Clinical significance of intraportal endovascular ultrasonography for the diagnosis of extrapancreatic nerve plexus invasion by pancreatic carcinoma

[Celiac trunk resection in patients with pancreatic cancer and severe pain syndrome]

AIM

To show the advisability, satisfactory tolerance and good analgesic effect of surgery for pancreatic ductal carcinoma with celiac trunk invasion.

MATERIAL AND METHODS

Distal subtotal pancreatectomy with resection of celiac trunk and common hepatic artery was made in 21 patients.

RESULTS

Early postoperative complications after distal subtotal pancreatectomy with celiac trunk resection occurred in 10 (47.6%) patients. There was no postoperative mortality. Resection edges including retroperitoneal space and pancreas did not contain tumor cells according to histological examination. Complete analgesic effect was obtained in 100% of patients after distal subtotal pancreatectomy with celiac trunk resection and neurodissection. 1- and 2-year survival was 59.1% and 21.5% respectively in patients with locally advanced pancreatic ductal carcinoma who underwent distal subtotal pancreatectomy with celiac trunk resection, median - 13 months, maximum lifetime - 57 months.

CONCLUSION

Distal subtotal pancreatectomy with resection of celiac trunk and common hepatic artery is safe, provides significant analgesic effect, increases resectability and expands the indications for pancreatectomy.

Is superior mesenteric artery reimplantation during surgery for pancreaticoduodenal tumors an underutilized procedure?

Resection and reimplantation of the superior mesenteric artery (SMA) as part of a pancreaticoduodenal resection for cancer is rarely performed even in high-volume centers because of the risks inherent in this procedure and the perceived lack of oncological benefit associated with arterial resection during pancreaticoduodenectomy. The role of arterial resection during pancreaticoduodenectomy has recently been reevaluated, and this procedure may be of greater benefit than previously believed in selected patients. It also has a definite role when necessary to resect low-grade pancreatic and peripancreatic malignancies or to salvage intraoperative injury to the SMA. This small case series presents the authors experience with this procedure.

The relationship between multiple clinicopathological features and nerve invasion in pancreatic cancer

BACKGROUND

Nerve invasion is a specific type of tumor expansion and characteristic manifestation of pancreatic cancer (PC), with an incidence rate ranging from 50% to 100%. It is an important prognostic factor for pancreatic cancer, and its early detection is helpful in the management of the disease. This study was undertaken to analyze retrospectively the relationship between neural invasion and multiple clinicopathological features and to provide evidences for clinicians in the management of neural invasion in patients with PC.

METHODS

Formalin-fixed paraffin-embeded specimens of PC taken from 215 patients were examined for the presence of neural invasion under a light microscope. Analyzed was the relationship between neural invasion and multiple clinicopathological feature including preoperative fasting blood glucose level, amylase level, serum CA19-9 level, abdominal pain, lumbar and back pain, and the expressions of p53 and Ki67 in tumor tissues.

RESULTS

Preoperative fasting blood glucose level, serum CA19-9 level and p53 positive cells in cancer tissue were increased with the rise of pathological grade (P<0.05). These indices were significantly higher in patients with neural invasion than in those without (P<0.05). Further analysis revealed a positive correlation between p53 and Ki67 overexpression and lymphatic metastasis (P<0.05). Referred pain was positively correlated with neural invasion (P<0.05). Patients with PC perineural invasion were more likely to have a higher pathological grade (P<0.05).

CONCLUSIONS

Our data indicated that the preoperative fasting blood glucose level, serum CA19-9 level, and referred pain are novel predictive markers for neural invasion in patients with PC. p53 and Ki67 play important roles in neural invasion of PC. Management of hyperglycemia may serve as an auxiliary treatment to curb neural invasion in PC.

CT and MR imaging patterns for pancreatic carcinoma invading the extrapancreatic neural plexus (Part II): Imaging of pancreatic carcinoma nerve invasion

Computed tomography (CT) and magnetic resonance imaging (MRI) are excellent modalities which have the ability to detect, depict and stage the nerve invasion associated with pancreatic carcinoma. The aim of this article is to review the CT and MR patterns of pancreatic carcinoma invading the extrapancreatic neural plexus and thus provide useful information which could help the choice of treatment methods. Pancreatic carcinoma is a common malignant neoplasm with a high mortality rate. There are many factors influencing the prognosis and treatment options for those patients suffering from pancreatic carcinoma, such as lymphatic metastasis, adjacent organs or tissue invasion, etc. Among these factors, extrapancreatic neural plexus invasion is recognized as an important factor when considering the management of the patients.

Intraarterial ultrasound in pancreatic cancer: feasibility study and preliminary results

Despite technological advances in computed tomography (CT) and magnetic resonance imaging, the involvement of the celiac or mesenteric artery in pancreatic cancer remains uncertain in many cases. Infiltration of these vessels is important in making decisions about therapy choices but often can only be definitively determined through laparotomy. Local (intraarterial) ultrasound may increase diagnostic accuracy. Using the Volcano intravascular ultrasound (IVUS) system, we applied a transfemoral method to scan the celiac and mesenteric arteries directly intraarterial. This technique was used in five patients with suspected pancreatic cancer. Technical success was achieved in all cases. In one case, a short dissection of the mesenteric artery occurred but could be managed interventionally. In tumors that did not contact with the vessels, IVUS was unable to display the tissue pathology. Our main interest was the infiltration of the arteries. In one case, infiltration was certain in the CT scan but uncertain in two patients. In the latter two cases, IVUS correctly predicted infiltration in one and freedom from tumor in the other case. In our preliminary study, IVUS correctly predicted arterial infiltration in all cases. IVUS did not provide new information when the tumor was far away from the vessel. Compared with IVUS in the portal vein, the information about the artery is more detailed, and the vessel approach is easier. These results encouraged us to design a prospective study to evaluate the sensitivity and specificity of this method.

Emphasis on the standardization of therapy for pancreatic cancer

Early pancreatic cancer is rarely discovered, and most patients are diagnosed at the middle or advanced stage. A number of clinical doctors treat operation indications differently, so many patients with resectable pancreatic cancer do not obtain a curable therapy due to this unstandardized process. This review aims to provide references for clinicians and press forward the unstandardized therapy of pancreatic cancer.

Radioimmunoscintigraphy of pancreatic cancer in tumor-bearing athymic nude mice using (99m)technetium-labeled anti-KL-6/MUC1 antibody

PURPOSE

KL-6 is an extracellular epitope of MUC1, a membrane-penetrating glycoprotein, and its overexpression has been reported in pancreatic cancer. The aim of this study was to examine whether radiolabeled anti-KL-6/MUC1 antibody could be used for molecular imaging of pancreatic cancer in vivo.

MATERIALS AND METHODS

Anti-KL-6/MUC1 antibody was labeled with 99mTC by the stannous reduction method. Immunoreactivity of the 99mTc-labeled anti-KL-6/MUC1 antibody was evaluated by a whole-cell binding study. In vivo experiments were performed by injecting the 99mTc-labeled anti-KL-6/MUC1 antibody into athymic nude mice bearing the KP-1NL pancreatic cancer cell line.

RESULTS

A whole-cell binding study showed that the radiolabeled antibody retained its immunoreactivity. On scintigrams, the density of the tumors remained unchanged during the 16-32 h after injection, whereas that of the kidneys decreased time-dependently. The radioactivity levels of the kidneys and tumors were measured densitometrically, and we found that the intensity in the tumors relative to that in the kidneys increased time-dependently. Radioactivity levels were the highest in the blood 32 h after injection, and those in the liver, kidney, lung, and tumor were also rather high.

CONCLUSION

99mTc-labeled anti-KL-6/MUC1 antibody appears to be a promising agent as a tumor-specific radiotracer for pancreatic cancer.

Extrapancreatic neural plexus invasion by carcinomas of the pancreatic head region: evaluation using thin-section helical CT

PURPOSE

The aim of this study was to determine the computed tomographic (CT) criteria for diagnosing the second portion of the extrapancreatic neural plexus (PLX-II) invasion by carcinoma of the pancreatic head region on thin-section helical CT.

MATERIALS AND METHODS

A total of 41 patients with carcinoma of the pancreatic head region (17 in the pancreas, 24 in the lower common bile duct) underwent three-phase helical CT (collimation 5 mm; reconstruction 2.5 mm) before surgery. Two criteria were established for the assessment of the PLX-II running between the superior mesenteric artery (SMA) and the medial margin of the uncinate process: criterion A: assessment of the area around the SMA and inferior pancreaticoduodenal artery; criterion B: assessment of the jejunal trunk.

RESULTS

PLX-II invasion was pathologically confirmed in 19 patients with pancreatobiliary carcinoma. For criterion A, all 19 patients with positive PLX-II invasion and 20 of the 22 with negative PLX-II invasion were correctly diagnosed (sensitivity 100%; specificity 91%; accuracy 95%). For criterion B, 3 of the 17 patients with positive PLX-II invasion and all 20 with negative PLX-II invasion were correctly diagnosed (sensitivity 18%; specificity 100%; accuracy 62%). The two false-positive cases using criterion A were correctly diagnosed using criterion B.

CONCLUSION

Thin-section helical CT provides sufficient diagnostic ability regarding PLX-II invasion by carcinoma of the pancreatic head region.

Analysis of long-term survivors after surgical resection for invasive pancreatic cancer

Pancreatic cancer remains a lethal disease. Although there are many reports on the survival rates of pancreatic cancer patients after surgical resection, the clinicopathological characteristics that influence long-term survival over 5 years remain controversial. Here, we clarify the favourable prognostic factors for long-term survival. One hundred and eighty-two patients with pancreatic cancer underwent surgical resections from 1981 to 1997 in our department. Among them, eight patients survived for at least 5 years after the surgery. The clinicopathological characteristics of the eight long-term survivors who underwent radical resections were studied retrospectively. R0 surgical resections, including five combined with portal vein resections (62.5%), were achieved in these eight patients. Negative invasions of the major regional artery (seven of eight, 87.5%) and to the extrapancreatic nerve plexus (seven of eight, 87.5%), and N0 or Nl lymph node metastasis (7 of 8, 87.5%) were detected as clinicopathological features of long-term survivors in our study. No exposure of carcinoma at the dissected surface and cut end (seven of eight, 87.5%) was characteristically confirmed by pathology. Portal vein invasion was seen in three of the eight patients (37.5%). For long-term survival in cases of pancreatic cancer, complete R0 resections should be performed and negative invasions in the major regional arteries and to the extrapancreatic plexus of the nerve were necessary. No invasion to the portal vein was not necessarily required if R0 was achieved by combined resection of the portal vein.