The Prognostic Effect of Clinical Staging in Pancreatic Adenocarcinoma

Rim Enhancement and Peripancreatic Fat Stranding in Preoperative MDCT as Predictors for Occult Metastasis in PDAC Patients

RATIONALE AND OBJECTIVE

To identify the radiological features and clinical biomarkers that could predict the occult metastasis (OM) of pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

This retrospective study included PDAC patients who were radiologically diagnosed resectable (R) or borderline resectable (BR) and underwent surgical exploration from January 2018 to December 2021. Depending on whether distant metastases were found during the exploration, patients were divided into OM and non-OM groups. Univariate and multivariable logistic regression analyses were performed to determine the radiological and clinical predictive factors for occult metastasis. Model performance was determined by discrimination and calibration.

RESULTS

A total of 502 patients (median age, 64 years; interquartile range, 57-70 years; 294 men) were enrolled, among which 68 (13.5%) patients were found with distant metastases, with 45 liver-only, 19 peritoneal-only, four patients had both liver and peritoneal metastases. Rim enhancement and peripancreatic fat stranding were more frequent in the OM group than in the non-OM group. Tumor size (p = 0.028), tumor resectability (p = 0.031), rim enhancement (p < 0.001), peripancreatic fat stranding (p < 0.001) and level of CA125 (p = 0.021) were independent predictors of occult metastasis according to the multivariable analyses, and the areas under the curve (AUCs) of these characteristics were 0.703, 0.594, 0.638, 0.655, 0.631, respectively. The combined model showed the highest AUC of 0.823.

CONCLUSIONS

Rim enhancement, peripancreatic fat stranding, tumor size, tumor resectability and level of CA125 are risk factors for OM of PDAC. The combined model of radiological and clinical features may help the preoperative prediction of OM in PDAC.

A simple risk score for detecting radiological occult metastasis in patients with resectable or borderline resectable pancreatic ductal adenocarcinoma

BACKGROUND

We advocated carbohydrate antigen (CA) 19-9 ≥ 150 U/mL and tumor size ≥30 mm as "high-risk markers" for predicting unresectability among patients with radiologically resectable (R) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC). The main aim is to establish a risk scoring system for occult abdominal metastasis (OAM) in R/BR PDAC.

METHODS

Predictors of OAM were investigated retrospectively in an experiment cohort from 2006 to 2018. The proposed risk scoring system was validated in another cohort from 2019 to 2020.

RESULTS

Five hundred and thirteen eligible patients were divided into the experimental (405 patients; OAM, 22%) and validation cohorts (108 patients). Multivariate analysis identified tumor location of body/tail (odds ratio [OR] 4.45, P < .0001) and "high-risk markers" (OR 2.07, P = .011) as independent predictors of OAM. A scoring system consisting of body/tail (yes: 1, no: 0) and "high-risk markers" (yes: 1, no: 0) was constructed. In the validation cohort, when staging laparoscopy (SL) was performed for patients with scores 1/2, the eligibility for SL, sensitivity, and negative predictive value of OAM were 55%, 91%, and 96%, respectively.

CONCLUSIONS

Tumor location of body/tail and "high-risk markers" were independent predictors of OAM, composing our simple and reproducible risk scoring system.

Preoperative prediction of futile surgery in patients with radiologically resectable or borderline resectable pancreatic adenocarcinoma

BACKGROUND AND AIM

The aim of this study is to identify the predictive factors for futile surgery in patients with radiologically resectable or borderline resectable pancreatic cancer and to develop a prediction model.

METHODS

This retrospective study included patients who underwent pancreatic surgery for pancreatic cancer between 2006 and 2017. To identify independent risk factors for futile surgery, logistic regression and random forest analyses were performed in the training cohort, based on which a nomogram was established. The predictive accuracy and discriminative ability of the nomogram were validated in the validation cohort.

RESULTS

Of 389 patients who underwent pancreatic surgery, the laparotomy was futile in 40 patients (10.3%). In the training cohort, the univariate and multivariate logistic regression analyses revealed that serum carbohydrate antigen 19-9 level of ≥ 150 U/mL (P = 0.003), the presence of suspicious lymph node (P = 0.013), and more extensive peripancreatic tumor infiltration (P < 0.001) were independent predictive factors for futile surgery. The bootstrap-corrected concordance index of the nomogram was high in the training cohort, 0.826 with a 95% confidence interval of 0.745-0.907. This model also showed a good discriminative performance in the validation cohort, with a concordance index of 0.831.

CONCLUSIONS

We established and validated a novel nomogram that predicts the risk of futile surgery due to occult distant metastasis in patients with radiologically resectable or borderline resectable pancreatic cancer.

Impact of Changes in the American Joint Committee on Cancer Staging Manual, Eighth Edition, for Pancreatic Ductal Adenocarcinoma

OBJECTIVE

Consistent and reliable tumor staging is a critical factor in determining treatment strategy, selection of patients for adjuvant therapy, and for therapeutic clinical trials. The aim of this study was to evaluate the number and extent of pancreatic ductal adenocarcinoma (PDAC) cases that would have a different pT, pN, and overall stages based on the new eighth edition American Joint Committee on Cancer staging system when compared with the seventh edition.

METHODS

Patients diagnosed with PDAC who underwent pancreaticoduodenectomy, total pancreatectomy, or distal pancreatectomy from 2007 to 2017 were retrospectively reviewed. A total of 340 cases were included.

RESULTS

According to the seventh edition, the vast majority of tumors in our cohort were staged as pT3 tumors (88.2%). Restaging these cases with the new size-based pT system resulted in a more equal distribution among the 3 pT categories, with higher percentage of pT2 cases (55%).

CONCLUSIONS

The newly adopted pT stage protocol for PDAC is clinically relevant, ensures a more equal distribution among different stages, and allows for a significant prognostic stratification. In contrast, the new pN classification (pN1 and pN2) based on the number of positive lymph nodes failed to show survival differences and remains controversial.

Comparative Accuracy of Tumor Size Assessment and Stage Analysis by Imaging Modalities Versus Gross Examination for Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Tumor size has been shown to be a strong predictor of patient survival in pancreatic ductal adenocarcinoma (PDAC). The aims of this study were to assess the consistency of preoperative imaging and gross examination for PDAC tumor size measurement and to evaluate the impact on T and overall tumor staging when size measurements by imaging and gross examination were different.

METHODS

Patients diagnosed with PDAC who underwent pancreaticoduodenectomy or distal pancreatectomy from 2007 to 2017 were retrospectively reviewed. A total of 268 cases were included.

RESULTS

Imaging studies underestimated tumor size in comparison with gross examination. Staging the tumors based on imaging size using the eighth edition American Joint Committee on Cancer resulted in an altered T stage in 106 cases (39.6%). There was no T-stage change in the remaining 162 cases (60.4%) despite the presence of variable size discrepancies (0.1-1.7 cm). When nodal metastases were also considered, there was no change in the overall tumor stage in most cases.

CONCLUSIONS

Although discrepancies exist between tumor size measurements by imaging modalities and gross examination, which may result in an altered T stage in a substantial number of cases, the overall tumor stage is only rarely altered.

Impact of tumor size on survival of patients with resected pancreatic ductal adenocarcinoma: a systematic review and meta-analysis

Background

The impact of tumor size on prognosis for surgically treated patients with pancreatic ductal adenocarcinoma (PDAC) remains controversial. A systematic review and meta-analysis was performed to evaluate this issue.

Methods

Relevant studies published from January 2000 to June 2017 were identified through EMBASE and PUBMED. Data were pooled for meta-analysis using Review Manager 5.3.

Results

Twenty eight observational studies involving a total of 23,945 patients were included. Tumors > 2 cm was associated with poor prognosis: the pooled hazard ratio (HR) estimate for overall survival was 1.52 (95% confidence interval [CI]: 1.41–1.64; P < 0.0001) by univariate analysis and 1.61 (95% CI: 1.35–1.91; P < 0.0001) by multivariate analysis; the pooled HR estimate for disease-free survival was 1.74 (95% CI: 1.46–2.07; P < 0.0001) by univariate analysis and 1.38 (95% CI: 1.12–1.68; P = 0.002) by multivariate analysis. When compared with patients with tumors ≤2 cm, those with the tumors > 2 cm had higher incidences of lymph node metastasis, poor tumor differentiation, lymph vessel invasion, vascular invasion, perineural invasion, and positive intraoperative peritoneal cytology.

Conclusion

These data demonstrate that PDAC size > 2 cm is an independent predictive factor for poor prognosis after surgical resection and associated with more aggressive tumor biology.

Evaluation of the prognostic value of the new AJCC 8th edition staging system for patients with pancreatic adenocarcinoma; a need to subclassify stage III?

BACKGROUND

There have been several proposed changes for the 8th edition of the American Joint Commission on Cancer (AJCC) for pancreatic adenocarcinoma. The aim of this study was to evaluate the prognostic value of the new staging system for patients with pancreatic adenocarcinoma, especially in stage III patients.

METHODS

We analysed the data of patients newly diagnosed with pancreatic adenocarcinoma between 2008 and 2016 at our hospital. Patients were staged according to 7th edition AJCC criteria, as well as the new 8th edition staging system. The pathologic stage was used in the surgical cases, and the clinical stage, determined by radiographic findings, was used in the unresectable cases.

RESULTS

Five hundred two patients were identified who met the inclusion criteria. In node-negative patients, there were no significant differences in survival among T 1, 2 and 3 groups according to the 8th edition. The survival rates of patients with N1 (1-3 positive nodes) and N2 (≥4 positive nodes) disease, according to 8th edition, were significantly different (p < 0.001). Although N2 and T4 patients are both stage III according to the new staging system, N2 patients had a better survival rate than T4 patients (p = 0.038). The new staging system stratifies patients more evenly across stages without sacrificing the prognostic accuracy.

CONCLUSIONS

The AJCC 8th edition has some advantages over the previous version. However, patients with N2 and T4, who have been integrated into stage III, showed different treatment modalities and prognoses, and we proposed dividing stage III into IIIA (T1-3N2M0) and IIIB (T4N_anyM0).

Role of staging laparoscopy in the management of Pancreatic Duct Carcinoma (PDAC): Single-center experience from a tertiary hospital in Brazil

BACKGROUND

Proper staging is critical to the management of pancreatic ductal carcinoma (PDAC). Laparoscopy has been used to stage patients without gross metastatic disease with variable success.

OBJECTIVES

We aimed to identify the frequency of patients diagnosed by laparoscopy with occult metastatic disease. Also, we looked for variables related to a higher chance of occult metastasis.

METHODS

Patients with PDAC submitted to staging laparoscopy either immediately before pancreatectomy or as a separate procedure between January 2010 and December 2016 were included. None presented gross metastatic disease at initial staging. We used logistic regression to search for variables associated with metastatic disease.

RESULTS

The study population consisted of 63 patients. Among all patients, nine (16.7%) had occult metastases at laparoscopy. Unresectable tumor (Odds ratio = 18.0, P = 0.03), increasing tumor size (Odds ratio = 1.36, P = 0.01), and abdominal pain (Odds ratio = 5.6, P = 0.04) significantly predicted the risk of occult metastases in univariate analysis. In multivariate analysis, only tumor size predicted the risk of occult metastases.

CONCLUSION

Laparoscopy remains a valuable tool in PDAC staging. Patients with either large or unresectable tumors, or presenting with abdominal pain present the highest risk for occult intra-abdominal metastases.

Validation of the American Joint Commission on Cancer (AJCC) 8th Edition Staging System for Patients with Pancreatic Adenocarcinoma: A Surveillance, Epidemiology and End Results (SEER) Analysis

BACKGROUND

The 8th edition of the AJCC staging system for pancreatic cancer incorporated several significant changes. This study sought to evaluate this staging system and assess its strengths and weaknesses relative to the 7th edition AJCC staging system.

METHODS

Using the Surveillance, Epidemiology and End Results (SEER) database (2004-2013), 8960 patients undergoing surgical resection for non-metastatic pancreatic adenocarcinoma were identified. Overall survival was estimated using the Kaplan-Meier method and compared using log-rank tests. Concordance indices (c-index) were calculated to evaluate the discriminatory power of both staging systems. The Cox proportional hazards model was used to determine the impact of T and N classification on overall survival.

RESULTS

The c-index for the AJCC 8th staging system [0.60; 95% confidence interval (CI), 0.59-0.61] was comparable with that for the 7th edition AJCC staging system (0.59; 95% CI, 0.58-0.60). Stratified analyses for each N classification system demonstrated a diminishing impact of T classification on overall survival with increasing nodal involvement. The corresponding c-indices were 0.58 (95% CI, 0.55-0.60) for N0, 0.53 (95% CI, 0.51-0.55) for N1, and 0.53 (95% CI, 0.50-0.56) for N2 classification.

CONCLUSION

This is the first large-scale validation of the AJCC 8th edition staging system for pancreatic cancer. The revised system provides discrimination similar to that of the 7th-edition system. However, the 8th-edition system allows for finer stratification of patients with resected tumors according to extent of nodal involvement.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.

G-protein-coupled receptor kinase 2 in pancreatic cancer: clinicopathologic and prognostic significance

G-protein-coupled receptor kinase 2 (GRK2) was found to regulate biological behaviors in some cancers, including pancreatic cancer (PC). However, its clinicopathologic and prognostic implications in cancer remain unclear. This study was designed to address the issues in PC. Expression of GRK2 was measured by Western blotting and tissue microarray-based immunohistochemical staining in 3 and 171 patients with PC, respectively. The H-score was used to evaluate the staining results. In addition, GRK2 expression was correlated with clinicopathologic variables and overall survival. Finally, the prognostic value of GRK2 was validated in a publically available PC dataset, GSE21501. It was suggested that GRK2 expression was highly up-regulated in 2 out of 3 tumor samples, in contrast to corresponding non-tumor ones. Furthermore, H-score of GRK2 staining was significantly higher in tumor than in non-tumor tissues. Tumoral expression of GRK2 was significantly associated with T stage. Univariate analysis showed that high GRK2 expression in tumor tissues was predictive for poor overall survival of PC. However, GRK2 expression was not identified as an independent prognostic marker in multivariate Cox regression test, although close to the statistical significance. In dataset GSE21501, GRK2 was also revealed to be prognostic. Our data establish that GRK2 is overexpressed in PC, and might serve as a potential indicator of unfavorable prognosis.

Indications for staging laparoscopy in pancreatic cancer

BACKGROUND

To identify indications for staging laparoscopy (SL) in patients with resectable pancreatic cancer, and suggest a pre-operative algorithm for staging these patients.

METHODS

Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords 'pancreatic cancer', 'resectability', 'staging', 'laparoscopy', and 'Whipple's procedure'.

RESULTS

Twenty four studies were identified which fulfilled the inclusion criteria. Of the published data, the most reliable surrogate markers for selecting patients for SL to predict unresectability in patients with CT defined resectable pancreatic cancer were CA 19.9 and tumour size. Although there are studies suggesting a role for tumour location, CEA levels, and clinical findings such as weight loss and jaundice, there is currently not enough evidence for these variables to predict resectability. Based on the current data, patients with a CT suggestive of resectable disease and (1) CA 19.9 ≥150 U/mL; or (2) tumour size >3 cm should be considered for SL.

CONCLUSION

The role of laparoscopy in the staging of pancreatic cancer patients remains controversial. Potential predictors of unresectability to select patients for SL include CA 19.9 levels and tumour size.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). There has been no systematic review or meta-analysis assessing the role of diagnostic laparoscopy in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 13 September 2012), and Science Citation Index Expanded (from 1980 to 13 September 2012).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in patients with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. Therefore, the sensitivities were meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in patients who had a negative laparoscopy (post-test probability for patients with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

Fifteen studies with a total of 1015 patients were included in the meta-analysis. Only one study including 52 patients had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 40.3% (that is 40 out of 100 patients who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 68.7% (95% CI 54.3% to 80.2%). Assuming a pre-test probability of 40.3%, the post-test probability of unresectable disease for patients with a negative test result was 0.17 (95% CI 0.12 to 0.24). This indicates that if a patient is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 17% probability that their cancer will be unresectable compared to a 40% probability for those receiving CT alone.A subgroup analysis of patients with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in patients with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 23 unnecessary laparotomies in 100 patients in whom resection of cancer with curative intent is planned.

Prognostic value of SUVmax measured by Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography with Computed Tomography in Patients with Pancreatic Cancer

PURPOSE

Recent studies have been conducted on the relationship between fluorodeoxyglucose (FDG) uptake in F-18 FDG PET/CT and prognosis in patients with pancreatic cancer, but these studies have been carried out in small numbers of patients. The aim of this retrospective study was to determine in a large number of patients whether glucose metabolism as assessed by F-18 FDG PET/CT provides prognostic information independent of established prognostic factors in patients with pancreatic cancer.

METHODS

We reviewed retrospectively the medical records of 165 patients (men 105, women 60, mean age 67 ± 10 years) with a diagnosis of pancreatic cancer that had undergone F-18 FDG PET/CT as part of a pretreatment workup from January 2004 to December 2009. Subsequently, all patients underwent surgery, cyberknife, radiotherapy, and/or chemotherapy. For the analysis, patients were classified by age, demographic data, maximum standardized uptake value (SUVmax), size, location, serum level of CA19-9, type of treatment, and AJCC stage. The relationship between FDG uptake and survival was analyzed using the Kaplan-Meier with log-Rank test and Cox's proportional-hazard regression methods.

RESULTS

Median survival for all 165 study subjects was 290 days and median SUV by PET/CT was 5.8 (range: 0-25.1). Patients were allocated to high (> 4.1) and low (≤4.1) SUV groups, and median survivals of these patients were 229 days and 610 days, respectively, which were significantly different (p < 0.0001). Furthermore, SUVmax was found to be significantly related to survival in each stage, i.e., there were 1267 days in stage I, 440 days in stage II, 299 days in stage III, and 143 days in stage IV (p < 0.0001). The median survival was also found to be significantly related to tumor size (p = 0.001), site (p = 0.0298), serum level of CA19-9 (p = 0.0017), distant metastasis (p < 0.0001), and type of treatment (p < 0.0001). Multivariate analysis study revealed that the patients with a low SUV (p = 0.0298), a lower serum level of CA19-9 (p = 0.0071), a lower stage (p = 0.0017), and no distant metastasis (p < 0.0001) had longer survivals. In addition, SUVmax values were found to have a similar hazard ratio of distant metastasis; it was well known predictor. Furthermore, SUVmax values showed a higher hazard ratio than that of other clinicopathologic predictors.

CONCLUSION

The present study shows that SUVmax on F-18 FDG PET/CT can provide a prognostic information in patients with pancreatic cancer.

An LED light source and novel fluorophore combinations improve fluorescence laparoscopic detection of metastatic pancreatic cancer in orthotopic mouse models

BACKGROUND

The aim of this study was to improve fluorescence laparoscopy of pancreatic cancer in an orthotopic mouse model with the use of a light-emitting diode (LED) light source and optimal fluorophore combinations.

STUDY DESIGN

Human pancreatic cancer models were established with fluorescent FG-RFP, MiaPaca2-GFP, BxPC-3-RFP, and BxPC-3 cancer cells implanted in 6-week-old female athymic mice. Two weeks postimplantation, diagnostic laparoscopy was performed with a Stryker L9000 LED light source or a Stryker X8000 xenon light source 24 hours after tail-vein injection of CEA antibodies conjugated with Alexa 488 or Alexa 555. Cancer lesions were detected and localized under each light mode. Intravital images were also obtained with the OV-100 Olympus and Maestro CRI Small Animal Imaging Systems, serving as a positive control. Tumors were collected for histologic analysis.

RESULTS

Fluorescence laparoscopy with a 495-nm emission filter and an LED light source enabled real-time visualization of the fluorescence-labeled tumor deposits in the peritoneal cavity. The simultaneous use of different fluorophores (Alexa 488 and Alexa 555), conjugated to antibodies, brightened the fluorescence signal, enhancing detection of submillimeter lesions without compromising background illumination. Adjustments to the LED light source permitted simultaneous detection of tumor lesions of different fluorescent colors and surrounding structures with minimal autofluorescence.

CONCLUSIONS

Using an LED light source with adjustments to the red, blue, and green wavelengths, it is possible to simultaneously identify tumor metastases expressing fluorescent proteins of different wavelengths, which greatly enhanced the signal without compromising background illumination. Development of this fluorescence laparoscopy technology for clinical use can improve staging and resection of pancreatic cancer.

Improving the diagnostic yield from staging laparoscopy for periampullary malignancies: the value of preoperative inflammatory markers and radiological tumor size

OBJECTIVES

The role of laparoscopy in staging periampullary malignancies is to detect small-volume metastatic disease not visible on preoperative imaging. Owing to improvements in preoperative imaging, some centers no longer undertake routine laparoscopic staging, whereas others still find it a useful pre-exploration tool.

METHODS

This study investigated the diagnostic yield of staging laparoscopies in 137 consecutive potentially resectable patients with periampullary malignancies. Serology on presentation, tumor size on computed tomography and proinflammatory markers such as C-reactive protein, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and Glasgow Prognostic Score were also examined to see if they were able to identify patients more likely to benefit from staging laparoscopy.

RESULTS

Laparoscopy identified occult disease in 16.1% of the patients. Only tumor diameter on cross-sectional imaging was related to an increase in diagnostic yield on staging laparoscopy. Area-under-curve values for tumor size and occult disease at laparoscopy were 0.8, with P = 0.0001.

CONCLUSION

Staging laparoscopy is a useful adjunct to computed tomography in staging periampullary cancers. Tumor size (especially >45 mm) is the only preoperative marker predictive of unexpected occult disease and may be used to select high-risk patients for laparoscopic staging.

Staging laparoscopy for proximal pancreatic cancer in a magnetic resonance imaging-driven practice: what's it worth?

BACKGROUND

Preoperative imaging is often inadequate in excluding unresectable pancreatic cancer. Accordingly, many groups employ staging laparoscopy (SL), although none have evaluated SL after preoperative magnetic resonance imaging (MRI). We performed a retrospective, indirect cost-effectiveness analysis of SL after MRI for pancreatic head lesions.

METHODS

All MRI scans administered for proximal pancreatic cancer between 2004 and 2008 were reviewed and the clinical course of each patient determined. We queried our billing database to render average total costs for all inpatients with proximal pancreatic cancer who underwent pancreaticoduodenectomy, palliative bypass or an endoscopic stenting procedure. We then performed an indirect evaluation of the cost of routine SL.

RESULTS

The average costs of hospitalization for patients undergoing pancreaticoduodenectomy, open palliative bypass and endoscopic palliation were: US$26, 122.43, US$21, 957.18 and US$11, 304.00, respectively. The calculated cost of SL without laparotomy was US$2966.25 or US$1538.61 prior to laparotomy. The calculated cost of treating unresectable disease by outpatient laparoscopy followed by endoscopy was US$5943.17. Routine SL would increase our costs by US$76, 967.46 (3.6%).

CONCLUSIONS

Staging laparoscopy becomes cost-effective by diverting unresectable patients from operative to endoscopic palliation. Given the paucity of missed metastases on MRI, the yield of SL is marginal and its cost-effectiveness is poor. Future studies should address the utility of SL by both examining this issue prospectively and investigating the cost-effectiveness of endoscopic vs. surgical palliation in a manner that takes account of survival and quality of life data.

Selective use of staging laparoscopy based on carbohydrate antigen 19-9 level and tumor size in patients with radiographically defined potentially or borderline resectable pancreatic cancer

OBJECTIVE

The aims of this study were to verify whether the selective use of staging laparoscopy can prevent unnecessary laparotomy and to find a surrogate marker for surgical unresectability in patients with potentially or borderline resectable pancreatic cancer.

METHODS

Group A consisted of consecutive 33 patients evaluated between 2005 and 2006 and who directly underwent open laparotomy for planned surgical resection. Group B consisted of consecutive 61 patients evaluated between 2007 and 2009 and of whom 16 patients (26%) had a staging laparoscopy due to the presence of high-risk markers of unresectability defined as carbohydrate antigen 19-9 level 150 U/mL or greater and tumor size 30 mm or greater.

RESULTS

The frequency of unnecessary laparotomies for occult distant organ metastasis was significantly different between groups A and B (18% and 3%, respectively; P = 0.021). Of 16 patients who underwent staging laparoscopy in group B, 5 patients (31%) had occult metastases. The multivariate analysis showed that the presence of high-risk markers and extrapancreatic plexus invasion on multidetector-row computed tomography were significant independent risk factors for unresectability.

CONCLUSIONS

The presence of high-risk markers was associated with surgical unresectability in patients with potentially or borderline resectable pancreatic cancer. The selective use of staging laparoscopy decreased the frequency of unnecessary laparotomy by detecting minute metastases.

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.

Laparoscopic surgery for pancreatic tumors

The rapid growth of minimally invasive technology and experience in recent decades has revolutionized many aspects of oncologic surgery. Adoption of laparoscopic pancreatectomy has been slow due to the inherent anatomic complexity of pancreatic surgery, as well as concerns of perioperative complications and compromised oncologic results. With increasing surgeon experience and growing data, laparoscopic pancreatic resection is generating considerable attention and enthusiasm. This article provides an overview of laparoscopic pancreatic tumor surgery with respect to tumor biology and technical approaches. Current applications of laparoscopic approaches to left pancreatectomy, tumor enucleation, central pancreatectomy, and pancreaticoduodenectomy for treatment of pancreatic tumors are considered in light of available evidence demonstrating feasibility, safety, and oncologic efficacy. Future directions in minimally invasive pancreatic surgery are explored.

The role of staging laparoscopy for intraabdominal cancers: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.

Carbohydrate antigen 19.9 accurately selects patients for laparoscopic assessment to determine resectability of pancreatic malignancy

BACKGROUND

Laparoscopy with laparoscopic ultrasonography (L-LUS) may be useful in the selection of patients for surgery to resect peripancreatic malignancy in addition to contrast-enhanced computed tomography (CE-CT). The present prospective study assessed the strategy of using carbohydrate antigen 19.9 (CA19.9) levels to select patients for L-LUS.

METHODS

Patients with suspected peripancreatic malignancy that appeared resectable on CE-CT were selected for immediate surgery if CA19.9 was low (up to 150 kU/l, or up to 300 kU/l if serum bilirubin was above 35 micromol/l), or to L-LUS if CA19.9 was high (over 150 kU/l, or over 300 kU/l if serum bilirubin was above 35 micromol/l). Data were assessed to determine the clinical utility of this strategy.

RESULTS

A total of 94 patients went straight to surgery, of whom 65 proved resectable: 63 of 80 with a low CA19.9 level but only two of 14 with a high CA19.9 level and gastric outlet obstruction. From 55 patients with high CA19.9 levels, L-LUS correctly identified 26 of 31 resectable tumours and eight of 24 unresectable tumours.

CONCLUSION

Using CA19.9 levels to help select patients with pancreatic malignancy for immediate surgery or L-LUS for further assessment of resectability effectively increased resection rates and reduced unnecessary laparotomies.

The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review

In the absence of metastatic disease patients with localized or locally advanced pancreatic cancer can benefit from surgical resection or chemoradiation. Despite the advances of imaging technology, however, noninvasive staging modalities are still inaccurate in identifying small volume metastatic disease leading potentially to inappropriate treatment and avoidable morbidity in a subgroup of patients. Staging laparoscopy may identify those patients with unsuspected metastatic disease on preoperative imaging and prevent unnecessary laparotomy or chemoradiation. A controversy exists, however, as to whether the procedure should be used routinely or selectively in pancreatic cancer patients with no evidence of metastasis on noninvasive staging. This review aims to assess the current role of staging laparoscopy by examining its diagnostic accuracy and ability to prevent unnecessary treatment as well as its morbidity, oncologic effect and cost-effectiveness. The available literature will be evaluated critically, its limitations identified and exisiting controversies addressed.