Prognostic factors in the palliation of pancreatic cancer

Prognostic factors for survival in patients with unresectable pancreatic cancer

OBJECTIVES

In patients with unresectable pancreatic cancer, estimation of individual prognosis is essential to provide the most suitable biliary stent (self-expanding metal stent or plastic stent). The aim of the current study was to determine prognostic factors for survival in patients with unresectable pancreatic cancer after initial biliary drainage.

PATIENTS AND METHODS

The current study included 278 patients with unresectable pancreatic cancer. Prognostic factors for survival were analyzed using the Cox proportional hazards model, the Kaplan-Meier survival estimator, and the Wilcoxon test for difference in survival.

RESULTS

In univariate analysis, advanced T stage according to the TNM classification (P = 0.021, Wald test) and the presence of distant metastases (P = 0.001, Wald test) were predictive factors for shorter survival. However, in multivariate analysis, the presence of distant metastasis was the only independent prognostic factor. The median survival time after initial biliary drainage was 3.1 and 6.6 months in patients with and without the presence of distant metastases, respectively.

CONCLUSIONS

The presence of distant metastases was identified as the only independent prognostic factor for survival after initial biliary drainage. A self-expanding metal stent should be systematically chosen for patient without distant metastases, whereas polyethylene plastic stents should be preferred in patients with distant metastases.

Prophylactic gastrojejunostomy for unresectable periampullary carcinoma

BACKGROUND

The role of prophylactic gastrojejunostomy in patients with unresectable periampullary cancer is controversial.

OBJECTIVES

To determine whether prophylactic gastrojejunostomy should be performed routinely in patients with unresectable periampullary cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until April 2010.

SELECTION CRITERIA

We included randomised controlled trials comparing prophylactic gastrojejunostomy versus no gastrojejunostomy in patients with unresectable periampullary cancer (irrespective of language or publication status).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and independently extracted data. We analysed data with both the fixed-effect and the random-effects models using Review Manager (RevMan). We calculated the hazard ratio (HR), risk ratio (RR), or mean difference (MD) with 95% confidence intervals (CI) based on an intention-to-treat or available case analysis.

MAIN RESULTS

We identified two trials (of high risk of bias) involving 152 patients randomised to gastrojejunostomy (80 patients) and no gastrojejunostomy (72 patients). In both trials, patients were found to be unresectable during exploratory laparotomy. Most of the patients also underwent biliary-enteric drainage. There was no evidence of difference in the overall survival (HR 1.02; 95% CI 0.84 to 1.25), peri-operative mortality or morbidity, quality of life, or hospital stay (MD 0.97 days; 95%CI -0.18 to 2.12) between the two groups. The proportion of patients who developed long term gastric outlet obstruction was significantly lower in the prophylactic gastrojejunostomy group (2/80; 2.5%) compared with no gastrojejunostomy group (20/72; 27.8%) (RR 0.10; 95%CI 0.03 to 0.37). The operating time was significantly longer in the gastrojejunostomy group compared with no gastrojejunostomy group (MD 45.00 minutes; 95%CI 21.39 to 68.61).

AUTHORS' CONCLUSIONS

Routine prophylactic gastrojejunostomy is indicated in patients with unresectable periampullary cancer undergoing exploratory laparotomy (with or without hepaticojejunostomy).

EUS-guided fiducial placement for stereotactic body radiotherapy in locally advanced and recurrent pancreatic cancer

BACKGROUND

Stereotactic body radiotherapy (SBRT) has been approved for the treatment of locally advanced pancreatic cancer. Placement of gold fiducials is required for real-time tracking and delivery of a high-dose therapeutic beam of radiation to the tumor. Traditionally, fiducials have been placed either intraoperatively or percutaneously. Recently, EUS-guided fiducial placement has been reported, but the safety and feasibility of this approach is not well defined.

OBJECTIVE

The aim of this study was to determine the safety, feasibility, and limitations of EUS-guided placement of 0.8 x 5.0 mm fiducials via a 19-gauge needle for locally advanced and recurrent pancreatic cancer.

DESIGN

Prospective study of patients with either locally advanced or recurrent pancreatic cancer referred for EUS-guided fiducial placement for SBRT at our institution over a 3-year period.

SETTING

Tertiary referral center conducting >1800 EUS procedures annually.

MAIN OUTCOME MEASUREMENTS

Primary outcome measurements included success, complications, and technical limitations of EUS-guided fiducial placement in pancreatic cancer. In addition, the percentage of patients successfully completing SBRT after EUS-guided fiducial placement was determined.

RESULTS

A total of 51 patients (mean age 73 years; 57% male) with locally advanced (n = 36) and recurrent (n = 15) pancreatic cancer were referred for EUS-guided fiducial placement. Fiducials were successfully placed in 46 patients (90%), with technical failures occurring in 4 patients (8%) with recurrent cancer after pancreaticoduodenectomy. In 3 patients (7%), the fiducials spontaneously migrated from the original site of injection, thereby requiring a second EUS procedure for placement of additional fiducials. Of the 46 patients with fiducials placed under EUS guidance, 42 patients (91%) successfully completed SBRT. Two patients experienced disease progression before SBRT, 1 patient was lost to follow-up, and 1 patient experienced a complication at ERCP that precluded further therapy. Only 1 complication (2%), of mild pancreatitis, occurred in a patient undergoing simultaneous placement of fiducials and celiac plexus neurolysis for intractable abdominal pain.

LIMITATIONS

Single-center experience and lack of a formal follow-up protocol to assess for complications.

CONCLUSION

EUS-guided fiducial placement for SBRT in locally advanced and recurrent pancreatic cancer is safe and feasible. Successful placement was achieved in 90% of patients, with a low complication rate (2%). Furthermore, 91% of patients successfully completed SBRT after EUS-guided fiducial delivery. Although fiducials can spontaneously migrate from the initial injection site, the rate of migration is relatively low (7%), and no migration-related complications occurred over the course of this study. Limitations to EUS-guided fiducial placement may include surgically altered anatomy (pancreaticoduodenectomy) in patients with recurrent pancreatic cancer.

Percutaneous palliation of pancreatic head cancer: randomized comparison of ePTFE/FEP-covered versus uncovered nitinol biliary stents

The purpose of this study was to compare the clinical effectiveness of expanded polytetrafluoroethylene/fluorinated-ethylene-propylene (ePTFE/FEP)-covered stents with that of uncovered nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer. Eighty patients were enrolled in a prospective randomized study. Bare nitinol stents were used in half of the patients, and ePTFE/FEP-covered stents were used in the remaining patients. Patency, survival, complications, and mean cost were calculated in both groups. Mean patency was 166.0 ± 13.11 days for the bare-stent group and 234.0 ± 20.87 days for the covered-stent group (p = 0.007). Primary patency rates at 3, 6, and 12 months were 77.5, 69.8, and 69.8% for the bare-stent group and 97.5, 92.2, and 87.6% for the covered-stent group, respectively. Mean secondary patency was 123.7 ± 22.5 days for the bare-stent group and 130.3 ± 21.4 days for the covered-stent group. Tumour ingrowth occurred exclusively in the bare-stent group in 27.5% of cases (p = 0.002). Median survival was 203.2 ± 11.8 days for the bare-stent group and 247.0 ± 20 days for the covered-stent group (p = 0.06). Complications and mean cost were similar in both groups. Regarding primary patency and ingrowth rate, ePTFE/FEP-covered stents have shown to be significantly superior to bare nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer and pose comparable cost and complications. Use of a covered stent does not significantly influence overall survival rate; nevertheless, the covered endoprosthesis seems to offer result in fewer reinterventions and better quality of patient life.

Role of systemic inflammatory response in predicting survival in patients with primary operable cancer

Disease progression in cancer is dependent on the complex interaction between the tumor and the host inflammatory response. There is substantial evidence in advanced cancer that host factors, such as weight loss, poor performance status and the host systemic inflammatory response, are linked, and the latter is an important tumor-stage-independent predictor of outcome. Indeed, the systemic inflammatory response, as evidenced by an elevated level of C-reactive protein, is now included in the definition of cancer cachexia. This review examines the role of the systemic inflammatory response in predicting survival in patients with primary operable cancer. Approximately 80 studies have evaluated the role of the systemic inflammatory response using biochemical or hematological markers, such as elevated C-reactive protein levels, hypoalbuminemia or increased white cell, neutrophil and platelet counts. Combinations of such factors have been used to derive simple inflammation-based prognostic scores, such as the Glasgow Prognostic Score, the neutrophil:lymphocyte ratio and the platelet:lymphocyte ratio. This review demonstrates that there is now good evidence that preoperative measures of the systemic inflammatory response predict cancer survival, independent of tumor stage, in primary operable cancer. The evidence is particularly robust in colorectal (including liver metastases), gastro-esophageal and renal cancers. As described in this article, measurement of the systemic inflammatory response is simple, reliable and can be clinically incorporated into current staging algorithms. This will provide the clinician with a better prediction of outcome, and therefore better treatment allocation in patients with primary operable cancer. Furthermore, systemic inflammation-based markers and prognostic scores not only identify patients at risk, but also provide well-defined therapeutic targets for future clinical trials.

Enzymes Involved in Processing Glutathione Conjugates

Many potentially toxic electrophiles react with glutathione to form glutathione S-conjugates in reactions catalyzed or enhanced by glutathione S-transferases. The glutathione S-conjugate is sequentially converted to the cysteinylglycine-, cysteine- and N-acetyl-cysteine S-conjugate (mercapturate). The mercapturate is generally more polar and water soluble than the parent electrophile and is readily excreted. Excretion of the mercapturate represents a detoxication mechanism. Some endogenous compounds, such as leukotrienes, prostaglandin (PG) A2, 15-deoxy-Δ^12,14-PGJ₂, and hydroxynonenal can also be metabolized to mercapturates and excreted. On occasion, however, formation of glutathione S- and cysteine S-conjugates are bioactivation events as the metabolites are mutagenic and/or cytotoxic. When the cysteine S-conjugate contains a strong electron-withdrawing group attached at the sulfur, it may be converted by cysteine S-conjugate β-lyases to pyruvate, ammonium and the original electrophile modified to contain an –SH group. If this modified electrophile is highly reactive then the enzymes of the mercapturate pathway together with the cysteine S-conjugate β-lyases constitute a bioactivation pathway. Some endogenous halogenated environmental contaminants and drugs are bioactivated by this mechanism. Recent studies suggest that coupling of enzymes of the mercapturate pathway to cysteine S-conjugate β-lyases may be more common in nature and more widespread in the metabolism of electrophilic xenobiotics than previously realized.

Evaluation of DNA ploidy in relation with established prognostic factors in patients with locally advanced (unresectable) or metastatic pancreatic adenocarcinoma: a retrospective analysis

Background

Most patients with ductal pancreatic adenocarcinoma are diagnosed with locally advanced (unresectable) or metastatic disease. The aim of this study was to evaluate the prognostic significance of DNA ploidy in relation with established clinical and laboratory variables in such patients.

Methods

Two hundred and twenty six patients were studied retrospectively. Twenty two potential prognostic variables (demographics, clinical parameters, biochemical markers, treatment modality) were examined.

Results

Mean survival time was 38.41 weeks (95% c.i.: 33.17–43.65), median survival 27.00 weeks (95% c.i.: 23.18–30.82). On multivariate analysis, 10 factors had an independent effect on survival: performance status, local extension of tumor, distant metastases, ploidy score, anemia under epoetin therapy, weight loss, pain, steatorrhoea, CEA, and palliative surgery and chemotherapy. Patients managed with palliative surgery and chemotherapy had 6.7 times lower probability of death in comparison with patients without any treatment. Patients with ploidy score > 3.6 had 5.0 times higher probability of death in comparison with patients with ploidy score < 2.2 and these with ploidy score 2.2–3.6 had 6.3 times higher probability of death in comparison with patients with ploidy score < 2.2.

Conclusion

According to the significance of the examined factor, survival was improved mainly by the combination of surgery and chemotherapy, and the presence of low DNA ploidy score.

Modelling prognostic factors in advanced pancreatic cancer

Pancreatic cancer is the fifth most common cause of cancer death. Identification of defined patient groups based on a prognostic index may improve the prediction of survival and selection of therapy. Many prognostic factors have been identified often based on retrospective, underpowered studies with unclear analyses. Data from 653 patients were analysed. Continuous variables are often simplified assuming a linear relationship with log hazard or introducing a step function (dichotomising). Misspecification may lead to inappropriate conclusions but has not been previously investigated in pancreatic cancer studies. Models based on standard assumptions were compared with a novel approach using nonlinear fractional polynomial (FP) transformations. The model based on FP-transformed covariates was most appropriate and confirmed five previously reported prognostic factors: albumin, CA19-9, alkaline phosphatase, LDH and metastases, and identified three additional factors not previously reported: WBC, AST and BUN. The effects of CA19-9, alkaline phosphatase, AST and BUN may go unrecognised due to simplistic assumptions made in statistical modelling. We advocate a multivariable approach that uses information contained within continuous variables appropriately. The functional form of the relationship between continuous covariates and survival should always be assessed. Our model should aid individual patient risk stratification and the design and analysis of future trials in pancreatic cancer.

Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma

BACKGROUND

The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass.

METHODS

This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma.

RESULTS

We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05).

CONCLUSIONS

On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.

Serum C-reactive protein concentration and the prognosis of ductal adenocarcinoma of the head of pancreas

BACKGROUND

The prognostic role of serum C-reactive protein in pancreatic cancer has received increasing attention; however the confounding effects of biliary obstruction have not been addressed in previous studies. We sought to determine the prognostic importance of serum CRP prior to biliary intervention in the prognosis of pancreatic adenocarcinoma.

METHODS

A retrospective case note review of patients diagnosed with pancreatic cancer between 2001 and 2006. Clinical, radiological and biochemical criteria were correlated with overall survival. Patients were divided into: Group 1 who underwent potentially curative resection, and Group 2 with advanced unresectable disease managed non-surgically.

RESULTS

In total, 199 patients were included (58 resected). The proportion of patients with biliary obstruction was equal in both groups. Serum CRP and serum bilirubin concentration at presentation were significantly higher among patients in Group 2 compared to Group 1 (P values). On multivariate analysis, advancing age (P=0.012) and raised serum CRP concentration were independently associated with overall survival only in Group 2 patients (P=0.027, 95% CI 0.31-0.93). This association was independent of biliary tract obstruction.

CONCLUSION

Raised serum C-reactive protein concentration at the time of presentation of advanced pancreatic cancer carries a poor prognosis independent of biliary tract obstruction.

Self-expanding metal stents versus polyethylene stents for palliative treatment in patients with advanced pancreatic cancer

OBJECTIVES

Endoscopic biliary drainage is widely accepted as palliative treatment in patients with pancreatic cancer. The current study was designed to compare self-expanding metal stent and polyethylene stent in a homogeneous patient group with advanced pancreatic cancer.

METHODS

The study included 154 patients initially treated with a metal or plastic stent. Median survival time, stent patency, and stent-associated hospital admissions were evaluated.

RESULTS

The median survival time in patients treated with metal and plastic stent was 5.9 and 4.4 months (P = 0.074), respectively. Self-expanding metal stents have a significantly higher patency rate than polyethylene stents. Stent occlusion was observed in 21 (33%) of 63 patients in the plastic stent group after a median period of 57 days and in 17 (19%) of 91 patients in the metal stent group after a median period of 126 days. The total time of hospital stay after initial implantation of metal or plastic stent was 7 and 16.5 days, respectively (P < 0.001).

CONCLUSIONS

Self-expanding metal stents have a longer patency than polyethylene stents. Additionally, the number of stent-associated hospital admissions and the total time of hospital stay were higher in the plastic stent group. The median survival time was not significantly different in both groups.

Artificial neural networks in pancreatic disease

BACKGROUND

An artificial neural network (ANNs) is a non-linear pattern recognition technique that is rapidly gaining in popularity in medical decision-making. This study investigated the use of ANNs for diagnostic and prognostic purposes in pancreatic disease, especially acute pancreatitis and pancreatic cancer.

METHODS

PubMed was searched for articles on the use of ANNs in pancreatic diseases using the MeSH terms 'neural networks (computer)', 'pancreatic neoplasms', 'pancreatitis' and 'pancreatic diseases'. A systematic review of the articles was performed.

RESULTS

Eleven articles were identified, published between 1993 and 2007. The situations that lend themselves best to analysis by ANNs are complex multifactorial relationships, medical decisions when a second opinion is needed and when automated interpretation is required, for example in a situation of an inadequate number of experts.

CONCLUSION

Conventional linear models have limitations in terms of diagnosis and prediction of outcome in acute pancreatitis and pancreatic cancer. Management of these disorders can be improved by applying ANNs to existing clinical parameters and newly established gene expression profiles.

Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas

BACKGROUND

Patients with occult metastasis or locally nonresectable pancreatic cancer found during surgical exploration have a limited life expectancy. We sought to define markers in these patients that could predict survival and thus aid decision making for selection of the most appropriate therapeutic palliative option.

METHODS

In a prospective 4-year single-center study, 136 consecutive patients with obstructive pancreatic cancer and intraoperative diagnosis of nonresectable or disseminated pancreatic cancer underwent a palliative surgical bypass procedure. Potential factors predicting survival were evaluated.

RESULTS

Ninety-eight patients had metastatic disease and 38 locally advanced disease. Surgical morbidity rate was 16 %, re-operation rate 1%, and overall in-hospital mortality 4%. Univariate analysis showed American Society of Anesthesiologists (ASA) score, pain, operation time, presence of metastasis, and levels of leukocytes, albumin, C-reactive protein (CRP), carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19-9 were associated significantly with survival. The multivariate analysis identified ASA score, presence of liver metastasis, pain, CA 19-9, and CEA levels as independent indicators for poor survival. Patients with none or 1 of these risk factors had a median survival of 13.5 months, whereas patients with 4 or 5 risk factors had a median survival of 3.5 months.

CONCLUSIONS

The clinical markers identified predict poor outcome for patients with palliative bypass surgery and therefore aid the appropriate selection of either surgical bypass or endoscopic stenting in these patients.

Chronic inflammation and pancreatic cancer

There is a proven association between carcinoma of the pancreas and both the sporadic and hereditary forms of chronic pancreatitis. In chronic pancreatitis the standardised incidence ratio for development of pancreatic cancer is 14-18 and is further increased by cigarette smoking. Underlying mechanisms are unclear but current theories point to the progressive accumulation of genetic mutations as a consequence of repeated DNA damage and cell regeneration in an environment favouring proliferation and neovascularisation. In patients who develop pancreatic cancer, there is interest in the role of the inflammatory response in the development of cancer cachexia and in determining prognosis. Furthermore, markers of a systemic inflammatory response have prognostic significance in both advanced, inoperable pancreatic cancer and in patients undergoing resection. Further understanding of the details of the relationship between inflammation, carcinogenesis and cancer prognosis may lead to new therapeutic possibilities as part of multi-modality management of this difficult disease.

Self-expanding metal stents for duodenal obstruction in advanced pancreatic adenocarcinoma

INTRODUCTION

Gastric outlet obstruction (GOO) is a frequent feature of advanced pancreatic carcinoma. Self-expandable metal stents (SEMS) allow the condition to be managed outside by endoscopy rather than surgical bypass. The aim of this study is to report our experience in a district general hospital with SEMS for palliation of pancreatic carcinoma-related GOO.

PATIENTS AND METHODS

All patients admitted with or developing GOO secondary to pancreatic adenocarcinoma between January 2004 and December 2005 were identified. Notes were retrieved to determine the efficacy of stenting including: complications of the procedure, length of stay, readmissions and long-term patency.

RESULTS

Of 39 new cases of pancreatic cancer, 9 patients presented with (n=6) or developed (n=3) duodenal obstruction. In one patient, previous gastric surgery restricted access. Stenting was attempted in 8 patients (4 M and 4 F) with a mean age of 63 years (range 42-76 years). In one case, the duodenal invasion was too extensive to allow passage of the guide-wire and open bypass was performed. Stenting was successful in the remaining seven patients with no early complications. The median hospital stay post-procedure was 7 days (range 5-11 days). One patient was re-admitted after 11 weeks with recurrent duodenal obstruction and a second stent was placed. The median survival post-stenting was 10 weeks (range 3-28 weeks).

CONCLUSIONS

SEMS allows patients to leave hospital quickly and return to daily activities, albeit for the short term. The procedure requires an experienced interventional endoscopist but can be accomplished safely in the DGH setting.

Predictors of early mortality in veteran patients with pancreatic cancer

BACKGROUND

Identification of predictors of outcome may assist in guiding treatment options for patients with pancreatic cancer. The aim of the current study was to determine clinical factors and laboratory values that predicted mortality of less than 6 months in a male population of the same age and body mass index at the time of diagnosis of pancreatic cancer who died as a result of their disease.

METHODS

Only patients with proven diagnosis of pancreatic cancer (n = 69) were included in the study. Patients were grouped into early (< or = 6 months; n = 31) and late (> 6 months; n = 38) survivors. Forty-four clinical factors were assessed by univariate analysis. Significant factors (P <.05) were included in a multivariate regression model to determine independent predictors of early mortality.

RESULTS

All patients in the cohort were men. Both the early and late death cohorts were of similar age and body mass index. Twenty-five patients (36%) underwent surgical intervention (palliative 17%, exploratory laparotomy without resection 6%, pancreaticoduodenectomy 13%). Thirty-six patients (52%) underwent placement of a biliary stent. Eight patients received exclusively palliative care. The mean overall length of survival was 7.8 +/- .6 months. Univariate analysis demonstrated that patients who died within 6 months had a significantly increased blood level of carbohydrate antigen 19-9, alkaline phosphatase, and white blood cell (WBC) count. Early mortalities also had a decreased blood albumin level. Multivariate analysis of these factors revealed that low serum albumin and an increased WBC count independently predicted survival of less than 6 months.

CONCLUSION

Serum albumin and WBC count may be used in conjunction with other diagnostic modalities and overall patient status in determining treatment options for patients with pancreatic cancer.

Predictive factors in pancreatic ductal adenocarcinoma: role of the inflammatory response

OBJECTIVE

Pancreatic ductal adenocarcinoma is a highly lethal disease and most patients are not eligible for curable resection. Estimation of prognosis is essential in order to provide the best individual treatment for patients with pancreatic adenocarcinoma. Prediction of survival by current methods is limited, therefore the objective of this study was to determine possible prognostic factors identified at the time of diagnosis.

MATERIAL AND METHODS

All 119 consecutive patients with pancreatic ductal adenocarcinoma receiving palliative treatment at the Department of Surgery, Lund University Hospital from 1999 through 2002 were reviewed retrospectively. Prognostic factors and interventions were analysed statistically. C-reactive protein (CRP) at the time of diagnosis was measured in 109 patients.

RESULTS

The overall median survival was 4.4 months. By means of a multivariate analysis it was shown that CRP (p<0.001) and tumour size (p=0.018) were independent predictors of survival. The median survival of patients with normal CRP at the time of diagnosis was 10.8 months versus 4.2 months for those with raised CRP levels (>or=5 mg/l; p<0.001). Chemotherapy was the only intervention associated with a longer survival time (p<0.001 versus no chemotherapy).

CONCLUSIONS

The poor prognosis for patients with pancreatic ductal adenocarcinoma was confirmed. CRP proved to be a strong independent predictor of survival. Together with previous reported factors, CRP could serve as a potential tool to determine future treatment strategies for optimal individual palliation.

Endoscopic palliation of pancreatic cancer

Endoscopic approaches have revolutionized the palliation of advanced pancreatic cancer. The ideal management consists of a multidisciplinary approach involving surgeons, endoscopists, radiologists, and oncologists. Concurrent advances in the fields of interventional radiology and laparoscopic surgical oncology should be readdressed and directly compared with endoscopic approaches in randomized controlled trials. Exciting novel endoscopic techniques are being developed and evaluated; however, these approaches require further validation with randomized clinical trials to determine the safety and efficacy when compared with more traditional approaches.

Prognostic factors predictive of response and survival to a modified FOLFOX regimen: importance of an increased neutrophil count

PURPOSE

The aim of this study was to identify prognostic indicators of survival and response in a homogeneous population of chemotherapy-naive patients treated with oxaliplatin as part of 3 successive trials.

PATIENTS AND METHODS

Patient data were derived from 3 successive phase II trials evaluating modifications of the FOLFOX4 (oxaliplatin/5-fluorouracil/leucovorin) regimen. Clinical and laboratory prognostic factors were identified from the literature. Multifactor analyses stratified by treatment cohort were performed to identify independent prognostic factors for progression-free survival (PFS), overall survival (OS), and response rate.

RESULTS

One hundred thirty-four patients were enrolled across all 3 studies. Reduced PFS (n = 128) was associated with patients with the following characteristics: no previous surgery (P = 0.003); previous adjuvant chemotherapy (P = 0.015); > 1 organ involvement (P = 0.001); baseline absolute neutrophil count (ANC) > or = upper limit of normal (P = 0.001); and time from diagnosis to metastases < 9 months (P = 0.043). Poor OS (n = 128) was associated with patients with the following characteristics: performance status > 1 (P < 0.001); > 1 organ involvement (P = 0.018); and baseline ANC > or = upper limit of normal (P < 0.001). Response rate was related to previous surgery (P = 0.017) and performance status (P = 0.02).

CONCLUSION

This analysis has identified the additional prognostic importance of an increased ANC for PFS and OS. Further consideration needs to be given to include markers of systemic inflammation such as ANC as well as relevant cytokine levels in a larger cohort of identically treated patients.

Prognostic factors in patients with gemcitabine-refractory pancreatic cancer

OBJECTIVE

The purpose of this study was to identify prognostic factors in patients with gemcitabine-refractory pancreatic cancer and to determine criteria for selecting candidates for second-line treatment.

METHODS

The records of 74 patients who were treated with gemcitabine (GEM) and followed up until disease progression were reviewed retrospectively. Sixteen clinical variables at the time of disease progression after GEM chemotherapy were chosen for analysis in this study. Univariate and multivariate analyses were conducted to identify prognostic factors associated with survival.

RESULTS

At the time of analysis, 71 patients had died because of tumor progression. The overall median survival time was 5.1 months after first-line chemotherapy with GEM was initiated. Median survival time after disease progression was 2.0 months. Three factors, performance status, peritoneal dissemination and C-reactive protein level, were identified as independent prognostic factors in multivariate analysis. Median survival time in the good prognosis group (patients with performance status 0 or 1, no peritoneal dissemination and C-reactive protein <5.0 mg/dl) was 3.4 months.

CONCLUSIONS

Performance status, serum level of C-reactive protein and peritoneal dissemination were identified as important prognostic factors in patients with GEM-refractory pancreatic cancer. These factors should be considered in determining the treatment following first-line chemotherapy in patients with advanced pancreatic cancer.

Preoperative lymphocyte count as a prognostic factor in resected pancreatic ductal adenocarcinoma

BACKGROUND AND AIMS

Recognized prognostic factors for resected pancreatic ductal adenocarcinoma (PDAC) include tumour size, differentiation, resection margin involvement and lymph node metastases. A further prognostic factor of less certain significance is lymphocyte count. The aim of this study was to investigate whether preoperative lymphocyte count is a prognostic indicator in patients with PDAC.

MATERIAL AND METHODS

Patients who had undergone a potentially curative pancreaticoduodenectomy (PD) for PDAC between 1998 and 2005 were analysed. Standard prognostic factors, preoperative lymphocyte count, preoperative neutrophil count and survival data were collected.

RESULTS

Of the 44 patients studied, univariate analysis identified predictors of a poor survival as lymph node status (node positive (+ve) 10.3 [5.4-20.9] months versus node negative (-ve) 14.2 [10.9-31.4] months; p=0.038), posterior resection margin invasion (margin +ve 7.0 [5.1-15.0] months versus margin -ve 13.1 [10.0-28.3] months; p=0.025) and lymphocyte count below the reference range (<1.5 x 10(9)/litre 8.8 [7.0-13.1] months versus > or = 1.5 x 10(9)/litre 14.3 [7.0-28.3] months; p=0.029). Low preoperative lymphocyte count (p=0.027) and posterior margin invasion (p=0.023) retained significance on multivariate analysis. Preoperative neutrophil to lymphocyte ratio was not a significant prognostic factor.

CONCLUSION

Preoperative lymphocyte count is a significant prognostic factor in patients with PDAC.

Prognostic factors in patients with unresectable locally advanced pancreatic adenocarcinoma treated with chemoradiation

BACKGROUND

Although patients with locally advanced pancreatic cancer (LAPC) have an extremely poor prognosis, they are a heterogeneous group. Prognostic factors are inadequately defined for disease-free survival and overall survival in patients with LAPC who are receiving chemoradiation, so more definitive prognostic factors would be very useful for designing clinical trials.

METHODS

Between December 1993 and July 2005, 247 patients with nonmetastatic LAPC were treated at M. D. Anderson Cancer Center (Houston, Tex) with concurrent chemoradiation (CRT). Median radiation dose was 30 Gy (range, 15-52.2 Gy). Radiosensitizers included 5-fluorouracil (54%), gemcitabine (33%), and capecitabine (13%). Actuarial univariate and multivariate statistical methods were used to determine significant prognostic factors for disease-free survival and overall survival.

RESULTS

Median follow-up was 4.3 months (range, 1-63 months). Median disease-free survival and overall survival were 4.2 months and 8.5 months, respectively. On univariate analysis, prognostic factors for improved disease-free survival were a Karnofsky performance scale (KPS) status of >80 (P < .01) and a hemoglobin (Hgb)level at presentation of >/=12 (P = .03). On multivariate analysis, KPS was the only independent prognostic factor for disease-free survival. Median disease-free survival was 4.9 months among patients with a KPS score of >80 and was 3.9 months among those with a KPS score of /=12 (P = .02), KPS>80 (P < .001), and <5% weight loss (P = .03). On multivariate analysis, Hgb and KPS were independent prognostic factors for overall survival.

CONCLUSIONS

In the current study, KPS score was an independent prognostic factor for disease-free and overall survival among patients treated with chemoradiation for LAPC. The pretreatment Hgb level was an additional independent prognostic factor for overall survival.

Evaluation of an inflammation-based prognostic score in patients with inoperable pancreatic cancer

BACKGROUND/AIMS

Patients with pancreatic cancer have one of the poorest survival rates and selection of patients for active treatment remains problematical. The present study assesses the value of an inflammation-based score (Glasgow Prognostic Score, GPS) in patients with inoperable pancreatic cancer.

METHODS

The GPS was constructed as follows: patients with both an elevated C-reactive protein (>10 mg/l) and hypoalbuminaemia (<35 g/l) were allocated a score of 2. Patients in whom only 1 or none of these biochemical abnormalities was present were allocated a score of 1 or 0, respectively.

RESULTS

One hundred and eighty-seven patients were studied and 49 (26%) underwent an operative palliative bypass procedure. At the end of follow-up, 181 (97%) patients died, 17% of patients were alive at 12 months. On univariate analysis, age (p < 0.01), TNM stage (p < 0.001) and the GPS (p < 0.001) were significant predictors of survival. On multivariate survival analysis, stratified for bypass procedure, age (hazard ratio 1.53, 95%CI 1.12-2.10, p = 0.008), TNM stage (hazard ratio 1.70, 95%CI 1.33-2.18, p < 0.001) and the GPS (hazard ratio 1.72, 95%CI 1.40-2.11, p < 0.001) remained independent significant predictors of survival.

CONCLUSION

At diagnosis, the presence of a systemic inflammatory response (as measured by the GPS) appears to be a useful indicator of poor outcome, independent of TNM stage, in patients with inoperable pancreatic cancer.

Prognostic factors in patients with recently diagnosed incurable cancer: a systematic review

GOALS OF WORK

To review the literature and develop a conceptual framework about prognostic factors for people presenting to medical oncologists with recently diagnosed incurable cancer.

MATERIALS AND METHODS

Medline was searched from January 2000 to October 2003 to identify articles testing associations between clinical or laboratory variables and survival time in adults with advanced solid tumours and median survival of 3 to 24 months. We recorded how frequently prognostic factors were significantly associated with survival in univariable and multivariable analyses.

RESULTS

There were 53 studies included. The factors associated with survival were organised into four categories related to attributes of the host the tumour, the treatment and the interactions between host, tumour and treatment (symptoms, quality of life, performance status and laboratory tests). Co-morbidity was consistently associated with shorter survival. Age and gender were not consistently associated with survival duration, except in lung cancer where females survived longer. Tumour-related factors associated with shorter survival included primary tumour (lung), metastatic site (liver, brain and visceral) and disease extent. Symptoms associated with shorter survival included those of the anorexia-cachexia syndrome, dyspnoea, pain and impaired physical well being. Performance status was strongly associated with survival in most studies. Laboratory tests associated with shorter survival included anaemia, thrombocytopenia, hypoalbuminaemia and elevated serum levels of both alkaline phosphatase and lactate dehydrogenase.

CONCLUSION

Prognostic factors in patients with advanced cancer can be conceptualised as attributes of the host, tumour, treatment and interactions between the three reflected in symptoms, quality of life performance status and laboratory tests.

Refining the role of laparoscopy and laparoscopic ultrasound in the staging of presumed pancreatic head and ampullary tumours

Laparoscopy and laparoscopic ultrasound have been validated previously as staging tools for pancreatic cancer. The aim of this study was to identify if assessment of vascular involvement with abdominal computed tomography (CT) would allow refinement of the selection criteria for laparoscopy and laparoscopic ultrasound (LUS). The details of patients staged with LUS and abdominal CT were obtained from the unit's pancreatic cancer database. A CT grade (O, A-F) of vascular involvement was recorded by a single radiologist. Of 152 patients, who underwent a LUS, 56 (37%) had unresectable disease. Three of 26 (12%) patients with CT grade O, 27 of 88 (31%) patients with CT grade A to D, 17 of 29 (59%) patients with CT grade E and all nine patients with CT grade F were found to have unresectable disease. In all, 24% of patients with tumours <3 cm were found to have unresectable disease. In those patients with tumours considered unresectable, local vascular involvement was found in 56% of patients and vascular involvement with metastatic disease in 17%, while 20% of patients had liver metastases alone and 5% had isolated peritoneal metastases. The remaining patient was deemed unfit for resection. Selective use of laparoscopic ultrasound is indicated in the staging of periampullary tumours with CT grades A to D.

Gemcitabine treatment in patients with inoperable locally advanced/metastatic pancreatic cancer and prognostic factors

OBJECTIVE

Most patients with pancreatic cancer show an inoperable locally advanced/ metastatic tumour at the time of diagnosis. The present study was aimed at determining the prognostic factors in patients with advanced pancreatic carcinoma treated with gemcitabine.

MATERIAL AND METHODS

Sixty-seven unresectable or metastatic pancreatic cancer patients treated with gemcitabine were included in the study and a total of 258 cycles of treatment were applied.

RESULTS

The overall response rate was 5%. Thirty-one percent of the patients had stable disease, whereas progressive disease was seen in 49%. Clinical benefit response rate was 15%. The median duration of response was 7.3 months. Median progression-free survival was 3 months, while median overall survival was 9 months. Univariate analysis revealed that worse results were found in patients with performance status (PS) = 2, and in patients with primary tumour location in the body or tail of the pancreas (p<0.05). Multivariate analysis of data revealed that the most important factor was PS of the patient, as the patients with PS = 2 had worse results than the patients with PS = 0-1 (p<0.05).

CONCLUSIONS

Low PS is a negative predictive factor for the survival of patients with advanced pancreatic carcinoma treated with gemcitabine.

Circulating levels of inflammatory markers and cancer risk in the health aging and body composition cohort

BACKGROUND

Chronic inflammation is associated with processes that contribute to the onset or progression of cancer. This study examined the relationships between circulating levels of the inflammatory markers interleukin-6 (IL-6), C-reactive protein (CRP), and tumor necrosis factor-alpha (TNF-alpha) and total as well as site-specific cancer incidence.

METHODS

Study subjects (n = 2,438) were older adults (ages 70-79 years) participating in the Health Aging and Body Composition study, who did not report a previous cancer diagnosis (except for nonmelanoma skin cancer) at baseline. Incident cancer events (n = 296) were ascertained during an average follow-up of 5.5 years. Inflammatory markers were measured in stored baseline fasting blood samples.

RESULTS

The adjusted hazard ratios (95% confidence intervals) for incident cancer associated with a 1-unit increase on the natural log-scale were 1.13 (0.94-1.37), 1.25 (1.09-1.43), and 1.28 (0.96-1.70) for IL-6, CRP, and TNF-alpha, respectively. Markers were more strongly associated with cancer death: hazard ratios were 1.63 (1.19-2.23) for IL-6, 1.64 (1.20-2.24) for CRP, and 1.82 (1.14-2.92) for TNF-alpha. Although precision was low for site-specific analyses, our results suggest that all three markers were associated with lung cancer, that IL-6 and CRP were associated with colorectal cancer, and that CRP was associated with breast cancer. Prostate cancer was not associated with any of these markers.

CONCLUSIONS

These findings suggest that (a) the associations between IL-6, CRP, and TNF-alpha and the risk of cancer may be site specific and (b) increased levels of inflammatory markers are more strongly associated with the risk of cancer death than cancer incidence.

Endoscopic palliation of pancreatic adenocarcinoma

PURPOSE OF REVIEW

Endoscopic therapies have become an indispensable modality in the treatment and palliation of complications from pancreatic adenocarcinoma. This review focuses on treatment of biliary obstruction, malignant gastric outlet obstruction, and intractable abdominal pain resulting from unresectable pancreatic adenocarcinoma. Novel and emerging endoscopic approaches are also briefly discussed.

RECENT FINDINGS

Endoscopic placement of a biliary stent is the modality of choice for palliation of biliary obstruction. Biliary self-expanding metal stents should be placed if expected survival is more than 6 months and plastic stents if expected survival is less than 6 months. For endoscopic palliation of gastric outlet obstruction, enteral self-expanding metal stents should be placed. Biliary self-expanding metal stents should be considered prior to the placement of a duodenal stent. Palliation of intractable abdominal pain can safely be performed with endoscopic ultrasound-guided celiac plexus neurolysis using bupivacaine and absolute alcohol. Exciting novel endoscopic approaches are being evaluated especially in the area of drug-eluted biliary stents, endoscopic creations of enteral anastomoses, and endoscopic ultrasound-guided injection of gene vectors.

SUMMARY

The frontier of endoscopic palliative therapies for pancreatic adenocarcinoma is expanding. Clinical trials are needed to evaluate novel endoscopic approaches.

Systemic inflammatory response predicts outcome in patients undergoing resection for ductal adenocarcinoma head of pancreas

The aim of the present study was to examine the relationship between the clinicopathological status, the pre- and postoperative systemic inflammatory response and survival in patients undergoing potentially curative resection for ductal adenocarcinoma of the head of the pancreas. Patients (n=65) who underwent resection of ductal adenocarcinoma of the head of pancreas between 1993 and 2001, and had pre- and postoperative measurements of C-reactive protein, were included in the study. The majority of patients had stage III disease (International Union Against Cancer Criteria, IUCC), positive circumferential margin involvement (R₁), tumour size greater than 25 mm with perineural and lymph node invasion and died within the follow-up period. On multivariate analysis, tumour size (hazard ratio (HR) 2.10, 95% confidence interval (CI) 1.20–3.68, P=0.009), vascular invasion (HR 2.58, 95% CI 1.48–4.50, P<0.001) and postoperative C-reactive protein (HR 2.00, 95% CI 1.14–3.52, P=0.015) retained independent significance. Those patients with a postoperative C-reactive protein ⩽10 mg l⁻¹ had a median survival of 21.5 months compared with 8.4 months in those patients with a C-reactive protein >10 mg l⁻¹ (P<0.001). The results of the present study indicate that, in patients who have undergone potentially curative resection for ductal adenocarcinoma of the head of pancreas, the presence of a systemic inflammatory response predicts poor outcome.

Pancreatic cancer: management and survival

AIM

To review the management and survival from all pancreatic cancer over a 5-year period at a tertiary referral hospital in New Zealand and to examine similar outcome data from the national cancer registry.

METHODS

A retrospective audit was conducted for the 5-year period 1994-99 of patients discharged from Christchurch Hospital (Christchurch, New Zealand) and all patients in the New Zealand Cancer Registry with a diagnosis of pancreatic cancer. Kaplan- Meier survival curves were used for analysis.

RESULTS

From Christchurch Hospital a total of 230 patients were identified with a discharge diagnosis of pancreatic cancer. Medium survival for all groups was 3.9 months. There was a median survival of 1.6 months for the non-interventional group, 3.1 months for the stent group, 6.2 months for the bypass group and 12.6 months for the pancreatico-duodenectomy group. These data are very similar to the New Zealand National Cancer Registry data, where the overall median survival was 3.1 months and median survival for a pancreatico-duodenectomy was 13.9 months.

CONCLUSION

A pancreatico-duodenectomy is usually a palliative surgical technique and not a curative procedure. Those selected for resection have been shown to have an advantage over operative bypass in terms of length of survival, however, this most likely reflects selection bias.

Dual-phase 18F-fluoro-2-deoxy-D-glucose positron emission tomography as a prognostic parameter in patients with pancreatic cancer

PURPOSE

Recently, dual-phase 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) was shown to be useful in the differentiation between malignant and benign pancreatic lesions. The aim of this prospective study was to evaluate the value of dual-phase FDG-PET as a prognostic parameter in patients with pancreatic cancer.

METHODS

Sixty-five consecutive patients with pancreatic cancer underwent dual-phase FDG-PET. Standardised uptake values at 1 h (SUV1) and 2 h (SUV2) following the injection of FDG were determined, and the retention index (RI) was calculated by dividing the difference between SUV2 and SUV1 by SUV1. The prognostic value of SUV1, SUV2 and RI was analysed, along with the various clinical and biochemical parameters.

RESULTS

Multivariate analysis showed that only three factors had an independent association with longer patient survival: female gender (p<0.01), TNM stage I-III (p<0.05) and RI>10% (p<0.01). Neither SUV1 nor SUV2 showed any prognostic significance. Combination of tumour stage and RI allowed more accurate prognostic evaluation. Patients at stage I-III with RI>10% survived longer than did patients at the same stage with RI<10% (15.3 vs 11.5 months, p<0.01). Patients at stage IV with RI>10% had an intermediate prognosis, with a median survival of 9.5 months; patients at stage IV with RI<10% showed the worst prognosis, with a median survival of 4.9 months (p<0.05).

CONCLUSION

RI calculated with dual-phase FDG-PET can be used not only as a tool for initial diagnosis and staging of pancreatic cancer but also as a strong independent prognostic parameter that can allow accurate identification of those patients who will benefit from intensive anticancer treatment at different stages of the disease.

Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients

Survival data of patients with pancreatic carcinoma are often overestimated because of incomplete follow-up. Therefore, the aim of this study was to approach complete follow-up and to analyse survival and prognostic factors of patients who underwent surgical treatment for pancreatic adenocarcinoma. Between 1992 and 2002, 343 patients underwent surgical treatment for pancreatic adenocarcinoma. One hundred and sixty patients underwent a resection with a curative intention and 183 patients underwent bypass surgery for palliation. Follow-up was complete for 93% of patients. Median survival after resection and bypass was 17.0 and 7.5 months, and 5-year survival was 8% and 0, respectively. In multivariate analysis, tumour-positive lymph nodes, non-radical surgery, poor tumour differentiation, and tumour size were independent prognostic factors for survival after resection. For patients treated with bypass surgery, metastatic disease and tumour size independently predicted survival. In conclusion, actual survival of patients with pancreatic adenocarcinoma is disappointing compared with the actuarial survival rates reported in the literature. The independent prognostic factors for survival of patients who underwent surgical treatment for pancreatic adenocarcinoma are tumour-related.