nutritional losses. With reduced closure time, the period of hospitalisation will be shortened with potentially considerable economic reductions and improvements in quality of life for the patient.

Palliative strategies for locally advanced unresectable and metastatic pancreatic cancer

Technical improvement in perioperative morbidity and mortality with improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma has clearly established a role for this operation when performed with curative intent. Most patients with pancreatic adenocarcinoma will not be candidates for surgical resection of their disease. These patients will experience significant symptoms potentially requiring surgical and nonsurgical palliative interventions to treat unrelieved cancer-associated pain, obstructive jaundice, or the development of GOO. The primary goal for palliative interventions should be to relieve symptoms with minimal morbidity and to maintain or improve the quality of life for patients with an expected limited survival.

Twelve-year survival after the diagnosis of locally advanced carcinoma of the pancreas: A case report

The long-term survival rate of patients with carcinoma of the pancreas is low. Even more so, long-term survival of patients with metastatic pancreatic carcinoma is extremely rare. In this case report, we describe a patient with an unusual course of disease. This patient was diagnosed with locoregional carcinoma of the pancreas and therefore underwent gastroenterostomy and cholecystojeojenostomy without resection of the primary tumor. Later he was treated with radiotherapy and chemotherapy and survived 12 years, during 11 of which he had no evidence of disease. He died 12 years after the initial diagnosis from peritoneal dissemination of poorly differentiated carcinoma complicated with obstructive jaundice and sepsis. To our knowledge, this patient had the longest reported survival with locally advanced pancreas carcinoma that was not resected. The case is presented and discussed in this article.

Patients with laparoscopically staged unresectable pancreatic adenocarcinoma do not require subsequent surgical biliary or gastric bypass

BACKGROUND

Laparoscopic staging is an effective and accurate means of staging pancreatic cancer. But, the frequency of subsequent surgical bypass to treat biliary or gastric obstruction in laparoscopically staged patients with unresectable adenocarcinoma is unknown. The development of biliary and gastric obstruction in patients with unresectable pancreatic adenocarcinoma has been reported to occur in as many as 70% and 25% of patients, respectively. Previously, staging for patients with pancreatic cancer was achieved by laparotomy and the anticipated high rate for these patients to develop obstruction led to prophylactic bypass procedures. As laparoscopic staging for pancreatic cancer becomes a standard modality, the need for prophylactic bypass procedures in these patients needs to be examined.

STUDY DESIGN

Analyses of laparoscopically staged patients (n = 155) with unresectable, histologically proved pancreatic adenocarcinoma, from a single institution treated between 1993-1997 were performed. The frequency of surgical bypass in a prospective cohort of patients with unresectable pancreatic adenocarcinoma who did not undergo open enteric or biliary bypass at the time of laparoscopic staging was determined.

RESULTS

Laparoscopic staging revealed that 40 patients had locally advanced disease and 115 had metastatic disease. Median survival for patients with locally advanced and metastatic disease was 6.2 and 7.8 months, respectively. Postlaparoscopy followup revealed that 98% (152 of 155) of these patients did not require a subsequent open surgical procedure to treat biliary or gastric obstruction.

CONCLUSIONS

These results do not support the practice of routine prophylactic bypass procedures. As such, we propose that surgical biliary bypass can be advocated only for those patients with obstructive jaundice who fail endoscopic stent placement, and gastroenterostomy should be reserved for patients with confirmed gastric outlet obstruction.

Nonoperative management of pancreatic pseudocysts. Problems in differential diagnosis

CONCLUSION

The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. Awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively.

BACKGROUND

The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic errors occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature.

METHODS

Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo.

RESULTS

Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12-154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period.

Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT--a prospective, histopathologically controlled study

BACKGROUND

An adenoma-carcinoma sequence also applies to adenomas of the major duodenal papilla. Therefore accurate preoperative diagnosis and tumor staging are essential to select the appropriate patients for adequate treatment. In a prospective, histopathologically controlled study of tumors of the main duodenal papilla, the preoperative diagnostic value of ultrasound (US) catheter probes applied during endoscopic retrograde cholangiopancreatography (ERCP) was investigated.

METHODS

Intraductal US was compared with conventional endoscopic ultrasonography (EUS) and computed tomography (CT). In 27 consecutive patients with benign polypoid tumors of the major duodenal papilla (n = 12) and carcinomas of the papilla (n = 15), respectively, the value of these imaging procedures in determining tumor visualization, tumor diagnosis and tumor staging according to the TNM classification was assessed. Every patient underwent surgical resection; histopathologic evaluation of resected specimens served as the reference standard.

RESULTS

Intraductal US was significantly superior to EUS and CT in terms of tumor visualization (100% vs 59.3% vs 29.6%, respectively). Sensitivity and specificity rates for intraductal US and EUS were 100% versus 62.5% and 75% versus 50%, respectively. Overall accuracy rate in tumor diagnosis for intraductal US (88.9%; 24 of 27) was significantly (p = 0.05) superior to EUS (56.3%; 9 of 16). The latter did not depict 4 adenomas and 7 carcinomas. Neither intraductal US nor EUS is suitable for detection of distant metastases.

CONCLUSION

Intraductal US appears to be the most effective imaging method in visualizing, diagnosing and staging tumors of the major duodenal papilla. Combining ERCP with catheter probe sonography offers a new diagnostic modality that has some potential advantages for local staging of small tumors of the main duodenal papilla. Consequently, minimally invasive techniques for resection of seemingly benign tumors of the papilla or, even more so, of small carcinomas should preferably be based on intraductal US.

Review article: current practice and future perspectives in detection and diagnosis of pancreatic cancer

Pancreatic cancer is the tenth most prevalent malignancy and the fifth most common cause of cancer death in the developed world. Less than 10% of patients survive for more than 1 year following diagnosis and the 5-year survival rate (0.4%) is the lowest of any cancer. The poor prognosis associated with this diagnosis led in the past to therapeutic nihilism on the part of clinicians who were all too aware of the limitations of their available therapeutic strategies. Breaking this therapeutic impasse requires a significant expansion in the knowledge of clinicians concerning the pathogenesis and behaviour of pancreatic cancer. Recent advances in the scientific understanding of the aetiology of pancreatic cancer has facilitated progress towards the development of promising and innovative approaches to the early detection and diagnosis of pancreatic cancer. While acknowledging that pancreatic cancer will continue to present significant challenges to both scientists and clinicians in the foreseeable future, it is becoming increasingly clear that recent advances in our scientific knowledge base holds the potential to significantly improve prognosis for patients. The challenge facing both scientists and clinicians is how best to translate such promising scientific advances into survival and quality of life benefits to patients.

Laparoscopic evaluation in pancreatic cancer

Pancreatic cancer continues to carry a poor overall prognosis. The majority of patients have advanced disease at the time of presentation. Dynamic, contrast-enhanced computed tomography (CT) has become the radiographic study of choice in the pre-operative staging of patients with pancreatic cancer. While it has been shown to be highly sensitive in determining unresectability of peri-ampullary tumors, the ability of CT to predict accurately which tumors can be safely resected is still limited. Laparoscopic staging of peri-ampullary tumors is superior to dynamic CT in visualizing small liver and peritoneal metastases. The addition of laparoscopic ultrasound during laparoscopic staging enhances the ability of laparoscopy to determine resectability of these tumors and approaches the accuracy of open exploration without increasing significant morbidity or mortality. Patients who are deemed unresectable at the time of laparoscopy can undergo palliative biliary and/or gastric bypass procedures laparoscopically and further minimize the morbidity of laparotomy.

Expression of CD44 variants and its association with survival in pancreatic cancer

Since the CD44 variant 6(v6) molecule has been noted as a marker for tumor metastasis and prognosis in several tumors, we examined whether or not v6 is a useful marker for evaluating the prognosis of pancreatic cancer patients. In addition, we attempted to assess the clinicopathological implications for pancreatic cancer of the variant 2 (v2) isoform using a recently developed monoclonal antibody against a v2 epitope. The expression of CD44 variants was evaluated immunohistochemically in paraffin-embedded pancreatic cancer tissues from 42 patients who were confirmed surgically and histologically to have received curative resection. An indirect immunoperoxidase method was used with monoclonal antibodies against epitopes of the standard (CD44s) portion, v6 and v2. Protein expression data were evaluated statistically for any correlations with the length of survival or with histological parameters. The expression of CD44v6 and v2 was observed only in tumor cells, if at all. On the other hand, expression of total CD44 (including CD44v, as well as CD44s) was observed in both tumors and adjacent normal sites. Tumor tissue from 21 (50%) and 16 (38%) patients showed positive immunoreactivity with mAb 2F10 (anti-CD44v6) and mAb M23.6.1 (anti-CD44v2), respectively. The expression of CD44v6 and v2 was correlated with decreased overall survival (P = 0.0160 and P = 0.0125, respectively). A significant correlation was obtained between CD44v2 peptide expression and vessel invasion (P = 0.026). These results suggest that CD44v2 and CD44v6 may be useful markers for poor prognosis in curatively resected primary pancreatic cancer.

Intraportal endovascular ultrasonography for pancreatic cancer

Intraportal endovascular ultrasonography (IPEUS) is a new diagnostic procedure for pancreatic cancer. In portal invasion, subtle invasion and compression are difficult to differentiate with conventional imaging techniques such as computed tomography and angiography. IPEUS is performed with an 8-French, 20-MHz intravascular ultrasound catheter. IPEUS provides high-resolution, real-time images perpendicular to the portal vein axis. With IPEUS, the portal vein wall is visualized as an echogenic band. A subtle portal invasion can be detected by observing this portal vein wall. Moreover, the segment II of the extrapancreatic nerve plexus is visualized as an echogenic area around the inferior pancreaticoduodenal artery (IPDA). The extrapancreatic nerve plexus invasion can be diagnosed as low echoic infiltration of the area around the IPDA. In the diagnosis of portal vein and extrapancreatic nerve plexus invasion, IPEUS provides a good diagnostic value and important information for the staging of local extension of the pancreatic cancer.

Palliative and adjuvant regional chemotherapy in pancreatic cancer

To improve the dismal prognosis of patients (pts) with pancreatic cancer we treated 32 patients with non-resectable (UICC III, 17 pts; UICC IV, 15 pts--group 1) and 20 patients with resected (UICC I, 1 pt; UICC II, 3 pts; UICC III, 16 pts--group 2) pancreatic cancer with palliative (group I) and adjuvant post-operative (group II) coeliac axis intra-arterial cyclic infusions (CAI). CAI consisted of mitoxantrone 10 mg/m2 on day 1, folinic acid 170 mg/m2 and 5-FU 600 mg/m2 during days 2-4, and cis-platinum 60 mg/m2 on day 5 for up to 11 (group I) or six (group II) cycles. In a total of 211 cycles toxicities at the level of WHO III occurred in 0-6% and of WHO IV in 0%. The median survival times, compared with institutional historical controls (treated vs controls), were 12 vs 4.8 months in UICC III (P < 0.006) and 4 vs 2.9 months in UICC IV (P < 0.05) group I pts, and 21 vs 9.3 months in group II (P < 0.0003). Hepatic disease progression appeared to be suppressed with CAI, which also appears to be effective for palliative and adjuvant treatment in non-resectable and resected pancreatic cancer.

Identification and characterization of motility stimulating factor secreted from pancreatic cancer cells: role in tumor invasion and metastasis

Cell motility is an important factor in the process of invasion and metastasis of tumor. In this study, the relationship between cell motility and experimental metastatic potential was examined using two human pancreatic cancer cell lines, SW1990 and PANC-1. Serum-free conditioned medium from the highly metastatic cell line SW1990 was found to contain a factor that stimulated the migration of and induced a fibroblast-like morphological change in the weakly metastatic cell line PANC-1. Preincubation of PANC-1 cells with SW1990 conditioned medium (SW-C.M.) induced liver metastasis following splenic injection of PANC-1 cells in nude mice, although no liver metastasis was observed without pretreatment of SW-C.M. This factor, temporarily termed PDMF (pancreatic cancer-derived motility factor) is a heparin non-binding protein having a molecular weight of 40 kDa calculated by gel-filtration HPLC which acts not only chemotactically but also chemokinetically, and also acts mainly in a paracrine fashion. However, this factor had no effect on the proliferation of PANC-1 cells; it therefore appears to be a so-called motility factor. Only TGF-beta1 and IL-6 were recognized in the SW-C.M. among cytokines thought to stimulate cell motility. These cytokines stimulated the motility of PANC-1 cells, but differed from PDMF in the neutralizing test with antibody against these cytokines. Results of characterization and preliminary purification suggest that this factor may be a novel motility factor. The above findings suggest that this motility factor may play an important role in the invasion and metastasis of pancreatic cancer, and complete purification of it will be useful in elucidating the mechanism of progression of cancer and designing a strategy for inhibition of invasion and metastasis of pancreatic cancer.

Multimodal therapies in ductal pancreatic cancer. The future

CONCLUSIONS

Intra-arterial infusion chemotherapy via the celiac axis combined with external beam radiotherapy might be an effective method for palliative and perioperative multimodal treatment in pancreatic cancer. To improve the dismal prognosis in resectable and nonresectable pancreatic cancer, the results of multimodal palliative, adjuvant, and neoadjuvant therapies were reviewed and put into perspective with the results of two intra-arterial palliative and adjuvant treatment studies conducted at our department. The benefits and pitfalls of each method were outweighed, resulting in a concept for performing intra-arterial chemotherapy with radiotherapy in nonresectable stage UICC-III pancreatic cancer that eventually will be developed as a combined neoadjuvant/adjuvant treatment of all potentially resectable ductal pancreatic carcinomas.

The use of EUS to diagnose malignant portal venous system invasion by pancreatic cancer

BACKGROUND

CT scanning and mesenteric angiography are insensitive tests diagnosing vascular invasion by pancreatic cancer. Endoscopic ultrasound (EUS) has been proposed as an alternative. The sensitivity, specificity, and accuracy of specific EUS criteria for diagnosing malignant invasion of the branches of the portal venous system have not been determined.

METHODS

This is a prospective blinded evaluation of EUS and angiography to diagnose malignant invasion of the portal venous system by pancreatic cancer in 45 patients, 28 of whom underwent surgery. Surgical staging was used as the gold standard for determining the accuracy of EUS and angiography.

RESULTS

Four EUS criteria were studied and the overall accuracy rates were as follows: irregular venous wall (87%), loss of interface (78%), proximity of mass (73%), and size (39%). Although "irregular venous wall" was the most accurate, it suffered from a low sensitivity rate (47%) because of its relative inability to detect superior mesenteric vein invasion (sensitivity of 17%). The angiographic criteria had accuracy rates of 73% to 90% with low sensitivity rates (20% to 77%). The clean resection rate was 86% when all tests were used, 78% if EUS was used without angiography, and 60% if only angiography was used.

CONCLUSION

EUS is highly sensitive for detecting portal and splenic vein invasion by pancreatic cancer, but may be insensitive for superior mesenteric vein involvement.

Palliation for pancreatic cancer. Feasibility of laparoscopic cholecystojejunostomy and gastrojejunostomy in a porcine model

BACKGROUND

Although laparoscopy reveals undetected metastases in many patients with pancreatic cancer, most surgeons have chosen to proceed directly with laparotomy in an attempt at resection or for palliation of biliary and gastric outlet obstruction. In an effort to overcome this limitation, this study attempted to determine the feasibility of laparoscopic cholecystojejunostomy and gastrojejunostomy.

METHODS

Under general anesthesia, seven pigs underwent laparoscopic cholecystojejunostomy and gastrojejunostomy using either a hand-sutured or the stapled/sutured technique.

RESULTS

Mean operating time was less with the stapled/sutured vs hand-sutured technique (150 +/- 21 vs 230 +/- 13 min, P < 0.05). All animals recovered completely and there was no change in their weight or liver function tests as a result of the procedure. At sacrifice, all anastomoses were patent, although some were significantly narrowed in these unobstructed animals.

CONCLUSIONS

These results suggest that simultaneous laparoscopic palliation of biliary and gastric outlet obstruction is feasible. We believe these results warrant further study in the clinical setting.

FDG-PET evaluation of indeterminate pancreatic masses

PURPOSE

The purpose of this study was to assess the ability of PET with 2-[18F]fluoro-2-deoxy-D-glucose (FDG) to differentiate benign from malignant pancreatic masses in patients with indeterminate findings on CT.

METHOD

We performed FDG-PET on 12 patients with indeterminate mass lesions and 2 patients with CT findings typical for malignancy. Eight were found to have pancreatic carcinoma and six had benign lesions. The final diagnosis was histopathologically confirmed in all patients but two with a presumed diagnosis of focal pancreatitis based on stable clinical follow-up for at least 12 months. Lesion uptake of FDG was evaluated qualitatively and semiquantitatively by determination of the standardized uptake value (SUV) RESULTS: With use of a 2.5 cutoff value for SUV, all eight malignant and four of six benign lesions were correctly categorized. Qualitative evaluation gave the same results. The two false-positive lesions had elevated SUV values of 3.4 and 3.8, respectively.

CONCLUSION

Our results indicate that FDG-PET has potential value for assessing patients with CT findings that are indeterminate for pancreatic carcinoma. FDG-PET may obviate invasive diagnostic procedures in many patients with benign disease.

Survival after resection for ductal adenocarcinoma of the pancreas

A retrospective study was performed of 113 patients who underwent surgical resection of carcinoma of the pancreas from 1970 to 1992. The postoperative mortality rate was 15 per cent (5 per cent in the last 11 years). The actuarial 5-year survival rate was 12 per cent. Survival was significantly influenced by age (P = 0.03), vascular resection (P = 0.02), radicality of operation (P = 0.01), number of transfused blood units (P = 0.01), tumour differentiation (P = 0.002), lymph node status (P = 0.001), perineural invasion (P = 0.01), tumour size (P = 0.008), preoperative diabetes (P = 0.001) and stage (P = 0.0001). Multivariate analysis showed that stage, diabetes, age and grade were independent predictors of long-term survival. The type of pancreatic resection (Whipple, subtotal, total or distal pancreatectomy) did not influence prognosis. The 5-year survival rate was 14 per cent in the period 1970-1981 and 11 per cent in the period 1982-1992, with no statistical difference. These results suggest that patient characteristics and tumour findings rather than operative procedures affect long-term survival after resection for pancreatic carcinoma.

AN EXPERIENCE IN MANAGEMENT OF SURGICAL OBSTRUCTIVE JAUNDICE

One hundred and five patients of surgical obstructive jaundice were admitted to Army Hospital, Delhi from July 1991 to June 1994. Patients were investigated as per the diagnostic protocol. The causes of obstruction were choledocholithiasis (24 patients), periampullary carcinoma and carcinoma head of pancreas (32 patients), carcinoma gall bladder and cholangiocarcinoma (11 patients each). The procedures performed to relieve obstructive jaundice in 89 cases included choledochojejunostomy (17), pancreato-duodenectomy (15), hepaticojejunostomy (15), choledocholithotomy (12) and choledochoduodenostomy (12). Mortality was 7 per cent in pancreatoduodenectomy and 8 per cent in palliative procedures.

Clinical relevance of serological markers in the detection and follow-up of pancreatic adenocarcinoma

Pancreatic adenocarcinoma is a relatively common malignancy and its incidence is increasing. Prognosis in these patients is poor, and surgery, the only effective treatment, saves only a minority of patients. The number in this small group of patients might be increased by early detection of pancreatic tumours. This review examines the current status of pancreatic tumour associated proteins in the detection of pancreatic cancer. As well as existing markers, the review also reports on newer markers that may offer advantages over existing ones in the detection of pancreatic adenocarcinoma. This is particularly important because recent studies have identified high-risk groups susceptible to pancreatic cancer. Future research in pancreatic cancer should be directed at earlier detection, and tumour markers may play an important role in this process.

Extrapancreatic nerve plexus invasion by carcinoma of the head of the pancreas. Diagnosis with intraportal endovascular ultrasonography

CONCLUSION

The intraportal endovascular ultrasonography (IPEUS) could diagnose the second portion of the extrapancreatic nerve plexus invasion and provide precise information in operative strategy. But, the first portion was not visualized clearly owing to poor tissue penetration of the ultrasound beam, which may have reduced diagnostic accuracy. Improvement of the scanning area is expected to make intraportal endovascular US even more useful.

BACKGROUND

Pancreatic cancer easily invades the retroperitoneal tissue, especially the extrapancreatic nerve plexus. We evaluated the extrapancreatic nerve plexus invasion of the pancreatic cancer with IPEUS. IPEUS was performed intraoperatively in 20 consecutive resected cases with carcinoma of the head of the pancreas.

METHODS

IPEUS was performed with an 8-French, 20 MHz intravascular ultrasound catheter. IPEUS visualized the inferior pancreaticoduodenal artery (IPDA) in the extrapancreatic nerve plexus. The high-echoic area around the IPDA corresponds to the second portion of the extrapancreatic nerve plexus. The sonographic criterion for detection of the extrapancreatic nerve plexus invasion is low-echoic infiltration around the IPDA.

RESULTS

Extrapancreatic nerve plexus invasion was confirmed with resected specimens in 10 patients. The IPDA could not be visualized in two patients. In 18 patients, the diagnostic accuracy of invasion was evaluated. For diagnosis of extrapancreatic nerve plexus invasion with intraportal endovascular US, the sensitivity, specificity, and overall accuracy were 87.5, 90, and 88.7%, respectively.

Combined use of nuclear morphometry and DNA ploidy as prognostic indicators in nonresectable adenocarcinoma of the pancreas

The introduction of combined modality treatment has only marginally affected the prognosis in nonresectable pancreatic carcinoma. Evaluation of easily accessible prognostic variables could be of clinical importance when selecting patients for proper therapy. DNA ploidy and morphometric variables were chosen as prognostic markers and assessed on cytologic material obtained by fine-needle aspiration biopsy (FNAB) from 128 patients with pancreatic carcinoma. The nuclear DNA content was measured by image cytometry. Patients were categorized as short-term (< or = 6 mo) and long-term survivors (> 6 mo). Ninety-eight of 116 nonresectable patients were possible to evaluate. There were significant differences between short- and long-term survivors with regard to DNA ploidy (p < 0.01) and the morphonuclear variable anisokaryosis (p < 0.001). In patients with either DNA aneuploid tumors or anisokaryosis > or = 0.6, the survival time was 6 mo or less in 85 and 93%, respectively. When both these criteria were fulfilled, only 5% survived for more than 6 mo. Thus, DNA ploidy and morphometry, separately or in combination, may provide prognostic information in nonresectable pancreatic carcinoma.

General surgical laparoscopic procedures for the "nonlaparologist"

OBJECTIVE

To assess our initial experience with a variety of laparoscopic procedures that can be performed by general surgeons with the basic skills used for laparoscopic cholecystectomy and without advanced laparoscopic expertise.

MATERIAL AND METHODS

We retrospectively reviewed a 36-month experience (1991 through 1994) at our institution with a consecutive series of patients who underwent basic laparoscopic surgical procedures but specifically excluding cholecystectomy, appendectomy, herniorrhaphy, and colectomy.

RESULTS

Procedures performed laparoscopically included gastrostomy, jejunostomy, small bowel resection, intra-abdominal and retroperitoneal biopsy, staging of intra-abdominal malignant lesions, and adhesiolysis for relief of small bowel obstruction. During the 3-year study period, 106 patients underwent 107 procedures, 89 of which were successful. Four patients had substantial complications, two of whom underwent surgical repair.

CONCLUSION

A spectrum of procedures may be safely performed with the skills learned from laparoscopic cholecystectomy and without the need for advanced laparoscopic skills such as intracorporeal suturing or tying of knots.